Epid Yankes

March 2001, Vol. 91, No.
3 476 American Journal of Public Health

20001 Expanded Family and Medical Leave
20002 Reducing the Incidence of Blindness, Lower Extremity Amputation, and Oral Health Complications in Minority Populations
Due to Diabetes
20003 (PP) Preserving Consumer Choice in an Era of Religious/Secular Health Industry Mergers (Position Paper)
20004 (PP) Supporting Access to Midwifery Services in the United States (Position Paper)
20005 Effective Interventions for Reducing Racial and Ethnic Disparities in Health
20006 (PP) Making Medicines Affordable: The Price Factor (Position Paper)
20007 Support for a New Campaign for Universal Health Care
20008 Affirming the Importance of Regulating Pesticide Exposures to Protect Public Health
20009 Support for International Action to Eliminate Persistent Organic Pollutants
200010 Creating Healthier School Facilities
200011 The Precautionary Principle and Childrens Health
200012 Reducing the Rising Rates of Asthma
200013 Maximizing Public Health Protection with Integrated Vector Control
200014 Protecting and Expanding OSHA Jurisdiction Over Home Workplaces
200015 (PP) Drinking Water Quality and Public Health (Position Paper)
200016 Effective Public Health Assessment, Prevention, Response, and Training for Emerging and Re-emerging Infectious Diseases,
including Bioterrorism
200017 Confirming Need for Protective National Health-Based Air Quality Standards
200018 Public Health Impacts of Job Stress
200019 Public Health Role of the National Fire Protection Association in Setting Codes and Standards for the Built Environment
200020 Raising Income to Protect Health
200021 International Trade Policy and Issues of Improving Access to Drugs for HIV/AIDS and Other Life-Threatening and Disabling
Diseases in Developing Countries
200022 Joint Resolution in Support of National Public Health Performance Standards Program
200023 The Need for Continued and Strengthened Support for Immunization Programs
200024 International Digest of Health Legislation
200025 Eliminating Access Barriers in Public Health Meetings
200026 International Multilateral and Bilateral Debt Relief
200027 Encourage Healthy Behavior in Adolescents
200028 Ensuring Optimal Vision Performance in Visually At Risk Drivers
200029 The Need for Mental Health and Substance Abuse Services for the Incarcerated Mentally Ill
200030 Preventing Genocide
200031 Criteria for Assessing the Quality of Health Information on the Internet
200032 Discontinuation of the Use of the Island-Municipality of Vieques, P.R., for the US Navys Training Exercises
Interim Policy Statements
00-LB-1 Research and Intervention on Racism as a Fundamental Cause of Ethnic Disparities in Health
00-LB-2 Opposition to the CRACK Campaign
00-LB-3 Restoration of Nutrition and Health Benefits Eligibility to Documented Immigrants
00-LB-4 Resolution to Improve the Social Conditions that Contribute to Health
00-LB-5 Addressing the Use of Fluoroquinolone Antibiotics in Agriculture
00-LB-6 Establishment of a Medicare Prescription Drug Benefit
00-LB-7 Support the Framework for Action on Oral Health in America: A Report of the Surgeon General
00-LB-8 Trust Fund for Developing Countries to Meet National Commitment Under the WHO Framework Convention for Tobacco Control
00-LB-9 Participation of Health Professionals in Capital Punishment
00-LB-10 Condemnation of Pharmaceutical Manufacturers Retaliatory Tactics
Association News
Policy Statements Adopted by the Governing Council
of the American Public Health Association, November 15, 2000
20001: Expanded Family and
Medical Leave
The American Public Health Association,
Recognizing that major life events such as ill-
ness of oneself or an immediate family member,
pregnancy, birth of a child,
1
or death in a family
constitute a significant source of individual stress
affecting the workplace and that in all, 47% of the
US. labor force has some type of dependent care
responsibility;
2
and
Recognizing that previous APHA policy rec-
ognizes the importance of public health measures
to improve the health of the elderly,
3
those with
chronic diseases, or catastrophic acute and chron-
ic health care needs, as well as increased services
for mothers and children and low-income popula-
tions; and.
Recognizing that the U.S. Family and Medical
Leave Act (FMLA) of 1993, requires employers
with 50 or more employees to provide unpaid
leave for up to 12 weeks, but unlike every other
industrialized country, shifts much of the eco-
nomic burden to the worker;
8
and that only 55%
of workers in the US are covered by the FMLA,
leaving 41 million workers uncovered, while most
other industrialized countries mandate paid ma-
ternity leave, offer more than the 12 weeks ac-
corded US. mothers, and provide such leave for
all, not just those working for companies with 50
or more employees;
9
for example a survey of
parental leave policies in 16 European countries
and Canada found that those countries averaged
68 weeks of leave, more than one full year, of
which 33 weeks were paid,
10
and a 1998 United
Nations study found that the United States is one
of only six countries out of 152 surveyed that did
not have paid maternity leave;
11
and
Recognizing that initial opposition to the
FMLA, primarily from the business community,
based on concern about high costs to employers
12
has proven to be groundless as numerous studies
have demonstrated that turnover costs are signifi-
cantly higher than temporary replacement;
13
fam-
ily leaves can lead to increased worker content-
ment, higher productivity,
14,15
and better public
relations;
16
and the Commission on Leaves
Employer Study
17
found that only 10% of em-
ployers surveyed reported increased costs from
implementing the FMLA; and countries that U.S.
businesses often consider as competitors such as
Germany and Japan implemented paid parental
leaves years ago;
18,19
and
Recognizing that paid leaves would cost more
than existing unpaid leaves but that these and
other employee benefits serve basic human
needs, essential for families and society and have
always met with resistance from the corporate
sector and that limits on overtime, minimum
wage and occupational safety and health stan-
dards are just some examples of laws that many
take for granted now but had to be won over the
opposition of employers; and
Recognizing that parent-infant bonding is es-
sential to child development,
20-22
and that other
studies report high levels of physical, emotional,
and financial stress from workers taking care of
new babies, sick children, and elderly and dis-
abled adults while continuing at their paid
jobs;
20,21
and
Realizing that millions of Americans cannot
afford to take the unpaid leave provided by the
FMLA and that eighty-three percent of US
women responding to the recent AFL-CIO work-
ing women poll rate laws to expand the FMLA
23
and provide paid leave as important legislative
priorities; and
Realizing that, while the FMLA does not re-
quire wage replacement, 47% of employees tak-
ing leave receive full pay and 20% collect partial
pay during their leave with the money coming
from sick pay benefits, vacation time, or disabili-
ty insurance.
17
Realizing that workers most likely to receive
wage replacement under FMLA are Caucasian,
salaried, highly educated, unionized, and have
higher household incomes; that the employees
least likely to collect wage replacement are those
in the youngest or oldest age groups with low lev-
els of income and/or education and who are
Latino/a;
17,24
and that nearly one in ten FMLA
users is forced onto public assistance during un-
paid leaves; and
Realizing that estimates of the US Depart-
ment of Labor Studies paid leaves for new babies
in California would cost about $768 million and,
for the United States as a whole, between $5 and
$10 billion per year, are small when one consid-
ers the most recent annual military budget;
26
therefore,
The American Public Health Association
urges Congress of the United States to,
1. Expand the Family and Medical Leave Act to
include paid family- or medical-related
leaves, such as those provided by most other
industrialized countries;
27,28
and
2. Give qualified support to President Clintons
plan to allow states to use surplus unemploy-
ment insurance for paid parental leaves as a
first step toward federal provision of paid
leaves; acknowledging that paid parental
leaves should not be paid from funds intend-
ed for workers unemployment benefits, but
instead, by employers or through general
taxes and that people need paid family and
medical leaves for reasons other than having
or adopting a new baby; and
3. Provide paid family and medical leaves to all
workers, who work for companies with 20 or
more employees, not just those who work for
a company with 50 or more employees; and
4. Expand the FMLA definition of immediate
family to include an employees spouse,
child, parent, or any other primary care giver.
References
1. Hyde JS, Klein MH, Essex MJ, Clark R.
Maternity leave and womens mental health. Psy-
chology of Women Quarterly. 1995;19:257-285.
2. American Association of Retired Persons
(AARP) and the Travelers Foundation, A
National Survey of Caregivers: Final Report.
Washington, DC: AARP, 1988; U.S. House of
Representatives, Select Committee on Aging,
Exploding the Myth: Caregiving in America.
Committee publication 99-611. Washington, DC:
U.S.GPO, 1987.
3. APHA Policy Statement 8201: Health Issues
of Older Women. APHA Policy Statements; 1948
present, cumulative. Washington DC: American
Public Health Association; current volume.
4. APHA Policy Statement 5602: Federal
Assistance to Programs to Improve the Health of
Older Persons. APHA Policy Statements; 1948
present, cumulative. Washington DC: American
5. APHA Policy Statement 8731PP: Toward a
Comprehensive National Policy on Catastrophic
Acute and Long Term Health Care. APHA Policy
Statements; 1948present, cumulative.
Washington DC: American Public Health
Association; current volume.
6. APHA Policy Statement 5817: Federal
Grants-in-Aid for Maternal and Child Health and
Crippled Childrens Services and Child Welfare.
APHA Policy Statements; 1948present, cumu-
lative. Washington DC: American Public Health
7. APHA Policy Statement 9611: Linkage of
Medical Services for Low-Income Populations
with Mental Health, Substance Abuse and Other
Supportive Services. APHA Policy Statements;
1948present, cumulative. Washington DC:
American Public Health Association; current
volume.
8. Grosswald B, Scharlach AE. Employee ex-
periences with family and medical leave: a case
study. Community, Work & Family. 1999; 2:187-
203.
9. Scharlach AE, Grosswald B. The Family
and Medical Leave Act of 1993. Social Service
Review. 1997;71:335-359.
10. Ruhm CJ, Teague JL, Parental Leave
Policies in Europe and North America,
Greensboro, NC: University of North Carolina,
Department of Economics, 1993.
11. Olson, E. U.N. surveys paid leave for
mothers: U.S. among nations without a policy.
New York Times: A5.
Review. 1997;71:337-338.
13. Phillips JD, Reisman B. Turnover and re-
turn on investment models for family leave.
Parental Leave and Productivity: Current Re-
search. Friedman DE, Galinsky E, Plowden V,
New York, NY: Families and Work Institute,
1992;33-53.
14. National Council for Jewish Women,
Accommodating pregnancy in the workplace.
New York, NY: National Council for Jewish
Women; 1987.
15. Scharlach AE, Stanger JK. Mandated
family and medial leave: Boon or bane? Compen-
sation and Benefits Management. 1995;1(3):1-9.
16. Ibid.
17. Commission on Leave. A workable bal-
ance: Report to Congress on Family and Medical
Leave policies. Washington, DC: Commission on
Leave; 1996;102-130.
18. Ferber MA, OFarrell B with Allen LR
(eds). Work and Family: Policies for a Changing
Work Force. Washington, DC: National Academy
Press; 1991; 161-162.
19. Jankanish MB. Conditions of work digest:
Maternity and work. International Labor Or-
ganization, Geneva. 1994;13:326-327, 241-242.
American Journal of Public Health 477 March 2001, Vol. 91, No. 3
Association News
20. Belsky J. Consequences of child care for
childrens development: A deconstructionist view.
Child Care in the 1990s: Trends and Conse-
quences. Booth A (ed.). Hillsdale, NJ: Erlbaum:
1992;83-93
21. Belsky J, Rovine M. Nonmaternal care in
the first year of life and security of infant-parent
attachment. Child Development. 1988;59:157-
167.
22. Vandell DL, Corasiniti MA. Child care
and family. New Directions for Child Develop-
ment. 1990;49:23-88
23. Scharlach AE, Boyd SL. Caregiving and
employment: Results of an employee survey.
Gerontologist. 1989; 29: 382-387.
24. Emlen AC, Koren PE, Louise D. Child and
elder care: Final report of an employee survey at
the Sisters of Providence. Portland, OR: Portland
State University; 1988.
25. AFL-CIO. Working women say...: Find-
ings from the Ask a Working Women 2000
Survey. Washington, DC: AFL-CIO; 2000; 10.
Review. 1997;71:335-359.
27. Ibid.
28. Institute for Womens Policy Research,
1995. Providing Paid Family Leave: Establishing
the cost of expanding Californias disability in-
surance program. Washington, DC.
20002: Reducing the Incidence of
Blindness, Lower Extremity
Amputation, and Oral Health
Complications in Minority
Populations Due to Diabetes
Observing that epidemiological studies have
shown that the prevalence of diagnosed diabetes
has increased dramatically in the last 30 years;
1-5
and
Noting that diabetes has reached epidemic
proportions, with more than 20 million Ameri-
cans of every age, gender, and race now afflict-
ed;
5,6
and
Recognizing that diabetes is a serious public
health concern, with a prevalence in minority pop-
ulations of African-Americans, Hispanic-Ameri-
cans and Native-Americans that is two to three
times that of non-Hispanic whites;
7-9
and
Noting that type 2 diabetes is also emerging
as a problem among minority children and ado-
lescents;
10-13, 47,48
and
Realizing that the increasing prevalence of di-
abetes among all groups has lead to an increase in
the microvascular and macrovascular complica-
tions, including blindness,
14,15
lower extremity
amputation,
16-20
and destructive periodontitis and
tooth loss;
44-46
and
Understanding that the lower extremity, peri-
odontal and visual complications of diabetes are
generally a function of the duration of diabetes
21-
23
and the level of glycemic control;
23-28
and
Recognizing that approximately 67,000 am-
putations occur among the diabetic population
annually, an incidence of at least 15 times greater
than non-diabetic populations;
5,20
and
Noting that foot ulcers precede amputation in
85 percent of cases;
16
and
Recognizing that the 5-year mortality rate of
diabetic patients increases by 39 to 68 percent fol-
lowing lower extremity amputation;
16
and
Understanding that periodontal complications
may lead directly to tooth loss and chronic infec-
tion. This adversely affects glycemic contol;
44-46
and
Recognizing that diabetic retinopathy is the
new leading cause of blindness among working-
age Americans, accounting for approximately 8%
of all cases of legal blindness and 12% of all new
cases of blindness in the United States each
year;
29
and
Knowing the health benefit and cost-effec-
tiveness of well established strategies of preven-
tion and treatment in diabetic foot and vision
care;
30,31,26,28,32
and
Knowing that much of the vision loss, peri-
odontal disease, and lower extremity amputation in
diabetes mellitus is preventable through early de-
tection and timely treatment;
33,34,20,32,35-38
and
Recognizing that annual foot examinations by
podiatrists and other foot care providers,
39,26,28,40
vision examinations through a dilated pupil by
opthalmologists and optometrists,
39,26
and dental
examinations by oral health providers are the ac-
cepted standards of care for all persons with dia-
betes; therefore,
urges health care professionals to
1. Promote awareness of the need for annual
foot screening and examinations for individ-
uals with diabetes and make appropriate re-
ferrals to podiatrists and other foot care
providers;
2. Promote awareness of the need for annual di-
lated fundus exams for all individuals with
diabetes and to make appropriate referrals to
ophthalmologists and optometrists;
3. Promote awareness of the need for at least
annual oral health examinations for all indi-
viduals with diabetes and to make ap-
propriate referrals to oral health providers;
and
4. Encourages federal, state, and privately fund-
ed health care organizations to target high-
risk minority populations, including African-
American, Hispanic-Americans, and Native-
Americans, for annual foot and vision care.
5. Promote interdisciplinary diabetes manage-
ment and appropriately timed referrals.
References
1. Harris MI. Diabetes in America: Epi-
demiology and scope of the problem. Diabetes
Care. 1998; Dec. 21 suppl 3:C11-14.
2. Trends in the prevalence and incidence of
self-reported diabetes mellitus-United States,
1980-1994. MMWR Morb Mortal Wkly Rep.
October 31, 1997; 46(43): 1014-1018.
3. Vinicor F. Is diabetes a public health disor-
der? Diabetes Care. 1994; 17: 22-27.
4. National Center for Health Statistics.
Healthy People 2000 Review, 1998-99. Hyatts-
ville, MD: US Public Health Service, 1999.
5. American Diabetes Association. Diabetes
1996 vital statistics. Alexandria, VA, 1996.
6. Healthy People 2010: National Health
Promotion and Disease Prevention Objectives.
Washington, DC. US Department of Health and
Human Services; 2000
7. Carter JS, Pugh JA, Monterrosa A. Non-in-
sulin-dependent diabetes mellitus in minorities in
the United States: Ann Intern Med. August 1,
1996; 125(3): 221-232.
8. Gavin JR 3rd. Diabetes in minorities:
Reflections on the medical dilema and the health
care crisis. Trans Am Clin Climatol Assoc. 1995;
107:213-223.
9. Prevalence of diagnosed diabetes among
American Indians/Alaskan Natives-United
States, 1996.; Morb Mortal Wkly Rep. October
30, 1998; 47(42):901-904.
10. Dabelea D, Pettitt DJ, Jones KL, Arslanian
SA. Type 2 diabetes mellitus in minority children
and adolescents. An emerging problem. Endo-
crinol Metab Clin North Am. December 1999;
28(4): 709-729.
11. Rosenbloom AL, Joe JR, Young RS, Win-
ter WE. Emerging epidemic of diabetes in youth.
Diabetes Care February 1999; 22(2): 345-354.
12. Delamater AM, Shaw KH, Applegate EB,
Pratt IA, Eidson M, Lancelotta GX, Gonzalez-
Mendoza L, Richton S. Risk for metabolic con-
trol problems in minority youth with diabetes;
Diabetes Care May 1999; 22(5): 700-705.
13. Rosenbloom AL, House DV, Winter WE.
Non-insulin diabetes mellitus (NIDDM) in mi-
nority youth: Research priorities and needs. Clin
Pediatr (Phila) February 1998; 37(2):143-152.
14. Moss SE, Klein R;, Klein BE. The Wis-
consin Epidemiological Study of Diabetic
Retinopathy (WESDR): XVII. The 14-year inci-
dence and progression of diabetic retinopathy and
associated risk factors in type 1 diabetes. Ophth
October 1998; 105(10): 1799-1800.
15. Moss S,Klein R. The 14-year incidence of
visual loss in a diabetic population. Ophth. June
1998 Jun; 105(6): 998-1003.
16. Weaver TD. Identification and Man
-
agement of the High Risk Diabetic Foot. Higgins
JR. Prevention and Management of Diabetes
Complications for Primary Care, Federal
Practitioner, (suppl 3) April 1998; 15(45).
17. Diabetes-related amputations of lower ex-
tremities in the Medicare population-Minnesota,
1993-1995, MMWR Morb Mortal Wkly Rep.
August 14, 1998; 47(31).
18. Reiber GE, Boyko EJ, Smith DC. Lower
extremity foot ulcers and amputations in diabetes;
Diabetes in America, 2nd ed. Washington, DC:
US Government Printing Office,1995.
19. Armstrong DG, Lavery LA, Harkless LB,
Van Houtum WH. Amputation and re-amputation
of the diabetic foot. J Am Podiatr Med Assoc June
1997; 87(6): 255-259.
20. Van Gills CC, Wheeler LA, Mellstrom M,
Brinton EA, Mason S, Wheeler CG. Amputation
prevention by vascular surgery and podiatry col-
laboration in high-risk diabetic and non-diabetic
patients: The operation desert foot experience.
Diabetes Care. May 1999; 22(5): 678-683.
21. Taylor R. Diabetic eye disease: A natural
history. Eye. 1997; 11(P4): 547-553.
22. Krowleski A. Epidemiology of late diabet-
ic complications. A basis for the development and
March 2001, Vol. 91, No. 3 478 American Journal of Public Health
Association News
evaluation of preventive programs. Endocrinol
Metab North Am. June 1996; 25(2): 217-242.
23. Klein R. Diabetic retinopathy. Annu Rev
Public Health. 1996; 17:137-158.
24. Henricsson M. Progression of retinopathy
is related to glycemic control even in patients with
mild diabetes mellitus. Acta Ophthalmol Scand.
December 1996; 74(6): 528-532.
25. Klein R. Relation of glycemic control to
diabetic complications and health outcomes.
Diabetes Care. 1998: (21 suppl 3): C39-43.
26. Centers for Disease Control Division of
Diabetes Translation: The Prevention and
Treatment of Complications of Diabetes Mellitus.
Atlanta, GA: January 1991;45: 30,47.
27. The DCCT Research Group: Diabetes
Control and Complications Trial, The effect of in-
tensive treatment of diabetes on the development
and progression of long-term complications in in-
sulin-dependent diabetes mellitus. New Engl J
Med. 1993; 329:977-986.
28. Veterans Health Affairs, Clinical Guide-
lines for Management of Patients with Diabetes
Mellitus, March 31, 1997.
29. Blindness caused by diabetesMassa-
chusetts, 1987-1994; MMWR Morbid Mortal
Wkly Rep. Nov 1, 1996; 45(43): 937-941.
30. Daschbach et al. Cost effectiveness of
strategies for detecting diabetic retinopathy. Med
Care. 1991; 29: 20-39.
31. Javitt et al. Preventive eye care is a cost
saving to the federal government. Diabetes Care.
1994; 17: 909-917.
32. Pecoraro RE, Reiber GE, Burgess EM.
Casual pathways to amputation. Pathways top
prevention; Diabetes Care. 1990; 13:513-521
33. Early Treatment Diabetic Retinopathy
Study Group. ETDRS Report No. 9: Early photo-
coagulation for diabetic retinopathy. Ophth. 1991;
98:766-785.
34. Early Treatment Diabetic Retinopathy
Study Group. ETDRS Report No. 4: Photocoagu-
lation for diabetic macular edema. Int
Ophthalmol Clin. 1987; 27: 265-272.
35. Armstrong DG, Lavery LA. Diabetic foot
ulcers: Prevention diagnosis and classification.
Am Fam Physician. March 15, 1998; 57(6): 1325-
1332.
36. Armstrong DG, Lavery LA, Vele SA,
Quebedeaux TL, Fleishli JG. Choosing a practi-
cal screening instrument to identify patients at
risk for diabetic foot ulceration. Arch Intern Med.
February 9, 1998; 158(3): 289-292.
37. Armstrong DG, Lavery LA, Vele SA,
Quebedeaux TL, Fleishli JG; Practical criteria for
screening patients at high risk for diabetic foot ul-
ceration. Arch Intern Med. January 26;, 1998;
158(2): 157-162.
38. Adler AL, Boyko EJ, Ahroni JH, Stensel
VL, Forsberg RC, Smith DG. Risk factors for di-
abetic peripheral sensory neuropathy: Results of
the Seattle prospective diabetic foot study.
Diabetes Care. July 1997; 20(7): 1162.
Promotion and Disease Prevention Objective 5-
12. Washington, DC: US Department of Health
and Human Services, HP 2010 Conference
Edition, January 2000.
Promotion and Disease Prevention Objective 5-
14, Washington, DC: US Department of Health
and Human Services, HP 2010 Conference
Edition, January 2000.
41. Veterans Health Affairs Directive 10-96-
007; Preservation of Amputation Care and
Treatment Program (PACT), Washington, DC:
Department of Veterans Affairs, Veterans Health
Administration, Washington, DC.
42. Lavery LA, Van Houtum WH, Armstrong
DG. Institutionalization following diabetes-relat-
ed lower extremity amputations. Am J Med.
November 1997; 103(5): 383-388.
43. Bernard AM, Anderson L, Cook CB,
Phillips LS. What do internal medicine residents
need to enhance their diabetes care? Diabetes
Care. May 1999; 22(5): 661-666.
44. Loe H. Periodontal disease: The sixth
complication of diabetes mellitus. Diabetes Care
16(S1):329-334. 1993.
45. Papapanou P. Periodontal diseases: Epide-
miology. Annals of Periodontology 1:1-36. 1996.
46. Taylor G. Periodontal treatment and its af-
fects of glycemic control. Oral Surgery, Oral
Medicine, Oral Pathology, Oral Radiology, and
Endodontics 87:311-316. 1999.
47. Fagot-Campagna A, Pettitt DJ, Engelgau
MM, et al. Type 2 diabetes among North Am-
erican cjhildren and adolescents: an epidemiolog-
ical review and a public health perspective. J
Pediatr 2000; 136:664-672.
48. American Diabetes Association. Type 2
diabetes in children: consensus conference. Dia-
betes Care 2000; 23:381-398.
20003: Preserving Consumer
Choice in an Era of Religious/
Secular Health Industry Mergers
(Position Paper)
I. Statement of Problem
In community after community across the
United States, patients are losing access to many
reproductive health services when their local sec-
ular hospitals merge with nearby religiously-affil-
iated facilities that object to those services on eth-
ical grounds. Depending on the denomination in-
volved and the form of the hospital partnership,
services banned by the merged entity may include
contraception, abortions, sterilizations, in vitro
fertilization, emergency contraception for rape
victims, and the discussion of condom use as part
of HIV prevention counseling.
Patients can also see their end-of-life choices
restricted at formerly secular hospitals and nurs-
ing homes. Decisions by patients or their surro-
gates to refuse or remove feeding tubes may be
denied, if deemed contrary to religious teaching.
Not only hospitals, but also affiliated outpatient
clinics, medical office buildings, nursing homes,
home health care agencies and managed care
plans can be affected by the adoption of religious
health care rules.
Patients who once had a choice of religious or
secular health care providers have seen this
choice disappear, unless compromises or creative
solutions preserved the historic missions and ser-
vices of both hospitals. The problem has been
particularly acute in two-hospital towns and in
medically-underserved rural and urban areas,
where patients may be left with only the health
care choices permitted by the religious institution
controlling their local health facilities.
The growing presence and market power of
religiously-affiliated health providers were shown
in an industry survey reporting that 11 of the 20
largest health care systems in the nation in 1999
were operated by religious entities. The three
largest religious systems were Catholic Health
Initiatives, with 69 hospitals (up from 65 in
1998), 10,023 beds and $4.7 billion in net patient
revenues; the newly-formed Ascension Health, 60
hospitals, 12,705 beds and $5.4 billion in rev-
enues; and Catholic Healthcare West, 48 hospitals
(up from 36 in 1998), 8,172 beds and $3.9 billion
in net patient revenues.
1
In May of 2000, another Catholic mega-sys-
tem was formed with the merger of the Michigan-
based Mercy Health Services and Indiana-based
Holy Cross Health System into Trinity Health,
with 43 hospitals and $4.2 billion in annual rev-
enue.
2
One of every 10 acute care hospitals in the
nation is now Catholic, and those facilities ac-
count for 16 percent of all U.S. hospital admis-
sions, according to the Catholic Health Associa-
tion of the United States.
3
The largest non-Catholic religious system, the
Adventist Health System, had 29 hospitals and $2
billion in net patient revenues in 1999.
4
These sectarian health providers (and the non-
sectarian institutions with which they become
business partners or which they acquire) are per-
mitted by federal and state legislation to opt out of
services they find ethically objectionable. This re-
lates back to 1973, when Congress passed the
Church amendment
5
that allows individual health
care providers and institutions to refuse to provide
abortion and sterilization services based on moral
or religious convictions. By 1978, most states had
adopted their own conscience clause laws.
6
The Alan Guttmacher Institute has reported
7
that these laws are now being broadened in two
ways: (1) they go beyond abortion and steriliza-
tion to encompass any health services about
which an ethical, religious or moral objection is
raised (including counseling and providing in-
formation about those services) and (2) they are
being extended beyond providers to include cor-
porate payers, such as health plans.
In the Balanced Budget Act of 1997, Con-
gress enacted the first so-called conscience lan-
guage specific to the Medicaid program, allowing
Medicaid managed care plans to refuse to pro-
vide, reimburse for, or provide coverage of a
counseling or referral service if the organization
objects to the provision of such service on moral
or religious grounds. One such Medicaid man-
aged care program, New Yorks Catholic-spon-
sored Fidelis Care, does not cover contraceptive
services or counseling, sterilizations or abortions.
Fidelis enrollees must find providers who will ac-
cept their Medicaid cards for these services.
8
Focused as they are on protecting sectarian
providers, these laws generally do not address the
impact of the permitted exemptions on third par-
ties, specifically the patients who are unable to
Association News
obtain needed services in their own communities
and the medical personnel who are unable to pro-
vide certain services, even when medically indi-
cated, because of institutional policies.
II. Purpose and Objectives
It has been the longstanding position of the
American Public Health Association that access
to the full range of reproductive health services,
including abortion, is a fundamental right. Fur-
ther, in a resolution adopted in November 1997,
9
APHA called for action preserve reproductive
health care in the context of hospital mergers and
affiliations with religious health systems.
This paper is designed to examine this serious
problem, its impact on community access to a full
range of health care services, the consequences
for patients and public health, and the potential
for disruption of the physician/patient relation-
ship when religious health care directives conflict
with a patients need for services. Most important
are examples of creative solutions that have
successfully preserved access to reproductive ser-
vices threatened by religious/secular hospital
mergers and steps that governments can take to
help protect patients rights and public health.
Finally, actions are proposed that the APHA and
its members can take to promote wider public ex-
amination of this problem and means of addres-
sing it.
III. Religious Health Care Directives
A number of religious denominations own
hospitals and health systems in the United States.
Some, such as those founded by Presbyterians,
Methodists, Episcopalians, and Jews, operate in
an essentially nondenominational manner that
does not limit patient choices for religious rea-
sons. Adventist and some Baptist facilities, how-
ever, ban elective abortions.
The impact on patient choices and physician
autonomy has been the most dramatic when merg-
ers or affiliations involve one of the nations 600
Catholic hospitals. These institutions are guided
by The Ethical and Religious Directives for Cath-
olic Health Care Services, a document issued by
the National Conference of Catholic Bishops.
10
The Bishops 70 specific directives include
prohibitions on some reproductive health services:
contraception (Directive 52), female and male
sterilizations when their sole immediate effect is
to prevent conception (Directive 53), abortion
(Directive 45), and infertility services such as in
vitro fertilization (Directives 40 and 41).
While Directive 36 appears to offer an excep-
tion to the ban on contraception for rape survivors
(a female who has been raped should be able to
defend herself against a potential conception)
few Catholic hospitals actually provide emer-
gency contraception to women who have been
raped. Some Catholic theologians view emer-
gency contraception as a potential abortifacient,
11
although it is not categorized as such by the
American College of Obstetricians and Gyne-
cologists or the American Medical Womens
Association.
12
Emergency contraception prevents
pregnancy by delaying ovulation, inhibiting fertil-
ization and preventing implantation. It is not ef-
fective if pregnancy is already established.
13
Directives 24, 25, and 28 state that a patients
advance directive for medical treatment or the de-
cision of the patients appointed surrogate will be
honored so long as it does not contradict
Catholic principles. If the treatment request is
determined to violate Catholic teaching, an ex-
planation should be provided as to why the direc-
tive cannot be honored.
14
The Catholic Church has also been one of the
leading opponents of the use of embryonic stem
cell tissue for experimental treatment of such dis-
eases as Parkinsons. Funding stem-cell research
would force new ground for active government
support of research that takes human life, said
Richard Doerflinger, a spokesman for the Na-
tional Conference of Bishops antiabortion secre-
tariat.
15
Physicians, nurses, and staff who work at the
merged hospitals must adhere to these moral
codes (Directive 5). Patients seeking these ser-
vices may be turned away without appropriate re-
ferrals to alternative providers.
16
When the nations Catholic Bishops reissued
the Directives in 1994, they included principles
of cooperation to justify a Catholic institutions
partnership with a non-Catholic institution under
certain circumstances, but specified that any
partnership that will affect the mission or reli-
gious and ethical identity of Catholic health care
institutional services must respect church teach-
ing and discipline.
17
IV. Mergers and Their Effects
In the current volatile health care environment
marked by the nearly-completed transition from
fee-for-service medicine to managed care, in-
creasing outpatient care, closing of excess hospi-
tal beds, escalating costs caused by expanding use
of sophisticated technology, and cutbacks in
Medicare and Medicaid spending institutions
have been confronted with increasing costs and
inadequate reimbursements. Seeking a solution,
they have turned to business partnerships with
other health facilities. These transactions may
take the form of affiliations, joint operating
agreements, joint ventures, full-asset mergers or
acquisitions, and may involve individual hospi-
tals, hospital systems or networks, as well as man-
aged care plans of various types. Certain repro-
ductive health services are reduced or even com-
pletely eliminated when religious and secular
medical partners come together.
From 1990 through 1998, 127 Catholic/ non-
Catholic hospital mergers and affiliations oc-
curred nationwide, including 43 in 1998 alone.
18
In about half the cases, all or most of the disput-
ed reproductive health care services were discon-
tinued at the non-Catholic facility. In the remain-
ing cases, either no information was available or
a creative solution was found to preserve some or
all of the reproductive services, as will be dis-
cussed below.
Mergers of religious and secular hospitals are
contributing to an already steep and continuing
decline in the percentage of hospitals providing
abortions (now 34 percent, compared to 81 per-
cent in 1973).
19
While outpatient clinics can and
do provide most abortions in metropolitan areas,
patients with complications (such as diabetes)
may require a hospital setting, and hospitals may
be the only available abortion providers for rural
women.
Also being lost through these mergers are
contraceptive services (including emergency con-
traception for rape victims),
20
prenatal testing and
genetic screening/counseling (because it might
lead to a patients decision to seek an abortion),
and the ability of female patients to participate in
medical trials, which typically require use of birth
control to avoid the risk of damage to a fetus.
21
Sterilization services often are discontinued, in-
cluding tubal ligations at the time of delivery, re-
quiring new mothers to undergo a separate surgi-
cal procedure and anesthesia, with attendant
risks, at a later time. HIV prevention counseling
for at-risk patients may be restricted by bans on
recommending the use of condoms.
The effect of religious/secular mergers on pa-
tients access to services is particularly acute in
emergency situations when services should be
provided immediately. Emergency contraception
for rape survivors is most effective in preventing
pregnancy when it is taken in the first 12 hours
following intercourse; delaying the first dose by
12 hours increases the odds of pregnancy by al-
most 50 percent.
22
Many women who have been
raped do not arrive at a hospital emergency room
until several hours after the assault, and then may
not be seen by a physician for as long as seven
hours.
23
Despite the urgency of immediate treatment
for rape survivors, the vast majority (82 percent)
of the 589 Catholic hospitals surveyed nation-
wide in 1999 reported they do not provide emer-
gency contraception to women who have been
raped. Of those, 31 percent reported they would
not provide a referral to another facility which did
offer the treatment.
24
Similarly, a study of emer-
gency room protocols at 125 general hospitals in
Pennsylvania completed in May of 2000 found
that only 6 percent of Catholic hospitals (as com-
pared to 33 percent of non-Catholic hospitals) are
consistently offering and providing emergency
contraception to rape survivors.
25
Similar problems for patients can be created
when hospital policies forbid the termination of
pregnancies, even in emergencies. In Manchester,
NH, in 1998, a 35-year-old Medicaid patient who
needed an emergency termination when her water
broke at 14 weeks of pregnancy was turned away
from Elliot Hospital, which had agreed to ban
abortions as a condition of merger with nearby
Catholic Medical Center. Her physician was
forced to put her in a cab and send her to an out-
of-town hospital.
26
In 1999, merger and acquisition activity be-
tween religious and secular hospitals slowed
somewhat, a development consistent with overall
trends in mergers in the country.
27
Nonetheless,
mergers remain a serious problem. Catholic
Healthcare West is the largest operator of hospi-
tals in California, running 48 hospitals of which
18 formerly were secular. Such religious health
systems have come to dominate certain geo-
graphic areas of the country, or have become the
only choice for patients in some communities.
For example, in Gilroy, CA, in 1999, a 34-
year-old patient was unable to obtain a desired
Association News
voluntary sterilization when she delivered her
ninth child. Gilroys only hospital, South Valley,
had been purchased by the rapidly-growing
Catholic Healthcare West system, which renamed
it St. Louise Medical Center and eliminated steril-
izations and other services deemed contrary to
Catholic moral principles.
28
That transaction also illustrated how some
health industry consolidations are being carried
out in a way that evades community or regulatory
review. When community opposition to the
planned purchase arose, the seller, Columbia/
HCA, simply closed the hospital and surrendered
its license. Catholic Healthcare West then pur-
chased the hospital buildinga real estate trans-
action that required no review of the impact on
patients.
29
V. Strategies to Preserve Reproductive
Health Services
In sharp contrast to the loss of services in
some communities are examples of places in
which religious and secular hospitals have found
ways to form mutually beneficial business part-
nerships, preserving the viability of both facili-
ties, while leaving the secular hospital and its staff
free to provide some or all disputed reproductive
health services. Creative solutions may be
reached by various means.
Form of affiliation
Some hospitals have chosen a looser form of
partnership, such as a joint operating agreement
or establishment of a network, rather than a full-
asset merger, in order to avoid the complete merg-
ing of funds and administration that would re-
quire negotiating joint ethical guidelines.
In Dallas, TX, four major religiously-affiliat-
ed hospital systems came together in a joint oper-
ating agreement that respects their denomina-
tions sharply differing views on reproductive
health services. An ethics panel established by
Presbyterian Healthcare Resources, Harris
Methodist Health System, St. Paul Medical
Center (which is Catholic) and Baylor Health
Care System (affiliated with the Baptist General
Convention of Texas) concluded that each hospi-
tal should maintain control over its own religious
destiny and set medical practices consistent with
its beliefs.
30
In another approach, secular John T. Mather
Hospital in Port Jefferson, NY, formed a joint
venture with Catholic St. Charles Hospital that
excluded (and thus protected) an in vitro fertiliza-
tion clinic at Mather.
31
Common values approach
Catholic Healthcare West has permitted the
continuation of birth control and sterilization ser-
vices at some of the non-Catholic hospitals it ac-
quires by utilizing a common values approach
that sets some ground rules (such as no abortion
services or assisted suicide), but leaves other ethi-
cal decisions up to a community task force.
32
Use of alternative providers
Under pressure from community groups and
Attorneys General, some secular hospitals have set
aside funds prior to a merger to pay for increased
family planning services at community clinics, as
well as referrals and transportation for women to
alternative abortion providers (Elizabeth, NJ, and
Great Falls, MN, are two examples).
33
Separately-incorporated womens
health centers
In Battle Creek, Michigan, a secular hospital
established a separately-incorporated condo-
minium hospital on its top floor to provide tubal
ligations to women at the time of delivery.
34
In
Murfreesboro, Tenn., sterilizations and vasec-
tomies are performed in a separately-incorporat-
ed womens pavilion within Middle Tennessee
Medical Center, which is jointly owned by the
Daughters of Charity and Baptist Hospital.
Surveying such approaches, the Wall Street
Journal reported that some Catholic health sys-
tems are employing special ethicists such as the
Rev. Gerard Magill, who told the newspaper that,
This may shock you, but the Catholic church is
very keen on finding practical solutions to com-
plicated problems. We certainly will not do im-
moral acts, but we certainly can come to arrange-
ments.
35
Buyouts and acquisitions
In Batavia, NY, a year-long dispute over the
reproductive services to be lost through a planned
merger of secular Genesee Memorial Hospital
and Catholic St. Jerome Hospital ended in 1999
when St. Jerome accepted a purchase offer from
Genesee Memorial. The purchase agreement
leaves Catholic religious directives in place at St.
Jerome for five years, while allowing Genesee
Memorial to continue provision of all reproduc-
tive services.
36
Community action
The resolution of ethical and religious con-
flicts between merging hospitals sometimes can
be achieved voluntarily at the local level when
community members are aware of the potential
loss of services and have the opportunity to
make their views known. In Poughkeepsie, NY,
citizen protests of a planned full-asset merger
which would have caused a loss of reproductive
services led to a joint operating agreement be-
tween secular Vassar Brothers Hospital and
Catholic-sponsored St. Francis Hospital that
permits Vassar Brothers to continue all repro-
ductive services.
37
Invoking existing regulatory measures
In some instances, concerned residents have
utilized existing regulatory processes to slow
down or block mergers that would have banned
services or to establish bottom-line requirements
for preserving emergency services and ensuring
that patients are informed of a hospitals new reli-
gious policies
38
or a religious Medicaid managed
care plans restrictions on services.
Where statutes require public hearings before
changes can be made in facilities or services, the
community has an opportunity to comment on
and suggest alternatives to planned restrictions of
reproductive health services. For example, the
provision of emergency contraception for rape
survivors was preserved at two non-Catholic
Long Island, NY, hospitals coming under the gov-
ernance of Catholic Health Services of Long
Island through citizen participation in the state
Certificate of Need regulatory process.
39
Legislation
In both New York and California, legislation
has been introduced to protect patients rights and
access to services. New Yorks measures
40
are de-
signed to better inform communities when mer-
gers are proposed, in that they (1) make the state
merger approval process more community-friend-
ly by encouraging public comment, (2) require the
State Health Commissioner to ensure that a merg-
er will not leave a community without access to
vital health services, and (3) eliminate loopholes
in state law and regulation that are permitting hos-
pitals to evade the state merger approval process
entirely.
In California, a law has been enacted to en-
sure that consumers are fully informed of restric-
tions in services provided by managed care plans
and private providers. As a result of this measure,
health plans will be encouraged to work with
womens health experts to ensure that their pro-
motional materials and provider directories give
women the information they need to make the
best health care choices.
41
Use of such creative solutions may be es-
sential to ensuring the financial futures of both re-
ligiously-sponsored and secular hospitals.
Without them, conflicts over ethical issues can
prevent financially-advantageous partnerships or
break up existing mergers. According to a
Modern Healthcare article, clashes over hospital
culture and ethical standards (including adoption
of the Catholic Ethical and Religious Directives
by nonsectarian hospitals) were among the lead-
ing causes of merger breakups.
42
The need to develop and share widely viable
creative solutions has been made even more ur-
gent by the reversal of some existing compromis-
es that had allowed some reproductive health care
services, as happened in Little Rock, AK.
43
Further, any loss of reproductive health ser-
vices caused by religious-secular hospital merg-
ers is in opposition to the finding that most
American women want and expect a wide range
of health services to be available to them, regard-
less of the religious affiliation of the hospitals,
pharmacies, or insurance companies that serve
them. The great majority of women want their
hospital to offer medically indicated abortions
(87%), birth control pills (91%), sterilization pro-
cedures (85%) and emergency contraception for
rape victims (78%).
44
VI. Recommendations for APHA
Action
The American Public Health Association can
and must assume a leadership role in addressing
this emerging health access issue. The APHA
should:
1. Inform its own members and other health
professionals on this issue;
2. Promote monitoring and research on the im-
pact of religious/secular mergers;
3. Encourage creative solutions to preserve
access to vital health services in communi-
Association News
ties facing mergers of religious and secular
institutions; and
4. Recommend that state and local agencies in
regulating health care facilities exercise their
authority to secure the availability of com-
prehensive reproductive health services and
end-of-life choices.
5. Urge that health care facilities receiving pub-
lic funding assure the availability of compre-
hensive reproductive health services and
end-of-life choices.
6. Develop a set of principles to guide commu-
nity action when religious and secular hospi-
tals or health systems propose to merge, in-
cluding:
advance notice to the affected community;
opportunity for public comment;
assurance that services lost through the
merger will be available elsewhere in the
community; and
protection of the right of physicians and
hospital staff to discuss reproductive health
services and end-of-life choices no longer
provided in the hospital and to assist patients
in obtaining those services elsewhere.
While voluntary, negotiated creative solutions
are desired, for those instances in when no such
approach is achieved, federal and state legislation
is needed to ensure communities are not left with-
out access to vital reproductive health services
and end-of-life choices.
References
1. Bellandi, D, Kirchheimer, B. and Saphir, A,
Profitability a matter of ownership status,
Modern Healthcare, June 12, 2000, pp. 24-44.
2. Bellandi, D. Making Room for the Laity,
Modern Healthcare, May 29, 2000
3. Fact Sheet, Catholic Health Association of
the United States, June 10, 2000, posted on the
associations website (www.chausa.org)
4. Bellandi, D. and Kirchheimer, B., op cit,
p. 32.
5. Church Amendment to the Health pro-
grams Extension Act of 1973, Pub. L. No. 93-45
(enacted June 18, 1973)
6. Gold, Rachel Benson, Conscience Makes a
Comeback, The Guttmacher Report on Public
Policy, February 1998, Vol. 1. No. 1
7. Ibid.
8. Eisenberg, C. No Birth Control Provided,
Newsday, Sept. 11, 1997
9. APHA Resolution 97-LB-1, Preservation
of Reproductive Health Care in Hospital Mergers
and Affiliations with Religious Health Systems,
November 1997
10. National Conference of Catholic Bishops,
Ethical and Religious Directives for Catholic
Health Care Services, Washington: United State
Catholic Conference, Inc.
11. ORourke, Rev. K. Applying the Dire-
ctives, Health Progress (journal of the Catholic
Health Association of the United States), July-
August 1998
12. Westley, E. Emergency Contraception: A
Global Overview, in Journal of the American
Medical Womens Association, Supplement 2, pp.
215-18, 1998.
13. Castle, M. and Coeytaux, F. A Clinicians
Guide to Providing Emergency Contraceptive
Pills, Pacific Institute for Womens Health, Los
Angeles, CA, 2000.
14. See, for example, the New York State
Catholic Conferences opposition to that states
proposed Family Health Care Decisions Act, at
<www.nyscatholicconference.org>, citing a pre-
sumption in favor of the continued provision of
food and water.
15. McGinley, L., and Fawcett, A., Patients
and Abortion Foes Clash on Stem-Cell Research,
The Wall Street Journal, June 21, 1999, p. A28.
16. See, for example, complaint in Amelia E.
v. Public Health Council, No. 7062 (N.Y. Su-
preme Court, filed Decemer 2, 1994)
17. National Conference of Catholic Bishops,
Appendix. See endnote 12.
18. Bucar, L. Merger Trends. See endnote 1
19. Henshaw, S. Abortion Incidence and
Services in the United States, 1995-96, Family
Planning Perspectives, Alan Guttmacher Institute,
November/December 1998.
20. Bucar, L. Merger Trends. See endnote 1
21. Ikemoto, L. When a Hospital Becomes
Catholic, 47 Mercer Law Review, 1087-1093,
1996
22. Piaggio, G. Timing of Emergency Con-
traception with Levonorgestrel or the Yupze Reg-
imen, The Lancet, Volume 353, Number 9154, 27
February, 1999.
23. Simons, R. MD, presentation at May 18,
2000, seminar in New York City on provision of
emergency contraception to sexual assault sur-
vivors at hospital emergency rooms.
24. Bucar, L. op cit, 1999.
25. Simons, R., MD Emergency Contra-
ception for Sexual Assault Survivors: A Survey of
Hospital Emergency Rooms in Pennsylvania, a
masters thesis supervised by the faculty of the
John Hopkins School of Hygiene and Public
Health, May 2000.
26. Jimenez, R. Abortion dispute hits N.H.
hospital: Woman transferred during emergency,
The Boston Globe, May 23, 1998, p. B1
27. Mergers and Acquisitions: The Pace
Slows, but Not the Impact, in Catholic Health
Restrictions Updated, Catholics for a Free
Choice, pp. 4-6, 1999.
28. Labi. N. Holy Owned: Is it Fair for a
Catholic Hospital to Impose its Morals on
Patients? Time, November 15, 1999, pp. 85-6
29. Susan Berke Fogel, California Womens
Law Center, oral communication, October 28-29,
1999.
30. Ornstein, C. Hospital merers tread fine
line between religion, economics, The Dallas
Morning News, July 10, 1998.
31. Vincent, S. Port Jeff Hospitals in Alli-
ance, Newsday, May 9, 1996, p. A25
32. Common Values for Community Part-
nership, Catholic Healthcare West, on file with
the MergerWatch Project of Family Planning
Advocates of NYS
33. Uttley, L. Religious Hospital Mergers &
HMOs: The Hidden Crisis for Reproductive
Health Care, Family Planning Advocates of
NYS, 1997, pp. 22-23, and Final Judgement of
Superior Court of New Jersey Chancery Division:
Union County General Equity par, Docket No.
UNN-C-97-99 In the Matter of the Application
of Elizabeth General Medical Center and St.
Elizabeths Hospital for Approval of Consoli-
dation, on file with the MergerWatch Project of
Family Planning Advocates of NYS
34. State Journal, Lansing, Michigan, Decem-
ber 20, 1996.
35. Lagnado, L. Religious Practice: Their
Role Growing, Catholic Hospitals Juggle Doc-
trine and Medicine, The Wall Street Journal,
February 4, 1999, p. 1
36. Coniglio, R. Hospital merger called off:
Genesee Memorial Group to take over ownership
of St. Jerome, The Daily News, Batavia, NY
February 27, 1999, p. A1
37. Werthamer, C. Hospital Mergers are not
Created Equal, The Daily Freeman, March 8,
1998, p. 1
38. See MergerWatch website, <www. merg-
erwatch.org>, and summary of new consumers
protections achieved in Long Island hospital
merger cases, October 1999 (on file with Family
Planning Advocates of NYS)
39. Save Our Services Long Island summary
of actions on Mid-Island Hospital and St. Johns
Episcopal Hospital transactions, on file with the
MergerWatch Project, Family Planning
Advocates of NYS
40. New York Assembly Bills A. 9886 and A.
9887
41. CA Statutes of 2000. Ch 347 (A.B.525)
42. Moore, J. D., System divorces on rise,
Modern Healthcare, May 29, 2000.
43.. Francis, T. St. Vincent agrees to end ster-
ilization, Arkansas Democrat-Gazette, Septem-
ber 29, 1999
44. Religion, Reproductive Health and Access
to Services: A National Survey of Women, con-
ducted for Catholics for a Free Choice by Belden
Russonello and Stewart, Washington, D.C., April
2000.
20004: Supporting Access to
Midwifery Services in the United
States (Position Paper)
I. Goal
(APHA) takes a position in support of the expan-
sion of midwifery as a key strategy to improving
access to care for childbearing families for the
purpose of increasing their health care options
and thereby to the subsequent improvement of
birth outcomes.
II. Statement of the Problem
The United States spends more per capita on
health care than any other country, and yet sub-
stantial gaps in maternal and child health care ac-
cess remain.
1,2
Although a large majority of the
nearly 4 million children born annually in the
U.S. result from an uncomplicated vaginal deliv-
ery, childbirth is increasingly viewed as a medical
event, with over 90% of all births attended by a
physician trained to focus on the pathologic po-
tential of pregnancy and birth. Childbirth is one
of most common reasons to seek health care and
Association News
the single most common cause for hospitaliza-
tion. Even with advances in prenatal care tech-
nology, low birth weight and preterm birth rates
fall short of the Healthy People 2010 goals.
3
The
APHA has publicly supported the use of innova-
tive strategies to improve birth outcomes and de-
crease maternal and newborn morbidity and mor-
tality.
4-13
These documents do not, however, ad-
dress access to midwifery services.
In summary, the World Health Organization
(WHO) defines a midwife as a competent care
giver in midwifery graduated from an education
program recognized by the government that li-
censes the midwife to practice. As the standard of
care for uncomplicated pregnancies throughout
much of the world,
14
midwives are the main
providers of care in 75% of all European births.
15
Conversely, in the U.S. midwives participate in
fewer than 10% of all births.
16
In terms of quali-
ty, satisfaction, and costs, the midwifery model
for pregnancy and maternity care has been found
to be beneficial to women and families, resulting
in good outcomes and cost savings.
17
A collabo-
rative approach between midwife and physician
utilizes the expertise of both professions, which is
key to ensuring optimal outcomes for women and
infants. With its focus on pregnancy as a normal
life event and health promotion for women of all
ages, the midwifery model of care is an appropri-
ate alternative or complement to the medical ap-
proach to childbirth.
18
In exploring the use of interrelated health pro-
viders within managed care and other staffing con-
figurations, the Health Services Resource Admin-
istration (HRSA), Bureau of Health Professions
project, Use and Impact of Alternative or Com-
plementary Providers, is developing methods de-
signed to forecast the need for alternative and/or
complementary providers and document their im-
pact on physician supply and demand.
19
For exam-
ple, the project examines the integrated use of ob-
stetrician/gynecologists with certified nurse-mid-
wives, anesthesiologists with nurse-anesthetists,
and the use of non-traditional providers in managed
care. Through the project, the National Center for
Health Workforce Information & Analysis will de-
velop recommendations for health professions
training that will reflect current and projected real
world use of alternative and complementary
providers to increase access to health care.
20
III. The Status of Midwifery in the
United States
Women comprise 52% of our nations popu-
lation and 46% of the workforce. In general,
women live longer than men, suffer more from
chronic illnesses, are more frequent users of
health services, and account for nearly two of
every three health care dollars spent. Addi-
tionally, women make three out of four of all
household health care decisions.
19
It is well doc-
umented that midwives contribute substantially
to the health care services of diverse populations
of women and their babies. In particular, studies
have demonstrated that 7 of 10 visits to certified
nurse-midwives (CNMs) were by women vulner-
able to poor outcomes.
21
CNMs attended 7% of
the approximately 4 million births in 1997 and
other midwives attended 0.4%.
22
However,
during 1995 and 1996 respectively, in the U.S.
only 6.7% of CNMs and 6% of homebirth mid-
wives in the U.S. were non-white, indicating that
the racial and ethnic diversity of midwives does
not reflect that of the nations population.
23
Na-
tionally, the midwifery profession has demon-
strated an increased commitment for diversity
within its ranks, especially given midwives his-
toric commitment to the care of vulnerable
women, children, and families.
24,25
Midwives in the United States with national
certification generally fall into three categories:
certified nurse-midwives (CNMs), who number
over 7,000
3
and who meet the educational criteria
of the American College of Nurse Midwives
(ACNM), and are certified by the American Col-
lege of Nurse-Midwives Certification Council
(ACC); certified midwives (CMs), who number
fewer than 20,
2
a relatively new category of di-
rect-entry midwives who are non-nurses educat-
ed within ACNM accredited educational pro-
grams and certified by the ACC; and certified
professional midwives (CPMs), another category
of direct-entry midwife who number approxi-
mately 1,000 and are certified by the North Am-
erican Registry of Midwives (NARM).
26
(Note:
direct-entry midwifery, which included CPMs
and CMs, is a term used to refer to midwives
whose education did not require a nursing back-
ground). It should be noted that there is small
number of other midwives who have not attained
these credentials. Most though not all recognized
midwifery educational pathways are accredited
by agencies recognized by the U.S. Department of
Education, which assures the quality and content
of midwifery education programs.
CNMs are educated in the fields of nursing
and midwifery. CMs are educated in midwifery
alongside CNMs, and thus have comparable com-
petencies and skills although they are not nurses.
This training differs from the professional prepa-
ration of CPMs certified by NARM focuses on
competent entry-level midwives who will prac-
tice in predominantly out-of-hospital settings.
23
CNMs, CMs, and CPMs must pass a national cer-
tification examination to use their respective ti-
tles. These categories of midwives are not inter-
changeable, and important differences exist in ed-
ucation and certification mechanisms, scope of
practice authority, and practice settings.
2,27,28
State laws and national certification regulate
the practice of midwifery and legislation differs
from state to state relative to credentialing and
scope of practice. Nurse-midwifery practice has
been legal in all states for over 20 years.
23
As of
January 2000, 17 states regulated non-nurse mid-
wifery practice and in 14 states, non-nurse mid-
wifery is legal but unregulated. In nine states
non-nurse midwifery practice is legally prohibit-
ed and in six states the practice is effectively pro-
hibited, as there is no legal way to gain legal au-
thority to practice. Regulatory provisions are un-
clear in five states. Of those states regulating
non-nurse midwifery practice, 14 states have
widely varying regulatory mechanisms regarding
the scope, qualifications, and requirements for
supervision, consultation, and referral.
2,26
Whichever professional entry is chosen, the
common connection for all midwives is their
philosophical adherence to the midwifery model
of care.
23
With the exception of birth registration which
captures only a portion of midwifery practice and
excludes ambulatory care entirely,
29
there is no
current national or state process for collecting
data on services provided by midwives.
23
Thus,
documentation of the practice of midwifery in the
U.S. is incomplete and varies widely between
CNMs and direct-entry midwives. Since 1928,
more than 20 peer-reviewed journals have report-
ed outcome studies of care by CNMs.
30
To date,
nine peer-reviewed studies have been published
addressing outcomes of care by direct-entry mid-
wives. These studies have primarily reported
homebirth outcomes with homebirth being the
predominant site of birth for direct-entry mid-
wives.
30
While a number of publications and re-
ports exist about process and outcomes for all
categories of midwives, this literature is difficult
to compare to studies about other womens health
providers (especially direct-entry midwives). This
is due in part to the lack of inclusion of midwives
in systematic national data collection.
23,25,30
In 1998 the University of California at San
Francisco Center for Health Professions charged
a National Taskforce on Midwifery with examin-
ing the current status of midwifery in the United
States. Participants of the Taskforce, who repre-
sented all levels of entry into the midwifery pro-
fession in terms of education, training, and prac-
tice, generated a comprehensive report which is
the most current description of midwifery in the
United States. As charged, the Taskforce also
made specific recommendations for practice, reg-
ulation, credentialing, education, research, and
policy.
23,25
The Taskforce on Midwifery report,
endorsed by the PEW Health Professions Com-
mission, presents a multifaceted approach to im-
proving access to health care for women, chil-
dren, and their families as well as increasing the
diversity of the health care work force. These rec-
ommendations provide for a grounded approach
to examining the field of midwifery and increas-
ing an accountable provider pool with quality,
high standards and sensitivity to the cultural
needs of the clientele (Appendix).
IV. Actions Desired and Methods
The APHA should:
1. Communicate in writing with the major
professional organizations whose members pro-
vide health care to women encouraging them to
recognize nationally certified midwives as inde-
pendent and collaborative practitioners
2. Recommend through correspondence to
and meetings with members of the health care
systems that enrollees be assured access to mid-
wives and the midwifery model of care.
3. Urge all state legislatures to legalize the
practice of midwifery and promulgate regula-
tions, including specification of minimal educa-
tional standards and assurance to access to appro-
priate liability insurance in order to assure the
safety of the publics health as it relates to mid-
wifery practice.
4. Recommend that states consider in their
regulations regarding midwives that the basis for
entry-to-practice standards should include: suc-
Association News
cessful completion of a recognized midwifery ed-
ucation process, and successful completion of the
appropriate national midwifery certifying exami-
nation.
5. Recommend that federal and state agencies
broaden systematic data collection in birth cer-
tificates, death certificates, out patient data sets,
the National Ambulatory Medical Care Survey,
and other data collection activities that include
visits or contacts made by midwives for the care
of women or newborns, to include midwifery and
midwives.
6. Recommend that the Bureau of Health
Professions strengthen federal grants and trainee-
ships to minority midwifery students.
7. Encourage entities including the Institute of
Medicine, National Institutes of Health, Centers
for Disease Control and Prevention, and the
Health Resources and Services Administration to
develop a research agenda addressing midwifery
practice, outcomes and cost-effectiveness.
References
1. Anderson GF, Hurst J, Hussey PS, Jee-
Hughes M. Health Spending and Outcomes:
Trends in OECD Countries, 1960-1998. Health
Affairs. 2000; 19(3).
2. Reed A, Roberts J. State Regulation of
Midwives: Issues and Options. J Nurse-Midwif-
ery. 2000; 45(2):130-149.
3. Williams DR. Preserving Midwifery Prac-
tice in a Managed Care Environment. J Nurse-
Midwifery. 1999; 44(4):375-383.
4. US. Department of Health and Human
Services, Washington, DC. US Public Health
Service. Developing Objectives for Healthy
People 2010. Washington, DC: September 1997.
5. APHA Policy Statement 5818: Grants for
Maternal and Child Health Research. APHA
Public Policy Statements, 1948 to Present, Cum-
ulative. Washington, DC: American Public Health
6. APHA Policy Statement 6615: Perinatal
Mortality. APHA Public Policy Statements, 1948
to Present, Cumulative. Washington, DC: Am-
erican Public Health Association; current volume.
7. APHA Policy Statement 6805: Credentials
for Health Occupations. APHA Public Policy
Statements, 1948 to Present, Cumulative. Wash-
ington, DC: American Public Health Association;
current volume.
8. APHA Policy Statement 7924: Alternatives
in Maternity Care. APHA Public Policy
current volume.
9. APHA Policy Statement 8209: Guidelines
for Licensing and Regulating Birth Centers.
APHA Public Policy Statements, 1948 to Present,
Cumulative. Washington, DC: American Public
Health Association; current volume.
10. APHA Policy Statement 8401: Infant
Mortality among the Poor. APHA Public Policy
current volume.
11. APHA Policy Statement 8529: Preventing
Low Birthweight. APHA Public Policy State-
ments, 1948 to Present, Cumulative. Washington,
DC: American Public Health Association; current
volume.
12. APHA Policy Statement 9615: Supporting
National Standards of Accountability for Access
and Quality in Managed Health Care. APHA
Public Policy Statements, 1948 to Present,
Cumulative. Washington, DC: American Public
13. APHA Policy Statement 9714: Support
for Research on Alternative and Complimentary
Practices. APHA Public Policy Statements, 1948
to Present, Cumulative. Washington, DC: Am-
14. APHA Policy Statement 9815: Meeting
Public Health and Epidemiologic Data Needs in a
Managed Care Environment. APHA Public Pol-
icy Statements, 1948 to Present, Cumulative.
Washington, DC: American Public Health
15. Care in Normal Birth Report of Technical
Working Group. WHO Maternal Health and Safe
Motherhood Program 1996.
16. Hafner-Eaton C, Pierce LK. Birth choices,
the law, and medicine: Balancing individual free-
doms and protection of the publics health. J
Health Polit Pol Law. 1994; 19:813-835.
17. Ventura SF, Martin JA, Curtin SC,
Mathews TJ. Report of the final natality statistics,
1996. Monthly vital statistics report: 46(11-s).
Hyattsville, MD: National Center for Health
Statistics, 1998.
18. Rooks JP. The midwifery model of care. J
Nurse-Midwifery. 1999; 44(4): 370-374.
19. US Department of Health and Human
Services, Health Resources and Services Ad-
ministration. Fact Sheet: Womens Health: A Life-
Span Issue. Washington, DC. Department of
Health and Human Services, May 1993.
Services, Health Resources and Services Admin-
istration. Agenda for Womens Health. Wash-
ington, DC. Department of Health and Human
Services, February 1999.
21. Paine LL, Lang JM, Strobino DM, John-
son TRB, DeJoseph JF, Declercq ER, et al. Char-
acteristics of nurse-midwife patients and visits,
1991. Am J Public Health. 1999; 89(6): 906-909.
22. Curtin SC. Recent changes in birth atten-
dant, place of birth, and the use of obstetric inter-
ventions, United States, 1989-1997. J Nurse-
Midwifery. 1999; 44(4): 349-354.
23. Dower CM, Miller JE, ONeil EH and the
Taskforce on Midwifery. Charting A Course for
the 21st Century: The Future of Midwifery. San
Francisco, CA: Pew Health Professions Commis-
sion and the UCSF Center for the Health Profes-
sions, April 1999.
24. Rooks JP. Midwifery and Childbirth in
America. Philadelphia, PA: Temple University
Press, 1997.
25. Paine LL, Dower CM, ONeil EH. Mid-
wifery in the 21st century: Recommendations
from the Pew Health Commission/ UCSF Center
for the Health Professions 1998 Task Force on
Midwifery. J Nurse-Midwifery. 1999; 44(4): 341-
348.
26. Myers-Cieko JA. Evolution and current
status of direct-entry midwifery education, regu-
lation, and practice in the United States, with ex-
amples from Washington state. J Nurse-Mid-
wifery. 1999; 44(4): 384-393.
27. American College of Nurse-Midwives
(ACNM), Division of Accreditation. Education
Programs Accredited by the ACNM Division of
Accreditation. Washington, DC: ACNM Division
of Accreditation, July 1998.
28. Midwifery Education Accreditation
Council (MEAC). Accredited and Pre-Accredited
Midwifery Programs. Flagstaff, AZ: MEAC,
1998.
29. Paine LL, Johnson TRB, Lang JM, Gag-
non D, Declercq ER, DeJoseph J, et al. A com-
parison of visits and practices of nurse-midwives
and obstetrician-gynecologists in ambulatory
care settings. J Nurse-Midwifery. 2000; 45(1):
37-44.
30. Summers L, Reed A. Quality and Safety
of Direct-Entry Midwifery Practice in the US
ACNM Resources and Bibliography. Washington,
DC: American College of Nurse Midwives,
February 16, 2000.
Appendix: Recommendations for
The Future of Midwifery
Practice
Midwives should be recognized as indepen-
dent and collaborative practitioners with the
rights and responsibilities regarding scope of
practice authority and accountability that all inde-
pendent professionals share.
Every health care system should integrate
midwifery services into the continuum of care for
women by contracting with or employing mid-
wives and informing women of their options.
When integrating midwifery services, health
care organizations should use productivity stan-
dards based on the midwifery model of care and
measure the overall financial benefits of such care.
Midwives and physicians should ensure that
their systems of consultation, collaboration and
referral provide integrated and uninterrupted care
to women. This requires active engagement and
participation by members of both professions.
Regulation and Credentialing
State legislatures should enact laws that base
entry-to-practice standards on successful comple-
tion of accredited education programs, or the
equivalent, and national certification; do not re-
quire midwives to be directed or supervised by
other health care practitioners; and allow mid-
wives to own or co-own health care practices.
Hospitals, health systems, and public pro-
grams, including Medicare and Medicaid, should
ensure that enrollees have access to midwives and
the midwifery model of care by eliminating bar-
riers to access and inequitable reimbursement
rates that discriminate against midwives.
Health care systems should develop hospital
privileging and credentialing mechanisms for
midwives that are consistent with the professions
standards, recognize midwifery as distinct from
other professions, and recognize established
processes that permit midwives to build upon their
entry-level competencies within their statutory
scope of practice.
Association News
Education
Education programs should provide opportu-
nities for inter-professional education and train-
ing experiences and allow for multiple points at
which midwifery education can be entered. This
requires proactive intra- and interprofessional
collaboration between colleges, universities and
education programs to develop affiliations and
complementary curriculum pathways.
Midwifery education programs should include
training in practice management and the impact of
health care policy on midwifery practice, with
special attention to managed care.
The profession should recognize and ac-
knowledge the benefits of teaching the midwifery
model of care in a variety of education programs
and affirm the value of competency-based educa-
tion in all midwifery programs.
The midwifery profession should identify, de-
velop and implement mechanisms to recruit stu-
dent populations that more closely reflect the US
population and include cultural competence con-
cepts in basic and continuing education programs.
Research
Midwifery research should be strengthened
and funded in the following areas:
Demand for maternity care, demand for mid-
wifery care, and numbers and distribution of
midwives;
Analyses of how midwives complement and
broaden the womans choice of provider, set-
ting, and model of care;
Cost benefit, cost-effectiveness, and cost-
utility analyses, including the relationship
between knowledge of economic/cost analy-
ses and provider practices;
Midwifery practice and benchmarking data
(among midwives) with a goal of developing
appropriate productivity standards;
Descriptions and outcome analyses of mid-
wifery methods and processes;
Analysis of midwifery practice outcomes,
from pre-conception through infancy, using
an evidence-based perspective;
Normal pregnancy, normal labor and birth,
healthy parent-infant relationships, and
breastfeeding; and
Satisfaction with maternity and midwifery
care.
Federal and state agencies should broaden
systematic data collection, which has traditional-
ly focused on medicine and physicians, to include
midwifery and midwives.
Policy
A research and policy body, such as the
Institute of Medicine, should be requested to
study and offer guidance on significant aspects of
the midwifery profession including:
Workforce supply and demand;
Coordination of regulation by the states;
Funding of research, education and training;
and
Coordination among the federal agencies
whose policies affect affect the practice of
midwifery.
Source: Dower CM, Miller JE, ONeil EH and
the Taskforce on Midwifery. Charting A Course for
the 21st Century: The Future of Midwifery. San
Francisco, CA: Pew Health Professions Com-
mission and the UCSF Center for the Health Pro-
fessions; April 1999.
20005: Effective Interventions for
Reducing Racial and Ethnic
Disparities in Health
Knowing that many ethnic* minorities in the
United States suffer substantially and dispropor-
tionately from adverse health conditions and inad-
equate access to quality health care services as de-
scribed in detail in Healthy People 2010;
1
and
Recognizing that over the years in the United
States there have been efforts in the United States
to reduce ethnic disparities in health through na-
tional health policy (e.g., Healthy People
2000);
2
and
Understanding that some of these efforts to
reduce ethnic disparities in health outcome may
have also successfully improved the nations
health during the 20th century as evidenced by
overall reductions in deaths from coronary heart
disease and stroke, an increase in the number of
healthy mothers and babies (e.g., in 1997 an all-
time low infant mortality rate of 7.2 deaths per
1,000 live births), and elimination or near elimi-
nation of a number of vaccine-preventable dis-
eases of childhood (e.g., in 1996, 90% of young
children were vaccinated with most critical vac-
cines);
1,3-6
and
Further understanding that the 20th century
has also given rise to other great public health
achievements, including improved motor-vehicle
safety, safer workplaces, control of infectious dis-
eases, safer and healthier foods, fluoridation of
drinking water, and recognition of tobacco use as
a health hazard;
3,7-13
and
Realizing that these 20th century achieve-
ments resulted from efforts to reach all Ameri-
cans through a variety of policies that focused on
legislation, regulation, research, and education; a
voluntary change in personal lifestyles; and pop-
ulation-wide policies and programs that also tar-
geted high-risk groups, including racial/ethnic
minority populations;
3-13
and
Recognizing that the public health communi-
ty needs to understand and replicate interventions
that have already demonstrated success in reduc-
ing or eliminating ethnic disparities in health; and
Further recognizing that lessons learned from
20th century achievements, particularly child-
hood immunizations, suggest that the following
eight activities, especially if taken together as a
strategy, would be effective in eliminating certain
disparities in health: setting a national priority,
adopting not only long-term goals but interim
goals (e.g., annual or biennial), providing of suf-
ficient funding for effective programs that is tied
to accountability, regularly monitoring and evalu-
ating progress toward goals at all levels of gov-
ernment and the community, providing financial
incentives for achievement of goals, engaging the
community by forming community partnership
and encouraging participation, expanding access
to quality health care services, and optimizing
health care services through performance moni-
toring, evaluation, and feedback;
1,3-22
and
Understanding that, while the overall health of
Americans improved during the 20th century,
persistent and often increasing disparities in the
burden of illness and death have been experi-
enced by ethnic minorities, particularly by
African Americans (e.g., hypertension, infant
mortality, adult immunizations;)
1
and
Recognizing that the persistent problem of
ethnic disparities in health led to President Clin-
tons announcement in 1998 of a goal to eliminate
health disparities in six areas as part of his
Initiative on Race and that elimination of dispari-
ties in health has become a national health goal
for the 21st century (Healthy People 2010) and a
priority issue for the American Public Health
Association;
1,23
and
Realizing that the previously mentioned eight
activities, taken together as a strategy, have dem-
onstrated success in addressing some ethnic dis-
parities and can be applied to the six areas that
President Clinton has targeted for elimination of
disparities (infant mortality, cancer screening and
management, diabetes, cardiovascular disease,
HIV infection and AIDS, and immunization), and
all other national health objectives of 2010 in
which ethnic minorities have a 25% or more dif-
ference in outcome;
1
and
Recognizing that the sum of four hundred
million dollars was initially appropriated to the
initiative for prevention, outreach, and education
in the six priority areas; and
Further recognizing that the action plan of the
Department of Health and Human Services
(DHHS) includes providing leadership in re-
search, expanding and improving programs to
purchase or deliver quality health care services,
reducing poverty and providing children with
healthy environments, and expanding prevention
efforts;
24
and
Realizing that a first step of the action plan of
the DHHS is to review existing programs to iden-
tify and implement strategies that work, our sup-
port in promoting effective interventions is time-
ly; therefore, APHA
1. Reaffirms the recent joint announcement of
APHA and DHHS as partners in a national
campaign to eliminate racial and ethnic
health disparities;
2. Supports the action plan of the DHHS for
eliminating ethnic disparities in health, par-
ticularly activities to identify existing inter-
ventions/programs effective in eliminating
health disparities and the community-based
demonstration projects that are identifying
new strategies by expanding our knowledge
of intervenable risk factors for eliminating
disparities (i.e., REACH 2010 projects);
3. Urges the DHHS and Congress to ensure that
the current plan for targeting specific priori-
ty areas for elimination be continued, partic-
ularly in future administrations, and to ex-
pand funding to fully implement effective in-
terventions for first eliminating disparities in
the six priority areas, and then to the focus
areas specified in Healthy People 2010 in
which ethnic minorities experience a 25% or
more difference in health outcome;
Association News
4. Urges the DHHS to provide a summary of ef-
fective strategies for eliminating health dis-
parities to the public;
5. Urges the public health community to pro-
mote effective strategies through presenta-
tion, publication, and implementation; and
6. Urges the convening of a meeting to identify
what works, how to translate the interven-
tions into to effective programs, and what are
the remaining underlying reasons for health
disparities.
* Ethnic means racial and ethnic as described
in the action plan of the DHHS titled Racial and
Ethnic Disparities in Health, February 1998.
References
1. Healthy People 2010 (Conference Edition
in Two Volumes). Washington, DC: US Depart-
ment of Health and Human Services; January
2000.
Full report commentary. Washington, DC: U.S.
Department of Health and Human Services,
1991. DHHS publication (PHS) 91-50212.
3. Centers for Disease Control and Prevention.
Ten great public health achievementsUnited
States, 1900-1999. MMWR. 1999;48: 241-243.
4. Centers for Disease Control and Preven-
tion. Achievements in public health, 1900-1999.
Decline in deaths from heart disease and stroke.
MMWR. 1999;48:649-656.
Healthier mothers and babies. MMWR. 1999;
48:849-858.
6. Centers for Disease Control and Pre-
vention. Achievements in public health, 1900-
1999. Impact of vaccines universally recom-
mended for childrenachievementsUnited
States, 1900-1999. MMWR. 1999;48: 243-248.
Motor vehicle safety: A 20th century public
health achievement. MMWR. 1999; 48:369-374.
tion. Vaccination coverage by race/ethnicity and
proverty level among children aged 19-35
monthsUnited States, 1997. MMWR 1998;47:
956-959.
January-December 1998: vaccination coverage by
race/ethnicity. http//www.cdc.gov/nip .coverage
10. Bernier R, Orenstein W, Hutchins S, et al.
Do vaccines reach those who most need them?
In: Vaccination and World Health. West Sussex,
England: John Wiley & Sons Ltd., 1994.
Improvements in workplace safetyUnited
States, 1900-1999. MMWR. 1999;48: 461-469.
Control of infectious diseases. MMWR. 1999;48:
621-629.
Achievements in public health, 1900-1999. Safer
and healthier foods. MMWR. 1999; 48:905-913.
Fluoridation of drinking water to prevent dental
caries. MMWR. 1999;48:933-940.
Tobacco UseUnited States, 1900-1999. MMWR.
1999;48:986-993.
Family Planning. MMWR. 1999;48: 1073-1080.
17. Orenstein W. Overview of immunization.
In 32nd National Immunization Conference
Proceedings. Atlanta, GA: Centers for Disease
Control and Prevention, 1998. 1-9.
tion. Status report on the childhood immunization
initiative: National, state, and urban area vaccina-
tion coverage levels among children 19-35
monthsUnited States, 1996. MMWR. 1997;
46:657-664.
tion. Status report on the childhood immunization
initiative: Reported cases of selected vaccine-pre-
ventable diseasesUnited States, 1996. MMWR.
1997;46:665-670.
20. Institute of Medicine. Improving Health in
a Community: A Role for Performance Moni
-
toring. Washington, DC: National Academy
Press, 1997.
21. Dever GE. Improving Outcomes in Public
Health Practice: Strategies and Methods. Gaith-
ersburg, MD: Aspen Publishers, 1997.
22. Fairbrother G, Hanson KL, Freidman S, et
al. The impact of physician bonuses, enhanced
fees, and feedback on childhood immunization
rates. Am J Public Health. 1999; 89:171-175.
23. Lasker RD. Medicine and Public Health:
The Power of Collaboration. New York, NY: New
York Academy of Medicine, 1997.
24. Task Force on Community Preventive Ser-
vices. Recommendations regarding interventions
to improve vaccination coverage in children, ado-
lescents, and adults. Am J Prev Med. 2000;18
(1S):92-96.
25. National Immunization Program. Asses-
sment feedback, incentives, and exchange
(AFIX). http://www.cdc.gov/nip/afix.
26. American Public Health Association.
Programs, projects, and practices. http://www.
apha.org/ppp
27. Department of Health and Human Ser-
vices. Race and health. http://www.raceand
health.hhs.gov.
20006: Making Medicines
Affordable: the Price Factor
(Position Paper)
Problem and Goal
Advances in pharmacology are driving a revo-
lutionary change in medical treatment. New drugs
are bringing more effective, safer treatments for a
variety of ailments. These treatments can, in some
cases, obviate costly and risky inpatient proce-
dures and, for some conditions, introduce effective
treatment for the first time. Increasingly, the right
to good health care becomes inextricably linked
with access to prescription drugs.
1-5
Expenditures for prescription drugs in the
United States are increasing much faster than
total health spending. They accounted for 7.9 per-
cent of total health spending in 1998, up from 5.6
percent in 1993. Drug spending accounted for
one fifth of the entire increase in health spending
during 1998. It is the fastest growing component
of spending on personal health. From an increase
of 8.7 percent during 1993, growth rose steadily
to 15.4 percent in 1998.
6
Given its continued
rapid growth, prescription drug spending appears
likely to reach about 10 percent of the health care
total in 2000.
7
A frequent response by insurers or employers
to rising prescription drug expenditures has been to
reduce utilization, commonly by increasing copay-
ment requirements, or to reduce or withdraw cov-
erage.
8
Seventy million Americans lack prescrip-
tion drug coverage. Others are losing coverage or
are being asked to bear increased cost sharing
which is leading to underutilization in many
cases.
9-11
Much of the loss of drug coverage is due
to loss of employer-based health coverage by re-
tirees. A survey of retiree health plans found that
between 1993 and 1997 the proportion of employ-
ers providing health coverage to Medicare-eligible
retirees dropped from 40 percent to 31 percent.
(Among large employers, the drop was from 63
percent to 48 percent.)
12
Even fewer beneficiaries
have Medigap coverage for prescription drugs.
13
Another cost-cutting response of insurers and
employers has been to limit pharmaceutical ben-
efits to products in formularies.
14
When such a
change is instituted, commonly a beneficiary who
is being treated effectively with one drug is re-
quired to switch to another. The result is that
some patients are harmed.
15,16
Current formula-
ries are heavily influenced by the deals that indi-
vidual insurers are able to strike with manufac-
turers.
17
To provide a sound basis for formularies,
it will be important to develop independent as-
sessments of the advantages, disadvantages, and
cost effectiveness of different medications.
18
However, that will take many years. To make vital
medications affordable in the meantime, it is es-
sential to address price directly.
Assessing the impact of reduced prescription
drug coverage on quality of care has not often
been a priority for purchasers or payors. However,
several studies suggest strongly that prescription
drug copayment requirements do harm some pa-
tients, particularly those in the poorest health.
19
Seventeen percent of Americans reported being
unable to afford to fill a prescription in 1998.
20
For several years, drug prices had remained
fairly flat, and rising expenditures reflected main-
ly increasing utilization.
21,22
Now the prices are
increasing more than twice as fast as overall in-
flation.
23
As measured by the year-to-year change
in the average retail price of prescriptions, prices
were up 7.1 percent in 1998 over 1997.
24
This re-
flects both price increases for existing drugs and
the introduction of costlier new drugs.
25
The drug price burden is distributed unfairly
among Americans. For those who have insurance
coverage that is provided by a large purchaser of
drugs; (for example, a government agency, man-
aged care organization, hospital chain, or major
employer) there is the benefit of markedly lower
Association News
prices. But manufacturers compensate them-
selves for this by charging far higher prices to all
other Americans.
26,27
Current price trends, if unabated, will serious-
ly erode benefits under prescription drug cover-
age plans. Whether the payor is one person or the
US government, as the cost burden increases,
coverage is put at risk. Ever larger subsidies not
only are not a sustainable solution but also may
mean ever greater waste of public resources.
Pharmaceutical coverage might reasonably be
considered an important component of a compre-
hensive universal national health program. Cur-
rently, however, there is particularly wide interest
in creating an outpatient prescription drug benefit
for Medicare beneficiaries, a large sector of the
population that, notwithstanding a high level of
need, is largely without such coverage. APHA
has called for the addition of a prescription drug
benefit to the Medicare program, at the same time
recognizing that drug pricing will be a major fac-
tor determining whether a Medicare drug benefit
is practicable.
28
While the goal must be affordable medicines,
insurance coverage alone will not suffice. The
price factor must be addressed, as well as the im-
portance of reducing excessive utilization.
However such efforts should be grounded in con-
siderations of quality, not merely of cost.
Purpose of the Paper;
Policy Objectives
Public policy must address the problems
posed by prescription drug prices.
We focus on the manufacturers price. Whole-
saler and retailer margins are smaller components.
Of the average retail payment for a prescription in
the third quarter of 1999, the manufacturer is esti-
mated to have received 75.7 percent, the whole-
saler 2.3 percent, and the retailer 22 percent.
29
A look at three factors clarifies why prescrip-
tion drugs are so expensive for Americans: (1) the
drug industry clears extraordinarily large profit
margins after R&D costs are accounted for, (2) it
spends wastefully on advertising and marketing,
and (3) it subjects American buyers to the high
end of large international price disparities.
Profits: By all conventional measures (that is,
whether earnings are compared with revenues, as-
sets, or equity), the prescription drug industry has
consistently led the Fortune 500 companies in
profitability in recent years. The median return on
equity for the Fortune 500 pharmaceutical firms,
one and-one-half times the all-industry average in
the 1970s and 1980s, soared to two and one quar-
ter times the average in the 1990s.
30,31
The drug industrys high profits mainly reflect
patent monopolies and the price-setting power
these bestow. Brand-name drug makers efforts to
suppress competition and current merger trends
in the industry tend to magnify this power. Two
other factors contribute heavily to profits: favored
tax treatment
32
and valuable technology transfer
from the public sector.
33,34
Thus, for example, as a
result of special treatment under six different pro-
visions of the corporate income tax code, the drug
companies effective tax rate, that in 1996 would
otherwise have been 35.2 percent, was only 17.1
percent. The average tax rate for companies in all
industries was 26.7 percent.
35
Repeatedly, in acts of striking generosity, the
federal government, after investing tens of mil-
lions of dollars to develop a new drug, has given
a private manufacturer exclusive marketing
rights. The government does not issue compre-
hensive reports listing transfers but, as reported
by the Boston Globe, salient examples have in-
cluded Taxol, Levamisole, Proleukin and AZT. In
FY 1996, for example, NIH spent more than $1
billion on drug and vaccine R&D and is reported
to have collected only $27 million in royalties.
The Boston Globe surveyed 50 of the prescription
drugs that reached the market between 1993 and
1998. It considered the 35 best selling of those
products deemed most important by the FDA, and
15 orphan drugs. It turned out that federal dollars
had helped in the discovery, development, or test-
ing for 33 of the 35, and for 12 of the fifteen.
36
Advertising and marketing: Out of $86 billion
in 1998 revenues, the US pharmaceutical industry
reported spending $8.3 billion to promote its prod-
ucts.
37
(On direct-to-consumer advertising, the in-
dustrys spending between January and October of
1999 exceeded its outlay for the same period in
1998 by 32 percent.)
38
This may well be under-
stated. In 1991, a Senate committee reported find-
ing that much of what some companies reported
as R&D expenditure was actually spent on post-
marketing surveys designed to enhance the com-
panies marketing strategies.
39
International price disparities: Prescription
drug prices in the US are the worlds highest. In
various countries of Western Europe, for example,
the prices average from 30 to 50 percent below
those in the United States for identical products
from the same manufacturers.
40-42
The govern-
ments of those countries protect their people
against high drug prices by negotiating the prices
with the manufacturers or by setting the prices di-
rectly by regulation. The drug industry acknowl-
edges that it charges higher prices in the US to off-
set those lower prices in other developed countries.
(Poor nations are also facing drug prices higher
than they can afford,
43
even though a few manu-
facturers are considering whether to cut prices to
some of those nations.
44,45
) According to the
Pharmaceutical Research and Manufacturers of
America, Americans pay higher prices because
they bear the worlds drug research burden.
46
The pharmaceutical industrys defense against
criticism of high drug prices is that it needs the
money if it is to continue bringing medically
valuable new products to the market. This con-
tention then branches into two somewhat separate
propositions. One relates to the overall cost of
R&D per new product brought to market. The
other relates to conditions for attracting the capi-
tal needed for R&D.
Pharmaceutical manufacturers contend that
product prices reflect the cost of developing new
products, taking into account that not all R&D
projects succeed. However, because they do not
open their books, it is difficult to verify this as-
sertion. A commonly cited industry cost estimate,
$500 million per product brought to market, turns
out to include not only actual costs but also the
opportunity cost of having failed to invest their
R&D moneys elsewhere while waiting for mar-
ketable products to emerge.
47-49
The opportunity
cost represents more than half the total estimate.
However, the US Office of Technology Asses-
sment called the industry estimate an arbitrary
number and suggested a substantially smaller fig-
ure even with opportunity cost included.
50
A public health assessment of the value of the
industrys R&D activities should consider also
what proportion is devoted to developing copycat
products and lifestyle products rather than drugs
that represent critical therapeutic gain. Among the
1,223 new chemical entities brought to market
from 1975 to 1997, only 379 (31%) represented
therapeutic innovation. Thanks to the US Orphan
Drug Act, implemented in 1983, 157 of these new
products addressed rare diseases, as did 837 new
indications of existing products. (However, this
included very few for diseases prevalent mainly
in poor nations).
51,52
Secondly, the drug industry asserts it is a high-
risk industry that needs super-profits to attract cap-
ital. However, its consistently high net profit mar-
gins year after year, after research costs have been
taken into account, hardly evidence high risk.
53
Indeed, a review of the earnings of research-inten-
sive drug manufacturers over a 12-year period by
Congress Office of Technology Assessment con-
cluded that, even with adjustment for risk, these
companies were more profitable than other kinds of
enterprises.
54
Current revenues of the industrys dominant
companies offer adequate margin to accommo-
date substantial price cuts. Among the 10 largest
US pharmaceutical companies, the median ratio
of 1998 net income to reported R&D expendi-
tures is 1.5 (range 0.6 to 2.0).
55
In 1998, the ag-
gregate profit of 12 Fortune 500 drug manufac-
turers exceeded the entire industrys spending on
R&D.
56
There is no firm link between a nations drug
price level (or an individual companys) and the
level of R&D there. Many factors other than price
affect research and development investments.
57
For
example, more new medicines in worldwide use
have been developed in the UK than in Germany
and Sweden combined,
58,59
notwithstanding higher
drug prices in the latter countries.
60
A report from Merrill Lynch noted that a price
cuts negative impact on drug company revenue
can be overwhelmed by the resulting increase in
sales volume. The report went on to estimate that,
were all 39 million Medicare beneficiaries to get a
40 percent discount on manufacturers prices, sales
volume would go up with the result that the manu-
facturers total revenue would drop no more than
3.3 percent, and might even show a slight in-
crease.
61
Likewise, universal coverage for medi-
cines would assure the pharmaceutical industry of
high sales volume. Reforms that restrain or reduce
prices without substantially cutting drug makers
total US revenues would appear to merit serious
consideration. Price reductions will mean a higher
volume of sales, but the marginal cost of producing
additional drugs is low. Volume growth, taken to-
gether with low marginal costs, suggests that man-
ufacturers could even produce all the medications
Americans need without requiring marked increas-
es in revenue.
62
Association News
To serve the publics health, public policy
should:
Minimize the price barriers that make life-
sustaining drugs unaffordable, and that
would make social insurance coverage for
prescription drugs unduly burdensome on the
public.
Minimize the price disparities among sectors
of the US market, disparities that too often
place the heaviest burden on those who can
least afford it.
Avoid public policies that, while aiming to
assure continued development of worthy new
drugs, fail to assure they are affordable to the
people those drugs could benefit.
We deem these ends to be attainable.
A Survey of Methods Available to
Public Policy Makers
One possible method for holding prices in
check that is available to both private and public
payors, is to use pharmacy benefit managers
(PBMs). PBMs are companies that manage the
drug benefit plans of managed care organizations
and large employers. They work to extract price
discounts from drug companies, generally in re-
turn for giving preference to a companys product
line, perhaps even creating a formulary around
that companys line. Typically, the arrangement
provides for a manufacturer rebate based on the
volume of retail sales generated. The manufactur-
ers discounts obtained by PBMs may often be
over-estimated, since a substantial share of their
savings stems from pharmacy discounts, utiliza-
tion review and other measures.
63
While the task
of the PBM is most simply seen to be the pur-
chase of discounted drugs, a preferable role defi-
nition might be the management of drug use. That
model has suggested the possibility that using a
more expensive drug could actually lower the
total direct medical costs.
64
Some PBMs reward pharmacists who per-
suade physicians to switch to the PBMs pre-
ferred product. Proponents argue that PBMs pro-
mote competition and thus reduce prices. Yet, as
for-profit entities, PBMs themselves become an-
other cost element. Because their price negotia-
tions are secret, it is hard to keep them from sy-
phoning off some rebate money to themselves.
Studies of PBMs tend to focus on their structure
and the range of services they provide. The im-
pact of PBMs on quality of care, and even on
costs is for the most part unstudied.
65
In the context of proposals for a Medicare pre-
scription drug benefit, drug manufacturers have
voiced a strong preference for involving PBMs.
Thereby they could avoid the pressures for ac-
countable pricing that they fear would arise in di-
rect transactions with a federal agency. Mean-
while, the federal Department of Justice has had
large PBMs under scrutiny, concerned that their
complex and confidential financial agreements
with manufacturers might be violating fraud or
anti-kickback laws.
66,67
A variety of other possible methods are avail-
able for containing drug prices through public in-
tervention, methods that range from direct price
controls to fostering more competitive markets.
These include:
1. Starting with the most direct method, require
that the price of a newly patented pharma-
ceutical bear a reasonable relation to the cost
of developing, manufacturing and distribut-
ing the product, with provision for a reason-
able return to the manufacturer.
2. Restrict the rate of rise in prices, for example
to the general rate of inflation as measured
by the consumer price index.
3. Function as purchaser on behalf of a large
pool of consumers and negotiate either the
price of each product or, more simply, a uni-
form discount for all drugs. The federal gov-
ernment already does this on behalf of the
Medicaid program, the Department of De-
fense, the Veterans Administration, the Indian
Health Service, the Public Health Service and
the Ryan White program. The governments
aim for those programs is to approximate the
prices charged to the most favored non-feder-
al customer, such as managed care organiza-
tions or hospital chains.
68
A variant of this ap-
proach would be to set, rather than negotiate,
the prices or discount rate. Also, instead of the
prices being set independently, they could be
pegged to a pre-existing reference standard,
(i.e., median price for the same product in the
OECD member countries or the G7 coun-
tries). The state of Maine has recently enacted
legislation aiming to reduce prices statewide
to the levels prevailing in federal programs.
69
4. Let the manufacturer set prices within a con-
straint on the companys overall return on eq-
uity, which could be capped either at a fixed
percentage or at the average experienced by a
range of industries (for example, the S&P
500 corporations). The UK, which has both
price controls and profit controls, is able to
sustain a strong, research-oriented pharma-
ceutical industry.
70
5. Aim for parity with the prevailing developed
world price of each product, thus, the price
would not be permitted to exceed the average
or median of the prices of that product in a
specified set of countries. (Canada uses this
principle to set prices for newly marketed
breakthrough drugs. For new products that
are more or less equivalent to preexisting
ones, the price is not permitted to exceed the
prevailing price range for those preexisting
ones.)
71
If it were deemed necessary as encourage-
ment for innovation, any of the foregoing could
be modified to permit manufacturers to charge
premium prices during the first year or two that
they market a new innovative drug, as has been
the policy in Japan.
72
The next three approaches can be seen as
ways to foster a more competitive domestic mar-
ket for prescription drugs:
6. A more limited way to approximate price
parity with other countries would be to legal-
ize the re-importation of products that U.S.
manufacturers sell abroad. A measure pur-
porting to accomplish this was enacted by the
Federal Government in October 2000. How-
ever, the kinds of loopholes identified in the
bill by the president and other analysts show
the problems in implementing this approach
if manufacturers are determined to impose
obstacles.
72a,72b
7. Institute compulsory licensing of would-be
competitors to manufacture a patented prod-
uct, and include a requirement for reasonable
royalty payment. (See H.R.2927, the Afford-
able Prescription Drugs Act.)
8. Facilitate the entry of generics into the mar-
ket and promote their use. Such a policy has
been pursued by the European Union.
73
In
the US, generics can and do appear on the
market soon after patents expire, notwith-
standing obstructive efforts by brand-name
firms.
74,75
The Congressional Budget Office
reports that in 1994, purchasers of generics at
retail saved $8-10 billion (more recent data
are not given) and that manufacturers of
generics often capture more than half the
brand-name drug market.
76
(See H.R. 805,
the Generic Drugs Access Act of 1999.)
9. Consider modifications in patent laws for
pharmaceuticals, (i.e., a change in the dura-
tion of patents).
10. Use tax strategies: (a) Make eligibility for fa-
vored tax treatment conditional on compli-
ance with a pricing standard such as 2, 4, 5 or
7 above. (See H.R. 3665, the Prescription
Price Equity Act of 2000.) Alternatively, (b)
enact an excess profits tax, reducing manu-
facturers incentive to set prices high. The
country had a general corporate excess prof-
its tax until 1954.
A broader, collaborative international ap-
proach to international price parity is possible:
11. The federal government could initiate inter-
national drug price negotiations with the aim
of securing affordable prices for all nations
while assuring adequate funding for pharma-
ceutical R&D. This framework could also
make prescription drugs available at low cost
to poor nations.
Methods 1, 4, 6, 7, 9 and 11 require action by
the federal government, while 2, 3, 5, 8 and 10
could be undertaken by either federal or state
governments.
A fact not widely appreciated is that the Fed-
eral Government already has the power to enforce
reasonable pricing for an important subset of
pharmaceuticals, those produced under privately
held patents arising out of Federally funded
R&D.
77
The Bayh-Dole Act of 1980, designed to
hasten development of marketable products out of
federally funded research, empowers the govern-
ment to ensure that such products are made avail-
able to the public on reasonable terms.
78
Yet the
government has apparently never exercised this
power.
79,80
A measure passed overwhelmingly in
June of 2000 by the U.S. House of Representatives
as an amendment to an appropriations bill basical-
ly calls on the government to exercise it.
81
In prin-
ciple, any of methods 1, 4, 5, or 11 could provide
a definition of reasonable price.
A more fundamental approach than any of the
foregoing would take into account other areas of
public policy that impinge on the issue, apart
from pricing policy per se. While it is beyond the
scope of the present paper, there would be merit
in a study of how most efficiently to support phar-
maceutical R&D with priority attention to the
Association News
most vital needs. One approach would be to fund
R&D separately, and drug pricing then would be
expected to cover just the costs of manufacturing
and distribution. One variant of that approach
would be public assurance of R&D funding in re-
turn for industry provision of medications to meet
the populations needs at affordable prices.
Action by APHA
1. APHA emphasizes that responsible public
policy on prescription drug affordability needs
to address not only coverage but also price.
2. APHA considers all of methods 1-11, togeth-
er with enforcement of the Bayh-Dole Act as
legitimate modes of public intervention in
pricing. It will promote support for such ap-
proaches in its legislative and public infor-
mation activities and will enter coalitions
that share these objectives. It urges its state
affiliates to do the same.
3. At this time, methods 2, 3, 5-8 and 10(a), to-
gether with enforcement of the Bayh-Dole
Act, are approaches that have been proposed
in national and/or state legislative form.
APHA encourages more legislators to sup-
port these initiatives and to introduce such
measures into additional state legislatures. In
the absence of decisive support in Congress
for such steps, APHA is particularly support-
ive of multi-state efforts like that among the
legislators of the eight northeastern states
that are collaborating to find ways to lower
pharmaceutical prices.
82,83
It urges its affili-
ates to encourage this process and parallel
moves among other states; and
4. Encourages efforts to provide clinicians with
periodic summaries of treatment and drug ef-
fectiveness guidelines issued by the U.S.
Agency for Healthcare Research and Quality.
References
1. Davis M, Poisal J, et al. Prescription drug
coverage, utilization, and spending among Medi-
care beneficiaries. Health Affairs. 1999:18(1):
231-243.
2. Soumerai SB, Ross-Degnan D. Inadequate
prescription-drug coverage for Medicare enrol-
leesa call to action. N. Engl. J. Med. 1999,340:
722-728.
3. Smith S, Heffler S, et al. The next decade of
health spending: A new outlook. Health Affairs.
1999:18(4):86-95.
4. Levit K, Cowan C, et al. Health spending in
1998: Signals of change. Health Affairs. 2000;
19(1):124-132.
5. IMS Health. World Drug Monitor. http://
www.imshealth.com/html/wdm/12_99.htm.
Accessed February 29, 2000.
6. See reference 4; also 3.
7. Sager A, Socolar D. Affordable medications
for Americans. http://www.house.gov/berry/
prescriptiondrugs/Resources/sager.pdf. Accessed
July 27, 1999.
8. Hillman AL, Pauly MV, et al. Financial in-
centives and drug spending in managed care.
Health Affairs. 1999;18(2):189-200.
9. Rasell ME. Cost sharing in health insur-
anceA reexamination. N. Engl. J. Med. l995;
332(17).
10. Gold M, et al. Medicare managed care:
Preliminary analysis of trends in benefits and pre-
miums, 1997-1999. Washington, DC: Mathemati-
ca Policy Research, June 1999.
11. Henry J. Kaiser Family Foundation. Anal-
ysis of benefits offered by Medicare HMOs, 1999:
Complexities and complications. August 1999.
12. Mercer/Foster/Higgins. National survey
of employer-sponsored health plans. 1997, as
cited in Prescription Drug Task Force, US House
of Representatives. Fact sheets. Seniors beware:
The need for medicare prescription drug cover-
age, how drug pricing has harmed seniors and de-
bunking the myths of drug makers. October 29,
1999.
13. Press Secretary. The White House. Pres-
ident Clinton and Senate Democrats unified in vi-
sion for new Medicare prescription drug benefit.
Mar. 9, 2000. http://www.whitehouse.gov/library/
ThisWeek.cgi?type=p&date=2&briefing=1.
14. Headden S. The big pill push. US News
and World Report. September 1, 1997. http://
www. usnews. com/ usnews/ i ssue/ 970901/
1drug.htm. Accessed June 19, 2000.
15. See reference 14.
16. Gelles J. US probe questions legality of
drug switches. Philadelphia Inquirer. March 15,
2000, p.1.
18. Rucker TD. A public policy strategy for
drug formularies: Preparation or procrastination?
Am. J. Health-Syst. Pharm. 1999;36: 2338-2342.
19. Stuart B, Zacker C. Who bears the burden
of Medicaid drug copayment policies? Health
Affairs. 1999;18(2):201-212.
20. Data from Commonwealth Fund 1988
International Health Policy Survey as cited by
Donelan K, Blendon RJ, et al. The cost of health
system change: Public discontent in five nations.
Health Affairs. 1999;18(3):206-216.
21. Employee Benefits Research Institute.
Prescription drugs: Issues of cost, coverage, and
quality. EBRI Issue Brief. 1999;208 (April):1-21.
22. National Institute for Health Care Man-
agement and Research Educational Foundation,
as reported in Am. J. Health-Syst. Pharmacists.
1999;58(18).
23. US Bureau of Labor Statistics. Consumer
Price Indexall urban consumers, all items, and
prescription drugs and medical supplies 1998-
1999.
24. National Association of Chain Drug
Stores. Facts at a glance. http://www.nacds.org/
industry/fastfacts.html. Accessed March 8, 2000.
25. Health Care Financing Administration.
Highlights. National health expenditures, 1998.
http://www.hcfa.gov/stats/nhe-oact/hilites.htm
26. US Department of Health and Human Ser-
vices. Report to the President: prescription drug
spending, utilization and prices. April 2000. http://
aspe.hhs.gov/health/reports/drugstudy. Accessed
June 19, 2000.
27. Minority Staff, Special Investigations
Division, Committee on Government Reform,
US House of Representatives. HHS report con-
firms existence of prescription drug price dis-
crimination. April 10, 2000.
28. APHA Policy Statement 9934(PP): Pro-
tecting and Strengthening Medicare: Financing
and prescription drug issues. APHA Policy State-
ments; 1948-present, cumulative. Washington,
DC: American Public Health Association; current
volume.
30. Fortune 500 medians. http://cgi.pathfinder
.com/fortune/fortune500/medians.html.
32. Guenther G. Federal taxation of the drug
industry from 1990 to 1996. Congressional Re-
search Service Memorandum to the Joint Eco-
nomic Committee. Library of Congress, Wash-
ington, DC: December 13, 1999. Released by
Representative Pete Stark, December 20, 1999.
33. Dembner A, et al. Public handouts enrich
drug makers, scientists. Boston Globe, April 5,
1998.
34. Public Citizen. Why the pharmaceutical
industrys R&D scare card does not justify high
and rapidly increasing US drug prices. http://
www.citizen.org/congress/drugs/press/r&dscare-
card.htm.
38. Both consumer- and physician-oriented
drug promotion booming. American Medical
News. April 10, 2000.
39. US Senate Special Committee on Aging.
The drug manufacturing industry: A prescription
for profits. Staff report. September 1991.
40. US House of Representatives, Prescrip-
tion Drug Task Force. Fact sheets. October 28,
1999.
41. Sasich LD, Torrey EF, Wolfe SM, et al.
International comparison of prices for antidepres-
sant and antipsychotic drugs. Public Citizen
Health Research Group Publication 1446. Avail-
able at http://www.citizen.org/hrg/publications/
1446.htm.
42. Canadian Patented Medicine Prices Re-
view Board. Annual report, 1999. Trends in drug
prices and expenditures. See p.23, Fig.8.
Available at http://www.pmprb-cepmb.gc.ca/ar-
99e.html. Accessed June 15, 2000.
43. Brundtland GH. Towards a strategic agen-
da for the WHO secretariat. Geneva: World
Health Organization, Office of the Director-
General. January 24, 2000. http:// www.who.int/
directorgeneral/speeches/2000/20000124_eb.
html. Accessed June 16, 2000.
44. McNeil DG, Jr. Companies to cut cost of
AIDS drugs for poor nations. New York Times.
May 12, 2000, p.1.
45. Taitz L. AIDS-drugs hopes dashed. Sun-
day Times of South Africa, May 21, 2000. http://
www.aegis.org/news/suntimes/2000/ST000503.
html. Accessed June 18, 2000.
46. Pharmaceutical Research and Manu-
facturers of America. International price compar-
isons. Industry issue brief. 1994, p.7.
47. DiMasi JA, Hansen RW, et al. Cost of in-
novation in the pharmaceutical industry. J. Health
Econ. 1991:10(2):107-142.
48. DiMasi JA, Hansen RW, et al. Research
and development costs for new drugs by thera-
peutic category. A study of the US pharmaceuti-
cal industry. Pharmacoeconomics. 1995;7(2):
152-169.
Association News
49. Gerth J, Stolberg SG. Drug companies
profit from research supported by taxpayers. New
York Times. April 23, 2000.
50. US Congress, Office of Technology As-
sessment. Pharmaceutical R&D: Costs, Risks and
Rewards. OTA H-522. Washington, DC: US Gov-
ernment Printing Office. February 1993.
51. Pcoul B, Chirac P, et al. Access to essen-
tial drugs in poor countries. A lost battle? JAMA
1999;281(4):361-367.
52. Silverstein K. Millions for Viagra, pennies
for diseases of the poor. The Nation. July 19,
1999; pp.13-19.
54. See reference 50, pp. 1, 24, 104.
56. Data from Pharmaceutical Research and
Manufacturers of America Annual Survey, as
cited in reference 40.
57. US General Accounting Office. Prescrip-
tion drugs: Spending controls in four European
countries. Washington: General Accounting Of-
fice, May 1994, GAO/HEHS-94-30, pp. 4-5, 8
and 39.
58. Pharmaceutical Research and Manu-
facturers of America. Facts & figures. Devel-
opment of 152 global drugs, by country of origin,
1975-1994. December 1999. http://www.phrma
.org/facts/phfacts/12_99c.html.
59. Redwood H. Price regulation and phar-
maceutical research: The Limits of Coexistence.
Suffolk, England: Oldwicks Press Limited, 1993,
p. 22, as cited in reference 57.
60. Canadian Patented Medicine Prices Re-
view Board. Trends in patented drug prices.
PMPRB Study Series S-9811, September 1998;
figures 10 and 11. http://www.pmprb-cepmb.
gc.ca/pub-e.html#study. Accessed June 17, 2000.
61. Merrill Lynch. Pharmaceuticals: A Medi-
care drug benefit may not be so bad. June 23,
1999.
63. Sager A, Socolar D. Affordable medica-
tions for all New Yorkers, Testimony on N.Y. State
Senate bills S.6068-B and S.4674. May 31, 2000,
citing data from the US General Accounting Of-
fice. Pharmacy benefit managers: FEHBP plans
satisfied with savings and services, but retail phar-
macies have concerns. Washington, DC: General
Accounting Office, GAO/HEHS-97-47. pp. 9-11.
64. Blissenbach HF. Use of cost-consequence
models in managed care. Pharmacotherapy.
1995;15(5,.2):595-615.
65. Lipton HL, Kreling DH, et al. Pharmacy
benefit management companies: Dimensions of
performance. Annu. Rev. Public Health. 1999;20:
361-401.
66. Cloud DS, Murray S. Clintons Medicare
proposal prompts search for kickbacks. Wall
Street Journal. July 28, 1999.
67. Freudenheim M. New questions on drug
plans as costs soar. New York Times. May 7, 2000,
p.1.
68. Minority Staff, Investigations Division,
Committee on Government Reform, US House of
Representatives. Prescription drug pricing in the
United States: Drug companies profit at the ex-
pense of older Americans. Prepared for Rep.
Henry A. Waxman. November 9, 1999.
69. Moore MO. State to oversee price of
drugs. Bangor Daily News. May 12, 2000.
70. Redwood H. New drugs in the world mar-
ket. The American Enterprise, 1993;4(4): 77, as
cited in US General Accounting Office. Pre-
scription drugs: companies typically charge more
in the United States than in the United Kingdom.
Washington, DC: General Accounting Office.
January 1994, p.2. GAO/HEHS-94-29.
71. Elgie RG. Canadas Patented Medicine
Prices Review Board: New approaches. Notes for
an address to the Drug Information Association
Washington conference. April 16, 1999. http://
www.pmprb-cepmb.gc.ca/pub-e.html#speech.
72. Kleinke JD. Expensive drugs lower health
care costs. Wall Street Journal. February 16, 1994.
72a. Thomas R. Drug snuggling in Washing-
ton. Wall Street Journal (New England Edition),
October 11, 2000.
72b. Clinton WJ. Statement by the President
[on H.R. 4461, the Agriculture, Rural Develop-
ment, Food and Drug Administration, and related
agencies appropriations act for FY 2001]. The
White House. October 28, 2000. http://www.pub.
whitehouse.gov/uri-res/I2R?urn:pdi://oma.eop
.gov.us/2000/10/30/13.text.1 Accessed Novem-
ber 8, 2000.
73. Emilien G. Future European health care:
cost containment, health care reform and scientif-
ic progress in drug research. Int. J. Health Plann.
Manage. 1997;12(2):81-101.
74. US Federal Trade Commission. FTC
charges drug manufacturer with stifling competi-
tion in two prescription drug markets. Press re-
lease, March 16, 2000. http://www.ftc.gov/opa/
2000/03/hoechst.htm.
75. Schondelmeyer S. Patent extension of
pipeline drugs: impact on US health care ex-
penditures. July 28, 1999. http://house.gov/berry/
prescriptiondrugs/schondelmeyer.htm.
76. Congressional Budget Office. How in-
creased competition from generic drugs has af-
fected prices and returns in the pharmaceutical in-
dustry. July 1998. http://www.cbo.gov/ show-
doc.cfm?index=655&sequence=0&from=1.
Accessed March 4, 2000.
77. Arno PS, Davis MH. Why dont we en-
force existing drug price controls. The unrecog-
nized and unenforced reasonable pricing require-
ments imposed upon patents deriving in whole or
in part from federally-funded research. Tulane
Law Review, in press.
78. 35 U.S. Code 200 ff. As cited in refer-
ence 77.
80. U.S. General Accounting Office. Trans-
ferring federal technology. Washington: GAO,
May 1998. GAO/RCED-98-126. As cited in ref-
erence 77.
81. Departments of Labor, Health and Human
Services, and Education, and Related Appropria-
tions Act, 2001. Cong. Rec. 106th Cong., H 4293,
H 4304 (June 13, 2000).
82. Moore MO. Legislators create drug price
group. Bangor Daily News. June 3, 2000. http://
www.bangornews.com/cgi-bin/article.cfm?
storynumber=16176. Accessed June 18, 2000.
83. Freyer FJ. States join to battle prescription
costs. Providence Journal. June 3, 2000.
20007: Support for a New
Campaign for Universal
Health Care
Recalling its longstanding commitment to the
establishment of publicly funded and guaranteed
comprehensive, affordable health care for all;
1-3
and
Noting the six-year long hiatus in nationally
organized campaigns toward that goal; and
Recognizing that the hiatus, following a major
political defeat for health care reform efforts, re-
flected a political environment widely viewed as
favorable, at most, to small, piecemeal steps to-
ward reform; and
Concerned that the market-oriented health care
environment has marginalized public health; and
Realizing that a broad constituency has been
developing for a strong, new effort to secure com-
prehensive, affordable health care for all,
4
as a re-
sult of factors such as the absence of any substan-
tial decline in the numbers of uninsured people
even as the economy boomed and unemployment
shrank,
5
and the increasingly evident failure of
market-oriented managed care to contain health
care costs,
6
to enhance health care access, to as-
sure health care quality,
7
or to value the profes-
sional roles and integrity of health care profes-
sionals;
8,9
and
Appreciating that recent public opinion
polling confirms the readiness of a great many
Americans for a new attempt to gain universal
coverage, with virtually half of all respondents in
one survey saying that the federal government
should provide health care for all;
10
and
Welcoming the actual initiation of such a cam-
paign by three national organizations, the Uni-
versal Health Care Action Network (UHCAN),
the Gray Panthers, and the National Council of
Churches, at a launching conference in Wash-
ington, DC, October, 22-24, 1999; and
Noting that the campaign for universal health
care is viewed as a multi-year effort to realize, early
in the next century, a government commitment as-
suring universal, affordable, comprehensive, quali-
ty, publicly accountable health care, and that the
objectives of the campaigns first year (a campaign
phase dubbed U2K are (1) to increase the politi-
cal prominence of the issue of fundamental health
care reform nationwide, (2) to strengthen local
health care reform coalitions and build new links
among organizations concerned about the national
crisis in health care, and (3) to help build a vigor-
ous block of committed universal health care pro-
ponents in the next Congress; and
Encouraged by the recent formation of a
Universal Health Care Taskforce by members of
Congress,
11
therefore, APHA
1. Reaffirms its commitment to the national
effort to enact universal, comprehensive health
care legislation;
2. Urges that such legislation reflects the
Associations 14 principles for a national health
care program and that it cover all residents of the
U.S., Puerto Rico, the Northern Marianas, and the
U.S. territories, regardless of legal resident or im-
migration status;
Association News
3. Calls on the President and Congress to take
all necessary steps to propose and enact legisla-
tion to achieve this; and
4. Pledges to maintain a high priority on ac-
tivities to develop and enhance understanding of
and support for legislation that embodies the
Associations principles.
References
1. APHA Policy Statement 7108: A National
Program for Personal Health Services. APHA
Policy Statements; 1948present, cumulative.
Washington, DC: American Public Health Asso-
ciation; current volume.
2. APHA Policy Statement 7601: Committee
for a National Health Service. APHA Policy
Statements; 1948present, cumulative. Wash-
current volume.
3. APHA Policy Statement 9502: Toward a
Comprehensive, Universal National Health Pro-
gram, APHA Policy Statements, 1948present,
cumulative. Washington, DC: American Public
4. Employee Benefit Research Institute. EBRI
survey examines Americans confidence in the
health care system. Preliminary findings. http://
www.ebri.org/prrel/pr493.htm. September 10,
1999. Accessed September 11, 1999.
5. US Census Bureau. Health insurance cov-
erage: 1999. Accessed November 8, 2000. http://
www.census.gov/hhes/hlthin99/fig01.gif
6. International Foundation of Employee
Benefit Plans. Health care cost statistics. 1999.
http://www. ifebp.org/ichothcs. html. Accessed
November 5, 1999.
7. Manian FA. Whither continuity of care? N
Eng J Med. 1999:340(17).
8. Fagin CM. Nurses, patients and managed
care. New York Times. March 16, 1999.
9. Jaklevic MC. Associations join pro-union
ranks; doc, nurse organizations want to give their
members a stronger voice, new services. Mod
HealthCare. July 5, 1999, p. 6.
10. A frustrated and angry nation. Newsweek.
November 8, 1999. Poll conducted for the Dis-
covery Health Channel by the firm of Penn,
Schoen & Berland.
11. Health Care Justice Now: U2K Update,
No. 12 (July 2000). http:\\www.u2kcampaign.
org/net/newsletter7-00.htm Accessed October 7,
2000.
20008: Affirming the Importance
of Regulating Pesticide Exposures
to Protect Public Health
Recognizing that 891 chemical active ingre-
dients are registered as pesticides,
1
and that pes-
ticides are marketed specifically because they are
toxic to some living thing; and
Recognizing that many pesticides are inten-
tionally and routinely introduced into the environ-
ment, including 523 pesticides allowed in or on
foods or animal feeds;
2
Understanding that an estimated 82% of
American households use pesticides, with home-
owners applying approximately 136 million
pounds of pesticides each year indoors, or to their
gardens or lawns;
3,4
and
Recognizing that each year, the nations poi-
son control centers, on average, report at least
59,000 children under age six suffering uninten-
tional exposures to pesticides,
5
while an average
of more than 10% of these incidents are due to
organophosphate insecticides;
6
and
Further recognizing that at least 140 pesti-
cides registered by the Environmental Protection
Agency have been identified as toxic to the brain
and nervous system,
7
while approximately 90
known, probable, or possible carcinogens are ap-
proved for use on foods; and
Understanding that when monitored, signifi-
cant residues of many pesticides or their metabo-
lites have been detected in the urine of a great per-
centage of the adult or child populations sam-
pled;
8,9
and
Scientific Basis for FQPA
Recognizing that the Food Quality Protection
Act of 1996 (FQPA), which amended the Federal
Insecticide, Fungicide and Rodenticide Act
(FIFRA) and the Federal Food Drug and Cosmet-
ics Act (FFDCA), adopted a public health stan-
dard of reasonable certainty of no harm for pes-
ticides found in foods, and also used in other non-
agricultural settings, with explicit protection for
infants and children; and
Further noting that prior to FQPA, laws re-
garding pesticides established conflicting stan-
dards, including a health standard of a reasonable
certainty of no harm for pesticides on processed
foods, and risk-benefit balancing for pesticides on
fresh fruits and vegetables; which created the
paradox where a particular pesticide could be
deemed safe on a fresh fruit or vegetable and
unsafe or even banned on processed foods by
application of the Delaney clause for certain car-
cinogenic pesticides, this paradox was addressed
by the FQPAs adoption of a single public health
standard of reasonable certainty of no harm for
all foods (which also repealed the application of
the Delaney clause to pesticide residues on food);
and
Recognizing that much of the impetus for
FQPA came from the National Academy of
Sciences (NAS) landmark 1993 scientific review,
Pesticides in the Diets of Infants and Children,
which found that (1) when it comes to risks from
toxic chemicals in general, children are not little
adults;
10
(2) children, rather, are a readily iden-
tifiable subpopulation with its own physiological
characteristics (e.g., body weight), uptake charac-
teristics (e.g., food consumption patterns), and in-
herent susceptibilities;
11
and (3) part of chil-
drens inherent susceptibility to toxic chemicals
derives from critical periods or windows during
in utero or post-natal development, when expo-
sure to pesticides and other toxic chemicals can
irreversibly alter the function of an organ system
or systems at maturity;
12
and
Noting that numerous scientific studies since
the landmark 1993 NAS study have confirmed its
conclusions about childrens greater potential ex-
posure and susceptibility, generally, to pesticides
and other toxic chemicals;
13
and
Noting, in particular, the NAS finding that tol-
erances, or legal limits for pesticides in food, set
prior to FQPA were not health based, do not pro-
vide a good basis for inferences about actual ex-
posures of infants and children to pesticide
residues in or on food, and may not adequately
protect children;
14
and
Reiterating the NAS finding that for specific
pesticides already on the market, data on their
toxicity to developing animals (including chil-
dren) typically are lacking;
15
and
Reaffirming the National Academy of Sci-
ences conclusion that in the absence of data to
the contrary, there should be a presumption of
greater toxicity to infants and children for indi-
vidual pesticides;
16
and also
Aggregate Exposures
Recognizing that FQPA mandates for the first
time that regulation of a pesticide in or on food
also take into account all non-dietary routes of ex-
posure to that pesticide;
17
and
Noting the several studies demonstrating that
non-dietary pesticide exposure(s) to young chil-
dren from contaminated carpets, bedding, coun-
tertops, toys, and other areas of homes or schools
may be an important component of total pesticide
exposure;
18-22
and
Understanding that preliminary data show
that toddlers in some farmworker families are ex-
posed to at least one common organophosphate
insecticide in house dust at concentrations that
may lead to exposures exceeding EPAs level of
safety;
23
and
Understanding that prior to FQPA, the addi-
tional health risks from exposure to household
pesticides, many of which are also used and
found in or on foods, had not been fully addressed
by regulatory agencies;
24,25
and
Cumulative Risks
Recognizing that FQPA mandates for the first
time that regulation of a particular pesticide in or
on food also account for the cumulative risk from
exposure to other pesticides or other agents with
which it shares a common mechanism of toxici-
ty;
26
and
Noting acknowledgment by both EPA and the
pesticide industry that 37 registered organo-
phosphate insecticides, for example, largely share
a common mechanism of toxicity, that being inhi-
bition of the cholinesterase enzyme; yet
Recognizing that EPA has not yet assessed
real world, cumulative risks from exposure to any
set of pesticides, including these organophos-
phates,
27
nor does it plan to do so until the year
2001 at the earliest;
28
and
Noting that EPAs own refined risk assess-
ments for single organophosphate insecticides, in-
cluding methyl parathion, azinphos methyl, and
chlorpyrifos, among others, find excessive expo-
sures and risks to infants or children, even before
any cumulative assessment for organophosphates
is completed as required under FQPA; and
Understanding that when a cumulative OP as-
sessment is completed, the combined risks from
current use of the organophosphate insecticides,
which are known to be toxic to the brain and ner-
Association News
vous system, likely will exceed EPA levels of
concern by even greater margins; and
Noting the NAS finding that childrens expos-
ures to organophosphates are of special concern
because exposure to neurotoxic compounds at
levels believed to be safe for adults could result in
permanent loss of brain function if it occurred
during the prenatal and early childhood period of
brain development; and
Recognizing that other groups of pesticides,
for example, carbamates, triazines, vinclozolin
and related compounds, alachlor and related com-
pounds, etc., have yet to be addressed by EPA for
cumulative risk, therefore
Reaffirms the principle of using a public health
based standard (reasonable certainty of no harm) to
regulate food safety as opposed to the former stan-
dard which involved trade-offs between health
risks and economic benefits; and
Asserts the principle that risk assessment,
generally, and in the case of pesticides specifical-
ly, should account for exposure through all possi-
ble routes as well as exposures that may have cu-
mulative effects; and
Endorses the science-based principle that reg-
ulatory standards based on pesticide toxicity and
exposure data should be adequately protective of
fetuses, infants, and children, as well as other
people who may have unique susceptibility deriv-
ing from biological, physiological or behavioral
characteristics often specific to their developmen-
tal age; and therefore
Reaffirms its full support for the Food Quality
Protection Act (FQPA) of 1996; and
Proclaims that in passing the FQPA unani-
mously in the House of Representatives, and not
without amendment in the Senate, the U.S. Con-
gress acted wisely and appropriately, on the basis
of science, to protect the publics health and espe-
cially the health of infants and children; and
Strongly defends full implementation of the
FQPA, including tolerance reassessment and test-
ing of pesticides and related chemicals for poten-
tial to disrupt the endocrine system; and
Strongly support agency funding adequate to
carry out full implementation of the FQPA; and
Strongly supports as prudent public health
practice and in the face of childrens known vul-
nerability and pesticides known toxicity, the
FQPAs mandated use of an additional tenfold
margin of safety in pesticide risk assessments to
better protect children, in the absence of complete
toxicity and exposure data for a particular pesti-
cide demonstrating that infants and children
would still be protected by use of a lesser margin
of safety.
References
1. U.S. EPA, Pesticides Industry Sales and
Usage: 1996 and 1997 Market Estimates, Office
of Prevention, Pesticides and Toxic Substances,
November 1999.
2. Ibid.
3. Whitmore RW, Kelly JE, Reading PL, Na-
tional Home and Garden Pesticide Survey: Final
Report, Volume 1, Research Triangle Institute
NC: RTT\5100.17-01F, Research Triangle Park,
NC, 1992.
4. U.S. EPA, November 1999.
5. U.S. EPA, Updated Review of Poison Con-
trol Center Data for Residential Exposures,
Office of Prevention, Pesticides, and Toxic
Substances, March 22, 1999.
6. Ibid.
7. Federal Register 64(151):2945-42947,
1999.
8. Hill RH, Head SL, Baker S, Gregg M,
Shealy DB, Bailey SL, Williams CC, Sampson
EJ, Needham LL, Pesticide Residues in Urine of
Adults Living in the United States: Reference
Range Concentrations, Environmental Research
71:99-108(1995).
9. Eskenazi B, Bradman A, Castorina R, Expo-
sures of Children to Organophosphate Pesticides
and Their Potential Adverse Health Effects, Envi-
ron Health Perspect 107(suppl 3):409-419 (1999).
10. National Research Council, Pesticides in
the Diets of Infants and Children, National Acad-
emy Press Washington, DC, 1993.
11. National Research Council, Science and
Judgment in Risk Assessment, National Academy
Press: Washington, D.C., 1994, p. 220.
12. NRC 1993, p. 43.
13. Eskenazi B, Bradman A, Castorina R,
Exposures of Children to Organophosphate Pesti-
cides and Their Potential Adverse Health Effects,
Environ Health Perspect 107(suppl 3):409-419
(1999).
14. NRC, 1993, p. 8.
15. NRC, 1993, p. 4.
16. NRC, 1993, p. 9.
17. FFDCA 408(b)(2)(A)(ii).
18. Lewis RG, Fortmann RC, Camann DE.
Evaluation of methods for monitoring the poten-
tial exposure of small children to pesticides in the
residential environment. Arch Environ Contam
Toxicol 26:37-46 (1994).
19. Whitmore RW, Immerman FW, Camann
DE, Bond AE, Lewis RG, Schaum JL. Non-occu-
pational exposures to pesticides for residents of
two U.S. cities. Arch Environ Contam Toxicol
26:47-59 (1994).
20. Simcox NJ, Fenske RA, Wolz SA, Lee IC,
Kalman DA. Pesticides in household dust and
soil: exposure pathways for children of agricul-
tural families. Environ Health Perspect 103:1126-
1134 (1995).
21. Bradman MA, Harnly ME, Draper W,
Seidel S, Teran S, Wakeham D, Neutra R. Pesti-
cide exposures to children from Californias Cen-
tral Valley: results of a pilot study. J Expo Anal
Environ Epidemiol 7:217-234 (1997).
22. Eskenazi et al., 1999.
23. Ibid.
24. U.S. EPA, Draft Guidance For Performing
Aggregate Exposure And Risk Assessments, Of-
fice of Pesticide Programs, February 1, 1999.
25. U.S. EPA FIFRA Scientific Advisory
Panel Final Report, A Set of Scientific Issues
Being Considered by the Agency in Connection
with DDVP (Dichlorvos) Risk Issues, For the July
30, 1998 SAP meeting, (undated).
26. FFDCA 408(b)(2)(D)(v).
27. See EPAs preliminary and final risk as-
sessments for various organophosphates available
online at http://www.epa.gov/pesticides/op/
28. EPA still has no final policy guidance for
how to do a cumulative risk assessment. See http://
www.epa.gov/oppfead1/trac/science/.
20009: Support for International
Action to Eliminate Persistent
Organic Pollutants
Recognizing that persistent organic pollutants
(POPs) are transported globally;
1
persist in the
environment, bioaccumulate and biomagnify in
food chains, and build up in the body fat of hu-
mans and animals; and
Noting, as did APHA Policy Statement #9304
(Recognizing and Addressing the Environmental
and Occupational Health Problems Posed by
Chlorinated Organic Chemicals) that many POPs
are known to adversely affect human and animal
reproduction;
2
growth and development;
3
immune
function;
4
and neurological function;
5
and are
known or suspected to cause various cancers;
6
and
Noting as well that the WFPHA has recog-
nized this problem by resolution in May 1998 and
established an educational project to provide its
member associations with information on this
topic; and
Understanding further that these effects may
be seen at levels similar to those already present
in the environment,
7
and developing fetuses and
young children are especially vulnerable;
8
and
Recognizing that protecting human health and
the environment from POPs cannot be accom-
plished by national regulatory actions alone, but
rather requires a global commitment to reduce
and ultimately eliminate them; and
Observing that international negotiations to-
ward a global POPs Convention are underway,
and negotiators expect to conclude a legally bind-
ing agreement by the end of the year 2000;
9
and
Recognizing that sufficient evidence of hu-
man and eco-toxicity exists for 12 POPsaldrin,
chlordane, DDT, dieldrin, dioxins, endrin, furans,
heptachlor, hexachlorobenzene, mirex, PCBs,
and toxaphene(that) the Intergovernmental
Forum for Chemical Safety has targeted these for
immediate action under the global Convention;
10
and
Understanding that a number of additional
POPs may pose similar but less well-documented
threats to the environment and human health;
11
and
Appreciating that scientific certainty about
the toxicity of some POPs may be impossible to
achieve, particularly of those POPs beyond the
initial list of 12, but that additional study is none-
theless needed; and
Noting, as did APHA Policy Statement #9606
(The Precautionary Principle and Chemical
Exposure Standards for the Workplace), that the
precautionary principle, as outlined in the Rio
Declaration on Environment and Development
(1992) states that where there are threats of seri-
ous or irreversible damage, lack of full scientific
certainty shall not be used as a reason for post-
poning cost-effective measures to prevent environ-
mental degradation;
12
and
Acknowledging that the successful elimina-
tion of POPs will require the development and
implementation of safer, more sustainable alter-
native products, processes, and materials, many
of which already exist; and
Association News
Recognizing, as did APHA Policy Statement
#9607 (Prevention of Dioxin Generation from
PVC Plastic Use by Health Care Facilities), that
pollution prevention is the most effective means
of reducing and eliminating the formation and re-
lease of POPs, such as dioxins and furans, that are
by-products of human industry; and
Understanding that the disposal of stockpiled
POPs and POP-contaminated soils by some
methods, including high-temperature incinera-
tion, may itself lead to the formation and release
of POPs;
13
and
Recognizing that developing countries and
economies in transition are in many cases severe-
ly contaminated, yet these same countries are
without the necessary infrastructure to effectively
implement commitments made under a POP
elimination Convention, including the environ-
mentally sound disposal of POP stockpiles and
the replacement of POPs and POP-producing
technologies with safer alternatives; therefore,
1. Urges the international community to con-
clude a legally binding POPs Convention by
the end of the year 2000;
2. Urges the United States government to sup-
port the principles outlined above in global
POPs negotiations;
3. Urges the United States to sign the POPs
Convention in Stockholm, May 2001;
4. Asserts that POPs are inherently unman-
ageable substances and that the ultimate
goal for the global Convention is the elimi-
nation of POPs and their significant anthro-
pogenic sources, where feasible and as
soon as possible;
5. Supports immediate global action under the
Convention to eliminate the use and produc-
tion of aldrin, chlordane, dieldrin, endrin,
heptachlor, hexachlorobenzene, mirex, and
toxaphene;
6. Supports an immediate end to the production
and use of new PCBs, and a phase-out of ex-
isting PCBs in use within a reasonable time
frame;
7. Urges reductions in the production and use of
DDT as much as possible without compro-
mise to human health, with the ultimate aim
of a complete phase-out, and that the
Convention work closely with the World
Health Organization to develop and imple-
ment safer, cost-effective alternatives for
malaria control;
8. Strongly encourages a pollution prevention
approach to dioxins, furans, and other by-
product POPs, emphasizing the use of alter-
native products, processes, and materials as
source elimination strategies, with the ulti-
mate aim of eliminating all significant an-
thropogenic sources and releases of POPs
by-products;
9. Supports the destruction of POP stockpiles
by means that do not themselves generate
POPs, and mandate measures to address
POP-contaminated soils, sediments and
other environmental reservoirs,
10. Urges that POPs, once their production and
use are banned, should not be traded, except
perhaps for the purpose of their environmen-
tally sound destruction, and that the POPs
Convention must not be subordinated to in-
ternational trade rules;
11. Recommends that all POPs, once identified
for action under the Convention, be slated for
eventual elimination, that the Convention em-
ploy country-specific and use-specific exemp-
tions to address countries special needs dur-
ing phase-out periods;
12. Urges that additional chemicals be identified
for elimination using science-based criteria,
including their capacity for long-range trans-
port, persistence, bioaccumulation, and toxi-
city, and that the thresholds set for numeric
criteria should allow for the capture of sig-
nificant POPs of concern;
13. Recommends aggressive programs of toxici-
ty testing directed to the many chemicals
whose toxic effects remain unknown, evalu-
ating these chemicals both individually and
in combination, and addressing the broad
range of relevant health outcomes, including
carcinogenicity and mutagenicity; endocrine
activity; and developmental, immune, neuro-
logical, and reproductive toxicity;
14. Urges that developed nations provide techni-
cal assistance and funding to less developed
nations directly, through multilateral agree-
ments, and through existing financial assis-
tance mechanisms such as the Global
Environment Facility, to support the elimina-
tion of POPs, including support for the im-
plementation of alternative means of malaria
vector and disease control;
15. Supports the principles of just transition, pro-
tecting the livelihoods of workers and com-
munities affected by the elimination of
POPs;
16. Pays careful attention to the occupational
health of workers engaged in the elimination
of POPs; and
17. Strongly encourages the U.S. to support the
development and use of alternatives to DDT
including, but not limited to, integrated vec-
tor management for malaria control in devel-
oping countries, through direct development
assistance, the World Health Organization,
and other international efforts.
References
1. Simonich SL, Hites RA. Global distribu-
tion of persistent organochlorine compounds. Sci-
ence. 1995; 269:1851-1854.
2. Fry DM, Toone SM. DDT-induced femi-
nization of gull embryos. Science. 1981; 213:922-
924. Leatherland JF. Endocrine and reproductive
function in Great Lakes salmon. In Chemically
Induced Alterations in Sexual and Functional
Development, Colborn T and Clement C, eds.
Princeton, NJ: Princeton Scientific Press, 1992:
129-145. Mendola P, Buck GM, Sever LE,
Zieiezny M, Vena JE. Consumption of PCB-cont-
aminated freshwater fish and shortened menstrual
cycle length. Am J Epidemiol. 1997; 146(11)
:955-960. Swain WR. Effects of organochlorine
chemicals on the reproductive outcomes of hu-
mans who consumed contaminated Great Lakes
fish: An epidemiologic consideration. Toxicol
Environ Health. 1991; 33(4):587-639.
3. Birnbaum LS. Developmental effects of
dioxins [review]. Environ Health Perspect. 1995;
103(suppl. 7): 89-94. Colborn T, vom Sal FS,
Soto AM. Developmental effects of endocrine-
disrupting chemicals in wildlife and humans.
Environ Health Perspect. 1993; 101(5):378-384.
Fein GG, Jacobson JL, Jacobson SW, Schwartz
PM, Dowler JK. Prenatal exposure to polychlori-
nated biphenyls: Effects on birth size and gesta-
tion age. Pediatr. 1984; 105:315-320. Guo Y-L,
Lambert GH, Hsu C-C. Growth abnormalities in
the population exposed in utero and early postna-
tally to polychlorinated byphenyls and dibenzofu-
rans. Environ Health Perspect. 1995; 103(suppl
6): 117-122. Jacobson JL, Jacobson SW. Intel-
lectual impairment in children exposed to poly-
chlorinated biphenyls in utero. N Engl J Med.
1996; 335(11):783-789. Rogan WJ, Gladen BC,
McKinney JD, Carreras N, Hardy P, Thullen J,
Tingelstad J, Tully M. Neonatal effects of
transplacental exposure to PCBs and DDE.
Pediatr. 1986; 109:335-341. Taylor PR, Stelma
JM, Lawrence CE. The relation of polychlorinat-
ed biphenyls to birth weight and gestational age
in the offspring of occupationally exposed moth-
ers. Am J Epidemiol. 1989;129: 395-406.
4. Queiroz ML, Bincoletto C, Perlingeiro RC,
Souza CA, Toledo H. Defective neutrophil func-
tion in workers occupationally exposed to hexa-
chlorobenzene. Hum Exp Toxicol. June 1997;
16(6):322-326. Weisglas-Kuperus N, Sac TCJ,
Koopman-Esseboom C, Van der Zwan CW, de
Ridder MAJ, Beishuizen A, Hooijkaas H, Sauer
PJJ. Immunologic effects of background prenatal
and postnatal exposure to dioxins and polychlori-
nated biphenyls in Dutch infants. Pediatr Res.
1995; 38(3):404-410.
5. Carson, R. Silent Spring. New York, NY:
Houghton Mifflin, 1962. 187-98.
6. Hoyer AP, Grandjean P, Jorgensen T, Brock
JW, Hartvig HB. Organochlorine exposure and
risk of breast cancer. Lancet. 1998; 352(9143):
1816-1820. Hunter DJ, Hankinson SE, Laden F,
Colditz GA, Manson JE, Willett WC, Speizer FE,
Wolff MS. Plasma organochlorine levels and the
risk of breast cancer. N Engl J Med. 1997;337
(18):1253-1258. International Agency for Re-
search on Cancer. Polychlorinated dibenzo-para-
dioxins and polychlorinated dibenzofurans. IARC
Monographs on the evaluation of carcinogenic
risks to humans, 1997; 69. U.S. Department of
Health and Human Services, National Toxicology
Program. 9th Report on Carcinogens. Research
Triangle Park, NC: Public Health Service, 2000.
Wolff MS, Toniolo PG. Environmental organo-
chlorine exposure as a potential etiologic factor in
breast cancer. Environ Health Perspect. 1995;
103(suppl 7):141-145.
7. Brouwer A, Longnecker MP, Birnbaum LS,
Cogliano J, Kostyniak P, Moore J, Schantz S,
Winneke G. Characterization of potential endo-
crine-related health effects at low-dose levels of
exposure to PCBs. Environ Health Perspect.
1999;107(suppl 4):639-649.
8. Jacobson JL, Jacobson SW, Humphrey HE.
Effects of exposure to PCBs and related com-
pounds on growth and activity in children. Neuro-
toxicol Teratol. 1990; 12(4):319-326.
Association News
9. United Nations Environment Programme.
Governing Council Decision 20/24. International
action to protect health and the environment
through measures which will reduce and/or elim-
inate emissions and discharges of persistent or-
ganic pollutants, including the development of an
international legally binding instrument. 1999.
10. Ritter L, Solomon KR, Forget J, Stemeroff
M, OLeary C. A Review of the Persistent Organic
PollutantsAn Assessment Report on: DDT,-
Aldrin, Dieldrin, Endrin, Chlordane, Heptaclor,
Hexachlorobenzene, Mirex, Toxaphene, Polychlor-
inated Biphenyls, Dioxins and Furans. The Inter-
national Programme on Chemical Safety (IPCS),
1995. United Nations Environment Programme.
Governing Council Decision 19/13C. International
action to protect human health and the environ-
ment through measures which will reduce and/or
eliminate emissions and discharges of persistent
organic pollutants, including the development of
an international legally binding instrument.
UNEP/GC.19/ INF.8, annex, 1997.
11. Hoque A, Sigurdson AJ, Burau KD,
Humprey HE, Hess KR, Sweeney AM. Cancer
among a Michigan cohort exposed to polybromi-
nated biphenyls in 1973. Epidemiology. 1998;
9(4):373-378.
12. United Nations Conference on Envi-
ronment and Development (UNCED), Principle
15. Declaration of Rio. Rio de Janeiro, Brazil:
United Nations, 1992.
13. United Nations Food and Agriculture
Organization. Disposal of bulk quantities of ob-
solete pesticides in developing countries. 1996.
200010: Creating Healthier
School Facilities
Recognizing the importance of including of
all children in all environmental policy-making;
1
and
Recognizing the need to support global, fed-
eral, state, and local policies that promote healthy
environments for children, that prevent exposures
to environmental hazards, that provide for a par-
ent right to know about hazards, and that promote
multi-disciplinary research on the effects of ex-
posures on children;
2
and
Recognizing that more than $250 billion is
needed to repair or upgrade Americas school fa-
cilities to good condition;
3-6
and
Understanding that other school facility prob-
lems include inadequate plumbing, lead, radon,
mold and moisture, asbestos, poor lighting, and
acoustics;
7,8
and noting that the lowest income
students are in the schools in the worst condi-
tion;
9-11
and
Recognizing that the US Government Ac-
counting Office has reported that while children
are compelled to attend school, it has estimated
that 15,000 schools in the United States have in-
door air pollution or ventilation problems affect-
ing over 11 million children;
12-15
and
Noting that schools are purchasers of a wide
array of hazardous cleaning and instructional sup-
plies that can contribute to indoor pollution af-
fecting health;
16-20
that pollution prevention is the
national environmental policy of the United
States;
21
and that no federal guideline or program
has been established to promote pollution preven-
tion purchasing for materials and supplies used
by schools; and
Further noting that although at least 30 states
have moved to curb pesticide exposures at
school;
22
that school use of pesticides is a signif-
icant environmental hazard causing about 2,300
pesticide-related exposures at school between
1993 and 1996;
23-27
that there are no federal re-
quirements for schools to reduce childrens
school-based exposures to multiple-risk pesti-
cides, including chemical carcinogens, and toxins
to the reproductive, endocrine, brain and nervous
systems;
28-31
and
Recognizing that model building codes and
industry ventilation standards are being devel-
oped without the inputs of the public health sec-
tor and therefore without protections specifically
referencing children at school;
32
and
Noting that programs of the US Environ-
mental Protection Agencys are available to im-
prove school facilities, including Tools for
Schools and the Energy Star Program, are not in
wide use by schools nationally;
33
and
Understanding that states and local school
districts need billions of dollars to construct and
repair school infrastructure and thus have an op-
portunity to advance healthier school facility sit-
ing, design, and construction;
34
and
Understanding that there is a federal re-
quirement for public schools to evaluate all chil-
dren K-12 with suspected educational disabilities,
and that the US Department of Education is not
spending educational research dollars on studies
on the effect of indoor pollutants or other envi-
ronmental factors on student health, learning, or
behavior problems;
35,36
and
Noting that the US Department of Education
is not actively participating in the federal Com-
mittee on Indoor Air Quality nor actively partici-
pating in the federal inter-agency task force on
childrens environmental health and safety as re-
quired by federal executive order;
37
Therefore, APHA concludes that
Every child and school employee should
have a right to an environmentally safe and
healthy school that is clean and in good re-
pair;
Federal funds should be appropriated to con-
struct and renovate schools, with priorities
placed on improving facility environmental
conditions;
Federal, state, and local entities must work
together to use resources effectively and effi-
ciently to address school siting, construction,
maintenance, and other practices to ensure
the provision of an environmentally safe and
healthy school;
Parents and personnel should have a right to
know about environmental health hazards
and threats in the school environment;
Schools be required to follow pollution pre-
vention principles for infrastructure siting,
construction, maintenance, and other prac-
tices that reduce or eliminate childrens ex-
posures that affect health, learning, or behav-
ior; and
The federal inter-agency task force on chil-
drens environmental health work collabora-
tively with the U.S. Department of Education
to create a system for the prevention, re-
search, evaluation, and reporting of chil-
drens school-based exposures that affect
health, learning, and behavior; therefore,
APHA
1. Urges the U.S. Department of Education to
work with the U.S. EPA on guidelines it has un-
derway for the design, siting, and construction of
new schools, and to work with other federal agen-
cies in the federal inter-agency task force on child
environmental health and in the federal commit-
tee on indoor air quality.
2. Advocates for federal funds for further re-
search on the extend and impact of childrens en-
vironmental health and safety risks and exposures
at schools and prevention measures, including re-
search sponsored by the U.S. Department of
Education.
3. Supports measures that provide a parent
right to know about childrens exposure to envi-
ronmental hazards at school.
4. Supports the School Environmental Pro-
tection Act (SEPA) that would require schools to
follow least-toxic pesticide practices and provide
prior notice to parents and personnel of certain
pesticide applications, and as a ppropriate, sup-
ports other federal legislation designed to promote
environmentally responsible purchasing by
schools.
5. Supports federal funding for school con-
struction and in support of targeting federal funds
to the remediation of school environmental health
hazards, especially in high-needs schools serving
low-income children and health-impaired or other
identified high-risk students.
6. Encourages APHA affiliates to advocate
for and to support state and local funding and pro-
grams to protect students and personnel from en-
vironmental health hazards at school.
References
1. APHA Policy Statement 9511. APHA Pol-
icy Statements; 1948present, cumulative. Wash-
ington, DC: American Public Health Association.
2. See 1.
3. Modernizing Our Schools: What Will It
Cost. National Education Association, April
2000.
4 Condition of Americas Schools, US
Government Accounting Office. HEHS 95-61,
February 1995.
5. The nations single largest school district
estimated its own need for school facility con-
struction at $11 billion November 1998, but did
not include remediating drinking water or indoor
air, or lead abatement. New York, NY: Board of
Education, Division of Facilities, November
1998.
6. Los Angeles Unified School District inves-
tigates its own Environmental Health and Safety
Branch and found staff pressured by school offi-
cials to underreport lead and asbestos problems,
as reported by Los Angles Times, September, 29,
1999.
7. See 3.
Association News
8. Lead Hazards in Californias Public Ele-
mentary School and Child Care Facilities: Report
to the State Legislature, California Department of
Health Services, Division of Environmental and
Occupational Disease Control, April 1998, esti-
mating 77% of schools and centers have been
painted with lead-based paints, and 18% of
schools have lead in drinking water at or above
federal action levels.
9. See 3.
10. Americas Schools Report Differing Con-
ditions, US Government Accounting Office,
HEHS 96-03. June 1996.
11. Report of the Advisory on School Envi-
ronmental Quality, 1994, and Recommendations
of the Facilities Advisory Committee 1995-96
and 1996-97. New York State Board of Regents.
12. See 3.
13. The American Lung Association estimates
10 million lost school days annually to asthma,
the leading cause of school absenteeism due to
chronic disease. School IAQ is a core program for
all ALA affiliates.
14. Tools for Schools, US Environmental
Protection Agency, a voluntary program for
schools to improve indoor air states that indoor
levels of pollutants may be 2-5 times (and some-
times 100 times) higher than outdoor levels, and
that most people spend 90% of their time indoors.
It also notes that children are especially suscepti-
ble to air pollution and ranks indoor air pollution
among the top four environmental health risks to
the public.
15. An Introduction for Health Professionals.
Washington, DC: US Environmental Protection
Agency. Handbook of Pediatric Environmental
Health, American Academy of Pediatrics, 1999.
16. Toxic Chemical Exposures in Schools: Our
Children At Risk; Vermont Public Interest
Research Group, March 1998. Chemical Use
Reduction for Improved Air Quality in Schools,
Office of Technical Assistance for Toxics Use
Reduction, Executive Office of Environmental
Affairs, Commonwealth of Massachusetts, May
1999. Healthier Cleaning & Maintenance:
Practices and Products for Schools, Healthy
Schools Network and NYS Assn. for Super-
intendents of School Buildings and Grounds,
1999.
17. APHA Policy 9606. APHA Policy
Statements; 1948present, cumulative. Washing-
ton, DC: American Public Health Association.
18. See 14.
19. What School Nurses Know, preliminary
survey report, New York State Association of
School Nurses, May 2000.
20. Neglected Buildings, Damaged Health:
Snapshot of New York City School Conditions.
Advocates for Children of New York. October
1999.
21. Federal Pollution Prevention Act. US
EPA, Office of Pollution Prevention and Toxics,
1990.
22. Schooling of State Pesticide Laws,
Beyond Pesticides/National Coalition Against the
Misuse of Pesticides. Pesticides and You,
1999;18(3).
23. Pesticides: Use, Effects, and Alternatives
to Pesticides in Schools, US Government
Accounting Office, RCED-00-November 17,
1999.
24. Unintended Casualties: Five Children
Whose Lives Were Profoundly Affected by Pesti-
cide Exposures at School, Northwest Coalition
for Alternatives to Pesticides, April 2000.
25. Pesticides and National Strategies for
Health Care Providers, workshop proceedings,
April 1998.
26. Posner, M. Preventing School Injuries: A
Comprehensive Guide for School Administrators,
Teachers, and Staff. New Brunswick, NJ: Rutgers
University Press, 2000.
27. Recognition and Management of Pesticide
Poisonings. 5th edition. Washington, DC: US
Environmental Protection Agency. March 1999.
28. Mott et al. Our Children At Risk: The 5
Worst Environmental Threats to Their Health.
Natural Resources Defense Council, 1997
29. Environmental Health Threats to
Children. Washington, DC: US Environmental
Protection Agency. 1996.
30. Gurunathan, et al. Accumulation of chlor-
pyrifos on residential surfaces and toys accessible
to children. Env. Health Perspec. 1998;106(1). Lu
and Fenske, Dermal transfer of chlorpyrifos
residues from residential surfaces. Env. Health
Perspec. 1999;107(6). Davis and Ahmed. Expo-
sures from indoor spraying of chlorpyrifos pose
greater health risks to children than currently es-
timated. Env. Health Perspec. 1998;106(6).
31. Parents Urged To Be Watchdogs on Pesti-
cides, New York Times, June 15, 2000; Schools in
New York Overuse Pesticides and Fail to Issue
Warnings, New York Times, June 14, 2000. Reports
from Attorney Generals in Connecticut and New
York.
32. APHA Policy Statement 9916. APHA
Policy Statements; 1948present, cumulative.
Washington, DC: American Public Health
Association.
33. US EPA and American Lung Association
(staff communication with author).
34. Sustainable America: A New Consensus.
The Presidents Council on Sustainable
Development, 1996. High Performance Building
Guidelines. City of New York Department of
Design and Construction, April 1999.
35. Federal Individual with Disabilities
Education Act. PL 94-142, 1975; also Section
504 of the Rehabilitation Act of 1973.
36. US Department of Education web site and
search for priorities and funded research.
37. Lack of participation long noted by other
federal agencies, and subject of a coalition letter
to USD Education (June 2000).
200011: The Precautionary
Principle and Childrens Health
Recognizing that, for centuries, the corner-
stone of public health policy and practice has
been the prevention of injury and disease; and
Recognizing that the US has signed the Rio
Declaration on Environment and Development
which states;
In order to protect the environment, the pre-
cautionary approach shall be widely applied by
States according to their capabilities. Where there
are threats of serious or irreversible damage, lack
of full scientific certainty shall not be used as a
reason for postponing cost-effective measures to
prevent environmental degradation, a statement
known as the Precautionary Principal;
1
and
Recognizing that the American Public Health
Association has previously encouraged the imple-
mentation of the Precautionary Principle with re-
gard to workplace chemical exposure prevention
policies;
2
and
Recognizing that current environmental regu-
lations are primarily aimed at controlling pollu-
tion rather than using primary preventive mea-
sures to avoid the use, production, or release of
toxic materials;
3
and
Recognizing that development of enterprises,
projects, technologies, products, and substances,
that may adversely affect public health proceeds
through initiatives that may or may not have con-
sidered a range of safer alternatives;
4
and
Recognizing that many of these enterprises,
projects, technologies, products, and substances
are considered safe until proven harmful; and
Recognizing that public health decisions must
often be made in the absence of scientific cer-
tainty, or in the absence of perfect information;
and
Recognizing that some industries engaged in
the production, release, or distribution of poten-
tially hazardous products and processes use their
influence to delay preventive action, arguing that
the immediate expense of redesign to achieve pol-
lution prevention is unwarranted, lacking scientif-
ic certainty about harmful health effects;
5
and
Recognizing that fetuses, children, and all de-
veloping organisms are often more susceptible to
environmental contaminants than adults, and that
agency policies and decisions often fail to reflect
this unique susceptibility;
6
and
Recognizing that proof of cause and effect re-
lationships is often difficult to establish because
of non-specificity of health effects, long latent
periods, subtle changes in function that are diffi-
cult to detect without resource-intensive studies,
and complex interactions of variables that con-
tribute to adverse health effects;
7
and
Recognizing that some lack of scientific cer-
tainty is irresolvable by more data collection; that
some residual lack of scientific certainty is actu-
ally the result of indeterminacy due to multiple
factors interacting in complex systems or due to
ignorance about what questions to ask or what ef-
fects to look for;
8
and
Declaring that children and other sensitive
populations are, therefore, in particular need of
protection from environmentally related hazards;
and
Recognizing that Presidential Executive
Order #13045 requires that all federal agencies,
when developing policies, must explicitly consid-
er their impacts on children, therefore,
Reaffirms its explicit endorsement of the
precautionary principle as a cornerstone of
preventive public health policy and practice,
both in the U.S. and throughout the world;
Encourages governments at all levels, the
private sector, and health professionals to
promote and abide by this principle in order
Association News
to protect the health and well-being of all de-
veloping children. Thus, APHA calls for ex-
plicit inclusion of the precautionary ap-
proach in all federal, state, and local legisla-
tion, rules, or policies intended to protect
children or that may impact the health of
children;
Urges that whenever an enterprise, project,
technology, product, or substance is pro-
posed for initiation, manufacture, or use or
continued manufacture or use the goal of
public health advocates should be to reduce
or eliminate the creation of conditions that
may adversely impact reproductive health,
infants, or children;
Advocates significant increases in pollution
prevention efforts through clean production,
assessment of safer alternatives, energy effi-
ciency, waste minimization, safer waste dis-
posal methods, and reduced consumption as
a general means to protect childrens health
and development, rather than relying on risk
management of individual hazards;
Encourages explicit consideration of the
kinds and magnitude of harm to reproductive
health, infants, or children that may result
from an activity and its alternatives;
Encourages explicit consideration of the
kinds and magnitude of uncertainties inher-
ent in assessing potential harm to reproduc-
tive health, infants, or children from an activ-
ity and its alternatives;
Encourages precautionary action to prevent
potential harm to reproductve health, infants,
and children, even if some cause and effect
relationships have not been established with
scientific certainty;
Urges scientists to engage in analysis and
studies to develop implementation strategies
using the precautionary principle that are
based on sound science.
Enunciates the urgent need for improved re-
search methods to understand better the addi-
tive, cumulative, and synergistic effects of
multiple stressors on childrens development
and health; and.
Urges the United States to honor and explic-
itly refer to the precautionary principle dur-
ing negotiations of international agreements,
while working to establish the precautionary
principle as a guiding principle of environ-
mental and health-related international law.
References
1. Rio Declaration on Environment and
Development (July 14, 1992). ILM. 1992; 31:873.
2. APHA Policy Statement #9606: The
Precautionary Principle and Chemical Exposure
Standards for the Workplace. APHA Policy
Statements; 1948present, cumulative. Wash-
ington, DC: American Public Health Association.
3. Ashford N, Caldart C. Technology, Law and
the Working Environment. Washington, DC:
Island Press, 1997. Jackson T (ed). Clean Pro-
duction Strategies: Developing Preventive Envi-
ronmental Management in the Industrial Econ-
omy. Boca Raton, FL: Lewis Publishers, 1993.
4. OBrien, M. Making Better Decisions.
Cambridge, MA: MIT Press, 2000.
5. Markowitz G, Rosner D. Cater to the chil-
dren: The role of the lead industry in a public
health tragedy, 1900-1955. Am J Public Health.
2000; 90:36-46. Fagin D, Lavelle M. Toxic De-
ception: How the Chemical Industry Manipulates
Science, Bends the Law, and Endangers Your
Health. Seacaucus, NJ: Birch Lane Press, 1996.
6. National Research Council. Pesticides in
the Diets of Infants and Children. Washington,
DC: National Academy Press, 1993.
7. Raffensperger C, Tickner J (eds). Protecting
Public Health and the Environment: Imple-
menting the Precautionary Principle. Washington,
DC: Island Press, 1999.
8. See 7 and 3.
200012: Reducing the Rising
Rates of Asthma
Observing that, according to the U.S. Centers
for Disease Control and Prevention, asthma preva-
lence and mortality have been steadily rising in the
US over the last 15 years in children and young
adults under the age of 35;
1
and
Noting that, while the cause of the rising asth-
ma rates is unknown, there are a number of envi-
ronmental factors known to exacerbate asthma;
such factors include ambient air pollution, occu-
pational allergens, environmental tobacco smoke,
and indoor environmental factors such as pesti-
cides, dust mite, cockroach, mold and pet aller-
gens,
2-7
as well as socioeconomic status, econom-
ic development, and urbanization;
1-3, 6-8
and
Noting that at present there is very little sur-
veillance for asthma prevalence at either a state,
national, or international level, leaving state and
local health departments, as well as national
agencies, uncertain about the prevalence rates in
the areas they serve; there is little surveillance for
asthma incidence, nationally or internationally;
9
and
Recognizing that numerous studies have doc-
umented that asthma disproportionately impacts
low income and minorities in terms of emergency
room visits and hospitalizations, such communi-
ties are more likely to have higher air pollution
levels, are likely to live in homes with higher al-
lergen loads, and have less control over their
home environments; to compound this they often
have less access to medical management to con-
trol asthma attacks and are more likely to utilize
emergency rooms and other acute care services
for routine medical care;
6,7,10-12
and
Noting that rates of asthma are highest in chil-
dren aged 6-16, that asthma in childhood is an im-
portant predictor of asthma over a lifetime, that
asthma rates are rising most steeply in children,
and that children are known to be more exposed
and susceptible to a number of environmental fac-
tors known to be associated with asthma;
1,5,13
and
Noting the continued high incidence of acute
respiratory infections in children in developing
countries, and that the significance of asthma as a
comorbid factor is not appreciated; and
Noting that infants breathe more air per kilo
of body weight per day than adults and their im-
mune systems and lungs are in sensitive stages of
development;
14
and
Noting that it passed a resolution in 1995 en-
titled Childrens Environmental Health, in
which it recognized the unique environmental
health concerns affecting children including asth-
ma; and
Recognizing that whereas primary and sec-
ondary prevention strategies have not been clearly
identified or evaluated for asthma, there is a set of
evidence-based treatment guidelines that have
been developed by the National Heart, Lung and
Blood Institute and its expert committees to guide
medical and environmental intervention for peo-
ple who have asthma;
15
and
Noting the importance of a strong evidentiary
basis for public health practice as well as assess-
ment of costs and effectiveness for public health
strategies and the lack of such data for many asth-
ma interventions; and
Observing that we are in the midst of an epi-
demic of asthma
1
and noting that broad-based
public health strategies are necessary to better un-
derstand, reduce and prevent the disease; there-
fore, encourages and supports:
1. The federal coordination effort and calls for a
long range and more comprehensive plan of
action on asthma involving all of the agencies
of the Public Health Service, but most notably
the Centers for Disease Control and Preven-
tion (CDC), National Institutes of Health
(NIH), Agency for Toxic Substances and Dis-
ease Registry (ATSDR), Health Resources
and Services Administration (HRSA),
Occupational Safety and Health Adminis-
tration (OSHA), and Food and Drug
Administration (FDA); the Health Care
Financing Administration (HCFA), and the
Environmental Protection Agency (EPA) and
voluntary organizations;
2. Federal and private research efforts directed
at identifying the cause or causes of the ris-
ing rates of asthma;
3. Federal, state, and local efforts to develop na-
tionwide surveillance of asthma cases and
environmental factors that may possibly be
involved with asthma causation and/or exac-
erbation;
4. Global efforts to strengthen surveillance and
to better understand the global pattern of
asthma and the cause for such distribution;
5. Inclusion of asthma in federal, state, and
local initiatives on reducing health dispari-
ties;
6. Public health and other interventions at all
levels of government and by nongovernmen-
tal organizations to reduce the severity of
asthma in the U.S. and help people with asth-
ma lead healthy, active lives, including re-
duction of indoor and outdoor air pollutants.
This includes provision of insurance cover-
age and/or reimbursement for programmatic
approaches to prevention of acute episodes
of asthma requiring emergency treatment;
7. Appropriations to public health agencies at
the federal, state, and local level for asthma
surveillance, education and public health in-
tervention and prevention efforts by health
departments and related agencies;
8. Provision by health care systems and school
health personnel, including school nurses
Association News
and physical education teachers, of adequate
diagnosis, treatment, family or caregiver, and
patient education, equipment, and case man-
agement systems, including implementation
of the National Heart Lung and Blood Insti-
tute asthma treatment guidelines;
9. Intervention trials designed to help to identi-
fy causal factors for the increased rate of
asthma and establish cost-effective measures
to relieve the burden of asthma on the popu-
lation;
10. Collaborative efforts among housing, trans-
portation planners, land use planners, educa-
tion, environmental, public health, labor and
employer representatives and health care pro-
fessionals to combat the rising rates of asth-
ma;
11. Effective education and training of public
health and health care professionals and the
public about the prevention and treatment of
asthma, including attention to the environ-
mental and occupational triggers associated
with asthma;
12. Rigorous evaluation of existing intervention
strategies and programs, including those of
the U.S. Department of Education and the
U.S. Department of Housing and Urban De-
velopment, and wide dissemination of re-
sults; and
13. Effective evaluation of existing prevention
and intervention strategies to determine the
most effective population-based approaches.
References
1. Mannino DM, Homa DM, Pertowski CA,
et al. Surveillance for asthmaUnited States,
1960-1995. Morb Mortal Wkly Rep CDC Surveill
Summ. 1998;47(1):1-27.
2. Samet JM. Asthma and the environment:
Do environmental factors affect the incidence and
prognosis of asthma? Toxicol Lett. 1995; 82-
83:33-38.
3. Institute of Medicine. Clearing the Air:
Asthma and Indoor Air Exposures. Washington,
DC: National Academies Press, 1999.
4. Holgate ST, Samet JM, Koren HS, May-
nard RL. Air Pollution and Health. San Diego,
CA: Academic Press; 1999.
5. Gern JE, Lemanske RF, Jr., Busse WW.
Early life origins of asthma. J Clin Invest.
1999;104(7):837-843.
6. Eggleston PA, Buckley TJ, Breysse PN,
Wills-Karp M, Kleeberger SR, Jaakkola JJ. The
environment and asthma in U.S. inner cities. Envi-
ron Health Perspect. 1999;107 suppl 3:439-450.
7. Claudio L, Tulton L, Doucette J, Landrigan
PJ. Socioeconomic factors and asthma hospitaliz-
ation rates in New York City. J Asthma. 1999;
36(4):343-50.
8. Stolberg S. Poor people are fighting baf-
fling surge in asthma. New York Times. 1999.
9. Healthy People 2010, conference edition.
Washington, DC: US Department of Health and
Human Services, 2000.
10. Sarpong SB, Hamilton RG, Eggleston PA,
Adkinson NF, Jr. Socioeconomic status and race
as risk factors for cockroach allergen exposure
and sensitization in children with asthma. J Aller-
gy Clin Immunol. 1996;97(6): 1393-1401.
11. Coultas DB, Gong H, Jr., Grad R, et al.
Respiratory diseases in minorities of the United
States [published erratum appears in Am J Respir
Crit Care Med. July 1994;150(1):290]. Am J
Respir Crit Care Med. 1994;149(3 pt 2):S93-131.
12. Gergen PJ, Mortimer KM, Eggleston PA,
et al. Results of the National Cooperative Inner-
City Asthma Study (NCICAS) environmental in-
tervention to reduce cockroach allergen exposure
in inner-city homes. J Allergy Clin Immunol.
1999;103(3 pt 1):501-506.
13. Weiss ST. The origins of childhood asth-
ma. Monaldi Arch Chest Dis. 1994;49(2): 154-
158.
14. Weiss ST. Environmental risk factors in
childhood asthma. Clin Exp Allergy. 1998;28
suppl 5:29-34, 50-51.
15. Action Against Asthma, Washington, DC:
US Department of Health and Human Services
2000.
200013: Maximizing Public
Health Protection with Integrated
Vector Control
Noting that integrated pest management is a
combination of educational, cultural, biological,
physical, chemical, and legal measures to control
pests and that the application of pesticides is re-
duced by the use of pest parasites, pathogens,
pheromones, predators, and resistant crops, thus
reducing the unnecessary exposure of humans to
harmful chemicals; and
Observing that numerous arthropods and ro-
dents serve as the vector of serious human diseases
such as viral encephalitis, Rocky Mountain spotted
fever, Hantavirus, and malaria;
1
and
Noting that hazard surveillance (monitoring
environmental conditions to identify conditions
that may contribute to the emergence or re-emer-
gence of vectors), disease health surveillance,
laboratory identification, vector management and
medical intervention continue to be important
factors in preventing morbidity and mortality
from vector-borne disease;
2
and
Recognizing that recent experience with West
Nile encephalitis and Hantavirus indicate that ef-
forts to combat vector-borne diseases are becom-
ing more complex and difficult to manage and
can have transnational implications;
3,4
and
Noting that public health agencies in health
and environmental departments in state and local
government have primary responsibility for man-
agement of vectors;
5
and
Noting that the capacity of local and state
health and environmental agencies to conduct
basic functions such as hazard surveillance for
the purpose of early identification of vector borne
outbreaks has been seriously eroded or eliminat-
ed over the past several decades; and
Recognizing that integrated vector manage-
ment that seeks to minimize unnecessary health
and environmental side effects of vector control
activities while assuring maximum protection to
the public and workers is a long-standing and well
established public health principle and practice;
6,7
and
Noting that in the U.S. in 1996 under the Food
Quality Protection Act (FQPA) the Congress
mandated that the Department of Health and
Human Services assess vector control needs as
part of Environment Protection Agencys review
of pesticides, including insecticides and rodenti-
cides; furthermore, the FQPA allows for public
health benefits to be considered in weighing the
risks of public health pesticides as part of EPAs
regulatory process;
8
and
Recognizing that in the U.S., despite the 1996
mandate of the FQPA, the DHHS has no evident
activities in this area, leaving state and local vec-
tor control agencies with great uncertainty about
what tools will be available to them for managing
public health vectors; and
Noting that while pesticides can and do play
an important public health role, the use of IVM
(integrated vector management) can decrease the
problems associated with pesticides and difficul-
ty controlling disease outbreaks;
9
and
Observing that the public has become more
concerned about any use of a pesticide in popu-
lated areas even when the intended use is for pub-
lic health vector control;
10
and
Recognizing that the public health use of pes-
ticides constitutes only a very small fraction of the
total pesticides manufactured and used in the US
and further recognizing that some pesticides used
for public health vector control may become un-
available due to actions taken to protect public
health by reducing the uses of some highly toxic
pesticides in agriculture, homes, and other com-
mercial markets;
11
and
Noting that debates over the use of pesticides
for public health vector control have sometimes
divided the public health and environmental com-
munities at the local, state, national and interna-
tional levels at a time when maximizing public
health and environmental protection requires
close coordination and mutual trust between
those communities, therefore, encourages and
supports
1. Efforts to expand the use of integrated vector
management techniques and to minimize the
unnecessary use of toxic pesticides in vector
control while maximizing public health pro-
tection from vector-borne diseases;
2. Aggressive environmental and disease sur-
veillance and early identification of condi-
tions that promote the growth or introduction
of vectors, as well as vector borne disease
outbreaks, to prevent morbidity and mortality
and to ensure that outbreaks can be controlled
when they are small, thus minimizing the po-
tential need for pesticides;
3. Increased federal funding to CDC to help
support the efforts by the CDC, states and
local government to strengthen efforts in lab-
oratory identification, vector management,
and nationwide surveillance of vectors and
vector-borne disease with the goal of an inte-
grated surveillance effort;
4. Efforts by and the provision of resources to
the Centers for Disease Control and Preven-
tion to establish the needed capability to
carry out toxicology and vector management
assessments of pest control agents as re-
quired by the 1996 Food Quality Protection
Association News
Act, such efforts including evaluation of non-
pesticide alternative means of vector control;
5. Promotion and funding by federal, state and
local public health and environmental health
agencies of the use of integrated vector man-
agement techniques to control public health
pests;
6. Funding to state and local governments for
larvicides and other preventive measures
should be available to state and local health
departments along with resources and the
ability to act quickly when necessary;
7. Efforts by the Centers for Disease Control
and Prevention in coordination with state and
local agencies, involvement of stakeholders
in decision making, risk communication and
education to bring the public, states and oth-
ers together to address this issue;
8. Efforts by HUD and state and local agencies
to assure healthier home environments
through appropriate prevention and manage-
ment of vectors;
9. Increased health communication and educa-
tion efforts regarding risks, concepts of inte-
grated vector management, personal protec-
tion actions, and individual efforts that can
decrease transmission through outreach and
advocacy programs for the general popula-
tion and populations at risk; and
10. International efforts by the World Health Or-
ganization, United Nations Environment Pro-
gram, Food and Agriculture Organization and
the US government, in support of the treaty ne-
gotiations on Persistent Organic Pollutants and
other efforts to reduce pesticide risks interna-
tionally, to rapidly identify effective methods
of vector control that do not rely on highly haz-
ardous pesticides while recognizing the current
important public health role of pesticides.
References
1. Gubler DJ. Resurgent vector-borne diseases
as a global health problem. Emerg Infect Dis.
1998;4:442-450.
2. Preventing emerging infectious diseases: A
strategy for the 21st century. Atlanta, GA: US
Public Health Service, Centers for Diseases Con-
trol and Prevention, 1998.
3. Epidemic/epizootic west Nile virus in the
United States: Guidelines for surveillance, pre-
vention, and control. Fort Collins, CO: US
Public Health Service, Centers for Disease
Control and Prevention, 2000.
4. Schmaljohn C, Hjelle B. Hantavirus: A
global disease problem. Emerg Infect Dis. 1997;
3:95-104
5. The Future of Public Health. Washington
DC: Institute of Medicine, 1988.
6. Pest management practices: 1998 summary.
Washington DC: US Department of Agriculture,
1999.
7. Introduction to Integrated Pest Manage-
ment for Urban Landscapes. IPM Associates,
Inc., 1996.
8. Food Quality Protection Act of 1996.
Public Law 104-170. 110 Stat. 1489. August
3,1996.
9. Brogdon WG, McAllister JC. Insecticide
resistance and vector control. Emerg Infect Dis.
1998;4:605-613.
10. Gratz NG, Jany WC. What role for insec-
ticides in vector control programs? Am J Trop
Med Hyg. 1994;50:11-20.
11. United Nations Environmental Program,
Persistent Organic Pollutants Committee. Report
of the intergovernmental negotiating committee
for an international legally binding instrument for
implementing international action on certain per-
sistent organic pollutants on the work of its third
session. September. 6-11, 1999, Geneva: United
Nations, 1999.
200014: Protecting OSHAs
Jurisdiction over Home
Workplaces
Considering that a fundamental goal of public
health is to protect the health and well-being of
the US workforce in manufacturing as well as
other types of industry; and
Recognizing that working at home can be a
positive option with benefits that include reduced
commuting time and increased flexibility; and
Considering that due to cost-saving strategies
and/or use of new technologies, private house-
holds are becoming hazardous worksites for con-
tingent, flexible, or non-standard arrangement
workers in the manufacturing and services sectors
of the economy;
1
and
Considering the violations identified by the
US Occupational Safety and Health Admin-
istration (OSHA) following a complaint from
home manufacturing workers in California;
2
and
Considering that the Federal Occupational
Safety and Health Act
2
covers private sector em-
ployees in businesses of two or more workers, re-
gardless of where employees are carrying out the
work (with certain exceptions such as family
farms and nuclear workers); and
Acknowledging that current economic projec-
tions from the US Bureau of Labor Statistics pre-
dict growth in home work occupations such as
home assemblers, garment laborers, home care
personnel, and clerical workers;
3
and
Acknowledging that OSHAs lack of enforce-
ment in the traditional workplace leaves the door
open for abuses in the home;
4
and
Acknowledging that OSHA does not cover
self-employed persons and primarily enforces in
response to a complaint, which raises practical is-
sues in the implementation when the employer
may be a family member or a neighbor; and
Recognizing that home assembly workers are
exposed to lead, acid, and fluxes, solvents, and
solders that may endanger their health as well as
that of their family members though systemic
poisoning and other mechanisms;
3,5-7
and
Considering that these assembly workers are
often vulnerable populations such as pregnant or
immigrant women that work at home without
proper ventilation, respirators, or protective cloth-
ing,
2,3,5-7
or that children may be in, or working in
these homes; and
Noticing that home office workers, in particu-
lar, female home-based clerical workers, who are
characterized by employers as independent con-
tractors, are most vulnerable to gender-based
discrimination and to health risks such as low
wages, quota systems, lack of health benefits,
lack of safety coverage, and increased job insecu-
rity;
3,7,8
and
Considering that home clerical workers are
also at greater risk of ergonomic injuries such as
repetitive motion injuries, because they often
work under piece rate or quota systems, systems
that are experiencing a comeback among US in-
dustries;
7
and
Whereas that home work weakens the cap-
acity of these workers to organize and defend
their health rights in the workplace due to forced
isolation, therefore
1. Urges that OSHA regulations be enforced
among employees, employers, or contractors
in home offices and home workplaces, in-
cluding requirements for employee training
and reporting of homework injuries and ill-
nesses on the OSHA log 200 forms, while re-
specting the privacy of individual homes;
2. Calls upon Congress, the Secretary of Labor,
and the secretary of Health and Human
Services to designate National Institute of
Occupational Safety and Health (NIOSH) as
the federal agency in charge of developing a
national and ongoing occupational injury and
illness surveillance system for home work.
home offices, work at home, and similar
non-standard workplace arrangements;
3. Urges the federal government to increase its
financial support for NIOSH to pursue the
aforementioned home workplace occupa-
tional and injury surveillance system; and
4. Calls upon the members of the Congress to
actively oppose legislation that will severely
limit OSHAs inspections of home offices
and would not hold employers accountable
for occupational injuries in home work-
places.
References
1. Landsbergis PA, Cahill J, Schnall P. The im-
pact of lean production and related new systems
of work on worker health. J Occup Health
Psychol. 1999;4:108-130.
2. Santa Clara Center for Occupational Safety
and Health. Statement to OSHA on need for
OSHA coverage of home workers. San Jose, CA.
Submitted 2000.
3. Daniels CR; Daniels E, (eds), Homework:
Historical and Contemporary Perspectives on
Paid Labor at Home. Christiansen K, Home-
based Clerical Work, 1989; pp. 183, 189-190.
4. McQuisson TH, Zakocs RC, Loomis D.
The case for stronger OSHA enforcementEvi-
dence from evaluation research. Am J Public
Health, 1998; 88:1022-1024.
5. LaDou J; Rohm TJ, Occupational hazards
in the microelectronics industry. Occupational
Medicine.
6. Mayhew C; Quinlan M. The effects of out-
sourcing on occupational health and safety: A
comparative study of factory-based workers and
outworkers in the Australian clothing industry.
International J Health Services. 1999; 29 (1): 83-
107; 1999.
Association News
7. US House of Representatives, Subcom-
mittee of the Committee on Government Opera-
tions, Home-based Clerical Workers: Are They
Victims of Exploitation? Washington, DC GPO
1986.
8. Hurrel JJ. Are you certain? Uncertainty,
health, and safety in contemporary work. Am J
Public Health. 1998; 88:1012-1013.
200015: Drinking Water Quality
and Public Health (Position Paper)
I. Purpose
The purpose of this position paper is to guide
further debate and decision-making by the Am-
erican Public Health Association (APHA) on a
public policy statement on safe drinking water.
This position paper provides the scientific basis
and justification for the importance of improving
our nations drinking water supplies. It also em-
phasizes the important role that public health prac-
titioners and policy makers can play on this im-
portant public health issue. The position statement
will enable APHA to become a policy leader for
safe drinking water. The objectives of this position
paper are for APHA to be well positioned to:
Provide expert guidance to the Environ-
mental Protection Agency on decision-mak-
ing regarding drinking water standards and
regulations;
Improve public health education about drink-
ing water risks, specifically education for pub-
lic health and health care professionals; and
Promote sufficient funding for federal and
state drinking water programs.
II. The ProblemScientific Basis
A. Overview
In the United States, the quality and safety of
our drinking water continues to be an important
public health issue. Individuals continue to be-
come sick, develop serious illness, and die as a
consequence of drinking contaminated water. It
has been estimated that up to 900,000 people fall
ill and up to 900 die annually from waterborne in-
fectious diseases in the US.
1
Informal Centers for
Disease Control and Prevention (CDC) estimates
are that 200,000 to 1,300,000 Americans become
acutely ill each year, and several hundred die
from microbiologically contaminated water. US
Environmental Protection Agency (EPA) data
suggested that in 1997, almost 30 million Ameri-
cans drank water from systems that were in viola-
tion of public health standards. Clearly, officially
recorded cases of waterborne disease represent
only the tip of the iceberg.
Most drinking water in the US is obtained
from surface or ground water sources, both of
which can be contaminated. Surface water from
rivers, streams, lakes and ponds is under threat
from environmental contamination. This contam-
ination may come from algal growth, geologic
formations, point sources (such as industrial or
wastewater treatment plant discharges), non-point
sources (such as runoff from urban streets, agri-
cultural runoff, etc.) and antiquated infrastruc-
ture. Because of this potential level of contamina-
tion, surface water usually requires aggressive
and sophisticated treatment prior to consumption.
Ground water may be contaminated from a num-
ber of natural sources including arsenic and radon
due to local hydrogeology. In addition, severe
contamination of the soil, such as from hazardous
waste dumps and leaking underground storage
tanks, can result in locally severe ground water
contamination. Properly treated water may be-
come contaminated again after it leaves the treat-
ment plant and enters the distribution system due
to infrastructure in need of repair. Outbreaks have
been associated with contamination of water
within distribution systems when sewage from
wastewater pipes has entered drinking water
pipes through leaks or improper connections.
B. Specific Contaminants of Concern
1. Microbial Contaminants of Concern
The bacteria, viruses, and protozoa that are of
major concern in drinking water are usually of
fecal origin. Bacterial waterborne pathogens,
once the scourge of human urban existence, are
now generally controlled by modern water treat-
ment systems. Waterborne disease in the US in
general, and bacterial disease in particular, usual-
ly occurs when water treatment and/or infrastruc-
ture systems fail or when untreated water is con-
sumed. However, viruses and enteric protozoa are
more common sources of waterborne disease out-
breaks. Norwalk and Norwalk-like viruses, rota-
virus, and Hepatitis A are all important viruses
transmitted by water.
2
Since 1981, enteric protozoa have been the
leading cause of waterborne disease outbreaks.
The major enteric protozoan, Cryptosporidium
parvum, is a parasite commonly found in rivers
and lakes, that can make its way into drinking
water supplies and can cause severe outbreaks of
gastrointestinal illness. Before 1982, the disease
was rarely reported, but as the AIDS epidemic in-
creased, so did the number of cryptosporidiosis
cases.
3
Initially, infection was recognized only in
immunocompromised people, but as diagnostic
methods improved, outbreaks and other inci-
dences have appeared in the healthy population.
Cryptosporidium is considered a major threat to
the US water supply, because it is highly infec-
tious, resistant to chlorine, and because of its
small size that makes it difficult to filter.
4
Even a
well-operated, modern water treatment system
cannot ensure that its drinking water will be
completely free of these protozoa.
2. Chemical Contaminants of Concern
Disinfection By-Products: The most ubiqui-
tous chemicals found in treated water are the dis-
infection byproducts (DBPs) formed by reactions
between one and two-carbon organic molecules
and added chlorine in water. Trihalomethanes are
among the best studied of the DBPs. DBPs have
been implicated in both cancer and non-cancer
health effects. Comparison of populations con-
suming chlorinated and non-chlorinated water
has shown an increase of bladder and possibly
colon and rectal cancer among those consuming
chlorinated water.
5
In addition, some studies have
suggested an increased risk of adverse reproduc-
tive outcomes, including spontaneous abortion
and neural tube defects.
6
Studies indicating an as-
sociation between DBP exposure and adverse re-
productive outcomes have resulted in EPA form-
ing an advisory committee to review the need for
additional controls on disinfection byproducts.
Lead: Since the removal of lead from gaso-
line, drinking water has become a more important
route of lead exposure for the general population.
Lead generally enters drinking water by leaching
from pipes and solder joints. Lead soldering is
still commonly used in taps, water coolers, and
other fixtures placed between building pipes and
the consumer. Brass fixtures, such as spigots, and
pumps used for wells may also be made with an
alloy that contains lead. Studies of fixtures in of-
fices and schools have shown a potential for high
exposures to lead in first-draw samples of water.
7
People living in older housing, and those served
by delivery systems with lead pipes especially in
areas with soft water, are most at risk for ingest-
ing significant amounts of lead through their
drinking water.
Other Metals: A variety of other metals, in-
cluding arsenic, cadmium, and mercury may be
found locally in drinking water supplies. Arsenic,
in particular, has been found in high levels in
community water supplies, usually as the result of
high concentrations found in regional geologic
formations. Arsenic in drinking water, primarily
in countries other than the US, has been associat-
ed with bladder, skin, and lung cancers.
8
The cur-
rent EPA drinking water standard was set in 1943
at 50 parts per billion (ppb). The World Health
Organization and the National Academy of
Sciences (NAS) have concluded that a lower stan-
dard is indicated.
9
Nitrates: Nitrates contaminate water supplies
as the result of ground applications of fertilizers
and seepage from septic tanks. Thus, concentra-
tions tend to be highest in rural, agricultural areas
and may vary widely depending on the season.
The EPA estimates that as many as 52% of com-
munity water wells and 57% of domestic water
wells in this country are contaminated with ni-
trates.
10
In infants under about four months of
age, ingestion of high concentrations of nitrates
from well waters results in methemoglobinemia,
which carries a 7-8% fatality rate. The United
States Geological Service (USGS) has estimated
that up to 15% of wells in agricultural and urban
areas have nitrate levels exceeding the EPA stan-
dard.
11
Radon: Radon in water constitutes a threat to
health both from direct ingestion as well as from
contribution to indoor air levels and inhalation
after water is heated and/or agitated, such as dur-
ing showering. Alpha particles emitted from
radon can ultimately cause cancer of the gastroin-
testinal tract or lung, depending on the route of
exposure. Levels of radon vary by source, treat-
ment process and by region. Water from New
England, the Southeast, and mountain areas has
more radon than other regions.
12
The EPA is cur-
rently developing standards for radon in drinking
water.
Synthetic Organic Chemicals: A variety of
pesticides are routinely found in drinking water at
Association News
very low concentrations. Tetrachloroethylene, also
known as perchloroethylene or perc, has been
found in high levels in water supplies as the result
of leaching from recently installed polyvinyl chlo-
ride or PVC water mains. Studies of populations
exposed through this route have associated perc
exposure with lung cancer and possibly colorectal
cancer.
13
Migration of fuel-associated chemicals
such as benzene and methyl-ter-butyl ether
(MTBE) from underground gasoline storage tanks
has also been reported.
14
C. Susceptible Populations
When considering drinking water quality, it is
vital to consider populations that are more suscep-
tible to exposures, including infants/ hildren, im-
mune-suppressed individuals, and the elderly.
Neonates, for example are especially at risk for
enteroviruses,
15
lead and mercury, and nitrates.
The immune-suppressed population includes not
only people living with AIDS, but also transplant
patients, persons undergoing chemotherapy, and
those suffering from less common congenital or
acquired immune system dysfunction. Crypto-
sporidiosis is deadly for the immunocompro-
mised. Disseminated Mycobaterium avium com-
plex (MAC) is another common infection in AIDS
patients who have CD4 counts less than 100/mm
3
,
and it can also occur in other immunocompro-
mised patients without AIDS. Transplant patients
are especially susceptible to developing dissemi-
nated adenovirus infections.
16
The elderly are at
increased risk of infection and disease from
microbial contamination because of many factors
including, reduced immunity, high incidence of
frailty from malnutrition or existing chronic ill-
ness, and institutional exposure (e.g., hospitals
and nursing homes). They are also at increased
risk of dying from waterborne infections. The case
fatality rates in nursing homes for certain water-
borne pathogens, such as rotavirus and E. coli
0157:H7, can be two orders of magnitude greater
than that in the general population.
17
Outbreaks of
Norwalk virus and other caliciviruses have been
frequently reported in nursing homes.
III. Federal and State Regulations
and Provisions
It is timely for APHA to be actively engaged in
policy activities related to safe drinking water.
There are weaknesses in federal statutes and regu-
lations governing the safety of drinking water, and
a number of EPA standards are being currently
being reviewed and revised. In some instances,
contaminants are not regulated, such as radon and
a number of pesticides. A few EPA standards have
not been updated for decades, such as arsenic, and
current scientific studies indicate that current
standards may not sufficiently protect public
health. EPA standards may protect the average
adult but may not protect vulnerable populations,
such as infants and children, the frail elderly, and
those with weakened immune systems. Moreover,
EPA standards are established to protect health
while considering the water treatment costs and
availability of clean-up technology.
One of the important public health provisions
in federal legislation is to ensure the publics right
to know what is in their drinking water. Under the
Safe Drinking Water Act (SDWA) Amendments of
1996, water utilities are required to issue Con-
sumer Confidence Reports (CCRs) or right-to-
know reports, which disclose results of monitoring
for regulated contaminants. The CCRs are good in-
formational tools, but they do not give the con-
sumer the full picture on drinking water quality,
and are shown to have important limitations. For
example, CCRs only provide information to people
drinking from community water supplies, however
it is estimated that 9% of people in the US (about
24 million) get their drinking water from private
wells or other individual systems. Only levels for
regulated contaminants are reported, and some im-
portant contaminants are not regulated.
EPA and state regulatory agencies need guid-
ance from public health experts on the setting and
implementation of drinking water standards. For
example, public health expertise is greatly needed
on setting appropriate standards for chemical and
microbial contaminants, ensuring the protection of
vulnerable populations, protecting drinking water
sources, evaluating risk trade-offs between conta-
minants and between controlling contaminants
and controlling costs, and participating in the
broader public disclosure about drinking water
quality.
IV. Goals for APHA
seeks to promote the basic right of all people and
all communities to safe and affordable drinking
water. APHA will work:
To foster greater involvement of the public
health professional as advisor, educator, and
advocate on issues related to drinking water
and health;
To promote understanding in public health
practice and policy making of the potential
public health impact of drinking water conta-
mination;
To ensure broader public access to informa-
tion on drinking water quality, including im-
provements in the consumer right-to-know
provisions that will inform everyone of their
drinking water quality;
To encourage public health departments to
prepare response plans for drinking water
contamination;
To call for greater accountability of EPA and
state regulatory agencies in the prevention of
waterborne diseases, especially among sus-
ceptible populations;
To promote increased federal funding for re-
search on links between drinking water cont-
amination and disease, as a foundation for in-
formed standard-setting; and
To support increased funding for public
health departments and other interested non-
governmental entities to educate the public
about drinking water quality and to be pre-
pared for public health emergencies related
to drinking water.
References
1. Microbial Pollutants in our Nations Water.
1999; ASM: Washington, DC.
2. Moe Manual of Environmental Micro-
biology, Washington, DC: American Society of
Microbiology, 1997.
3. Guerrant RL. Cryptosporidiosis: An emerg-
ing and infectious threat. Emerging Infectious
Diseases. 1997;3(1).
4. Ibid.
5. Morris et al. Clorination and chlorination
by-products and cancer: A meta-analysis. Am J
Public Health. 1992:82:955-963.
6. Deane et al. Epidemiol. 1992;3(2):94-97;
Klotz and Pyrch. Epidemiol. 1999;10(4):383-
390.
7. Maas et al. Am Ind Hyg Assoc J. 1994;
55(9): 829-832.
8. Kurttio et al. Environ Health Perspect.
September 1999; 107(9): 705-101; Smith et al.
Am J Epidemiol. April 1998;147(7):660-669.
9. World Health Organization, Arsenic in
Drinking Water. February 1999.
10. Http://www.epa.gov/seahome/groundwa-
ter/src/overview/htm. Accessed 1/31/00.
11. The Quality of Our Nations Waters, 1999.
US Geological Survey. http://water.usgs.gov/
pubs/circ/circ1225. Accessed 2/17/00.
12. Risk Assessment of Radon in Water.
Washington, DC: National Academy of Sciences,
1999.
13. Paulu et al. Environ Health Perspect.
1999; 107:265-271.
14. Stern and Tardiff. Risk Anal. December
1997: 17(6):727-43.
15. Abzug, Human Enterovirus Infections.
Washington, DC: American Society of Microbio-
logy, 1995. Dagan, Pediatr Inf Dis J. 1996;15:67-
71.
16. Hierholzer. Clin Microbiology Rev.
1992;5:262-274.
17. Gerba et al. 1996.
200016: Effective Public Health
Assessment, Prevention, Response,
and Training for Emerging and
Re-emerging Infectious Diseases,
including Bioterrorism
Recognizing the essential public health role of
assessment, prevention, response, and training to
mitigate the potential disastrous consequences of
emerging and re-emerging infectious diseases, in-
cluding bioterrorism; and
Recognizing that our public health system
would be called upon to detect and respond to a
bioterrorism event, just as we are asked to re-
spond to other disasters, conventional infections
and disease outbreaks; and
Recognizing that APHA previously called for
increased training of the public health work force
to prepare for and respond to disasters
1
and that
this need has only increased since that time; and
Recognizing that preparedness for emerging
and re-emerging infectious diseases, including
bioterrorism, requires collaboration between pub-
lic health authorities and civilian emergency man-
agers that can also enhance public health partici-
pation in common natural and technological dis-
asters; and
Association News
Noting that CDC has chosen not to recom-
mend the mass vaccination of the civilian popu-
lation; and
Noting that the US Department of Health and
Human Services designated the Centers for
Disease Control and Prevention (CDC) to lead
the effort to upgrade national public health capa-
bility to counter potential acts of bioterrorism and
that in September 1999, CDC provided $40 mil-
lion to fund 127 bioterrorism-related projects at
state and local health departments to build public
health infrastructure for both routine and emer-
gency use;
2
and
Understanding that the CDC, in cooperation
with the working group on domestic and interna-
tional surveillance for possible bioterrorism, is
providing public health leadership
3-5
to strengthen
public health readiness to address bioterrorism
through (1) surveillance to detect unusual events;
(2) investigation and containment of outbreaks;
(3) laboratory diagnosis; (4) coordination and
communicating with the Department of Justice,
Office of Emergency Preparedness, Food and
Drug Administration, National Institutes of
Health, Department of Defense, Federal Emer-
gency Management Agency, and others; and (5)
preparedness and planning; therefore,
1. Supports federal government efforts to pro-
vide financial resources to build state and
local capacity of health departments and
urges the federal government to allocate new
dedicated funding to assure minimum na-
tionwide capacity in all state and local health
departments; and
2. Supports the activities of CDC in providing
national public health leadership in surveil-
lance, investigation and containment of out-
breaks, laboratory diagnosis, coordination
and communication, and preparedness and
planning; and
3. Supports the activities of state and local
health departments in providing local public
health leadership in surveillance, investiga-
tion, and containment of outbreaks; laborato-
ry diagnosis; coordination and communi-
cation; and preparedness and planning; and
4. Supports training of public health profes-
sionals in their preparation for and response
to emerging and re-emerging infectious dis-
eases, including bioterrorism and similar
events; and
5. Urges that the planning for public health
emergencies, such as emerging and re-emer-
ging infectious disease, including bioter-
rorism, include public health professionals as
a full partner with sufficient autonomy to
protect the publics health; and
6. Calls on DHHS to develop a participatory
process to fully evaluate whether the current
funding for building capacity of the public
health infrastructure and training the public
health work force has been sufficient to pro-
tect the public from all outbreaks of infec-
tious disease, including bioterrorism; and
7. Urges that this process include an objective
characterization of the bioterrorist threat; an
evaluation of alternatives for threat reduc-
tion; an assessment of measures necessary to
guarantee that defensive programs do not
promote offensive capabilities; an examina-
tion of other ways to primarily protect U.S.
and global populations from deliberately-in-
duced, naturally occurring, or re-emerging
infectious diseases, including strengthening
public health infrastructure; an analysis of
potential effects on civil liberties; and, if
CDC should reconsider mass vaccination of
civilians populations, a scientifically rigor-
ous assessment of the effectiveness of mass
vaccinations for organisms that could be ge-
netically modified prior to use as weapons;
and
8. Reaffirms APHAs support of federal re-
sources for security being directed to build-
ing the global capacity of the public health
infrastructure to strengthen laboratories, sur-
veillance, and technology; and
9. Urges the federal government to allocate new
funding for protection of the public from
emerging and re-emerging infectious dis-
eases, including bioterrorism, that does not
divert resources allocated for other human
needs, underscoring APHAs long-standing
commitment to the provision of adequate nu-
trition, housing and health care as a central
tenet of public health protection.
References
1. APHA Policy Statement 9116: Health Pro-
fessionals and Disaster Preparedness. APHA Pol-
icy Statements 1948present, cumulative. Wash-
ington DC: American Public Health Association;
current volume.
2. Operating Plan for Anti-Bioterrorism
Initiative FY 99. Washington, DC: US Depart-
ment of Health and Human Services, 1999.
3. Statement of James M. Hughes, MD, Dir-
ector, National Center for Infectious Diseases,
Centers for Disease Control and Prevention,
Before the Subcommittee on Labor, Health and
Human Services, and Education Committee on
Appropriations, US Senate, June 2, 1998.
4. Statement of James M. Hughes, MD, Dir-
Before the Subcommittee on Technology, Ter-
rorism and Government Information, Subcom-
mittee on Youth Violence, Committee of the
Judiciary, US Senate, April 20, 1999.
5. Statement of Scott R. Lillibridge, MD, Dir-
Before the Subcommittee on National Security,
Veteran Affairs and International Relations,
Committee on Government Reform, US. House
of Representatives, September 22, 1999.
200017: Confirming Need for
Protective National Health-Based
Air Quality Standards
Recognizing that more than 25 million chil-
dren and more than 14 million seniors over the
age of 65 live in areas that fail to meet federal
standards for healthy air; and that over 6.5 million
people with asthma and 7.2 million people with
chronic lung diseases live in these same areas;
and that these populations represent those most
vulnerable to high levels of ground-level ozone
pollution;
1
and
Understanding that children diagnosed with
asthma are especially sensitive to high levels of
particulate air pollution, and are more likely to
develop both acute and persistent lower respirato-
ry tract symptoms such as increased phlegm pro-
duction and bronchitis;
2
and
Understanding that many children grow up in
urban and suburban areas with persistent elevated
summertime ground-level ozone concentrations,
and that exposure to ozone over a period of sev-
eral years results in diminished lung function and
increased respiratory symptoms;
3,4
and
Recognizing that elevated ozone levels are
correlated with increased numbers of hospital ad-
missions and visits to emergency rooms for asth-
ma and other respiratory problems;
5
and that
young people with asthma are more likely to visit
emergency rooms for asthma treatment on days
following elevated ozone levels;
6
and
Recognizing that people who exercise out-
doors on days with elevated ozone pollution lev-
els experience decreased lung function, shortness
of breath, wheezing, and chest tightness;
7,8
and
Recognizing that exposure to elevated levels
of particulate air pollution has been positively as-
sociated with premature mortality from car-
diopulmonary conditions and reduced heart rate
variability, and has been observed to exacerbate
pneumonia and chronic obstructive pulmonary
disease;
9-13
and
Recognizing that the largest sources of ozone
and particulate air pollution are automobiles,
diesel trucks, and buses, and coal-fired electricity
generating plants;
14
and
Recognizing that the US Court of Appeals in
May 1999 remanded to the US Environmental
Protection Agency (EPA) the stricter federal ozone
and fine particulate health-based standards pro-
mulgated by EPA in 1997 for further review of the
constitutional limits on EPAs discretion to set the
health-based standards;
15
and
Recognizing that the US Court of Appeals did
not question the health science supporting EPAs
decision to tighten the ozone and fine particulate
standards;
16
and
Further recognizing that the US Supreme
Court will review in 2000 the lower courts deci-
sion prohibiting EPA from setting revised health
standards; with a decision expected before June
2001; and
Understanding that feasible and affordable so-
lutions exist to significantly improve air quality
nationwide;
17
therefore
1. Affirms the importance of national health-
based air quality standards to offer health pro-
tection to susceptible populations, including
children, from the harmful effects of air pol-
lution, as well as the importance of basing
such standards on the latest science; and
Association News
2. Urges EPA to proceed with finalizing and
implementing national emission reduction
strategies aimed at reducing ozone-forming
pollutants, as well as other pollutants of con-
cern such as particulate matter, using their
authority under existing standards.
References
1. Health Effects of Outdoor Air Pollution.
Washington DC: American Lung Association 1996.
2. McConnell R, Berhane K, Guilliland F, et
al. Air pollution and bronchitis symptoms in
Southern California children with asthma. Envi-
ron Health Perspect. 1999;107:757-760.
3. Galizia A, Kinney PL. Long-term residence
in areas of high ozone: Associations with respira-
tory health in a nationwide sample of nonsmok-
ing young adults. Environ Health Perspect. 1999;
107:675-679.
4. Peters JM, Avol E, Gauderman WJ, et al. A
study of twelve Southern California communities
with differing levels and types of air pollution. II.
Effects on pulmonary function. Am J Respir Crit
Care Med. 1999; 159:768-775.
5. Breathless: Air Pollution and Hospital Ad-
missions/Emergency Room Visits in 13 Cities.
Washington, DC: American Lung Association,
1996.
6. White MC, Etzel RA, Wilcox WD, et al.
Exacerbation of childhood asthma and ozone pol-
lution in Atlanta. Environ Res. 1994; 65:56-68.
7. Korrick et al. Effects of ozone and other
pollutants on pulmonary function of adult hikers.
Environ Health Perspect. 1998;106:93-99.
8. Brunekreef B, Hoek G, Brugelmans O, et
al.. Respiratory effects of low-level photochemi-
cal air pollution in amateur cyclists. Am J Respir
Crit Care Med. 1994; 150:962-966.
9. Schwartz J, Morris R. Air pollution and
hospital admissions for cardiovascular disease in
Detroit, Michigan. Am Epidemiol. 1995;142: 23-
25.
10. Gold DR, Litonjua A, Schwartz J, et al.
Ambient pollution and heart rate variability.
Circulation. 2000; 101(11):1267-1273.
11. Dockery DW, Pope CA, Xu X, et al. An
association between air pollution and mortality in
six US cities. N Engl J Med. 1993;329: 1753-
1759.
12. Pope Ca, Thun MJ, Namboordiri MM, et
al. Particulate air pollution as a predictor of mor-
tality in a prospective study of US adults. Am J
Respir Crit Care Med. 1995; 151:669-674.
13. Schwartz J. Air pollution and hospital ad-
missions for the elderly in Birmingham, Ala-
bama. Am J Epidemiol. 1994; 139:589-598.
14. National Air Quality and Emissions
Trends Report, 1997. Washington, DC: US Envi-
ronmental Protection Agency, 1998.
15. American Trucking Association Inc. v US
Environmental Protection Agency, No. 98-1497
(Court of Appeals for the District of Columbia
Circuit), order granting Petitioners motion for
partial stay; May 25, 1999.
16. American Trucking Association v US
Environmental Protection Agency, No. 16.
17. Regulatory impact analysis for the partic-
ulate matter and ozone national ambient air qual-
ity standards and proposed regional haze rule,
Washington, DC: US Environmental Protection
Agency, July 1997.
18. Emission Control Retrofit of Diesel-
Fueled Vehicles, Washington, DC: Manufacturers
of Emission Controls Association, August 1999.
19. The Cost of Ozone Transport: Achieving
Clean Air in the East, Boston, MA: Northeast
States for Coordinated Air Use Management, July
1998.
200018: Public Health Impacts
of Job Stress
Recognizing that workers in the United States
are taking fewer and shorter vacations, and are
working more hours over the course of a year, sur-
passing even Japan as the leader among major de-
veloped nations in annual hours worked per per-
son,
1
and
Recognizing that 20% of American workers
saw his or her job disappear during the 1980s, and
downsizing and layoffs have continued through
the end of the 1990s, despite an unprecedented
economic boom, with income disparities rising to
their highest levels in over a century,
2
and
Recognizing that in the US, many previously
secure and well-paying jobs in diverse manufac-
turing industries have been exported oversees,
leaving workers in the US to take lower wage
nonunionized jobs,
3
and
Recognizing that more people in the US feel
stressed now than in 1985, because of time ur-
gency and worries about gaining a sense of con-
trol over their lives;
4
most with job stress rooted
in heavy workloads and job insecurity combined
with a lack of control over schedules and other
factors;
4
jobs which constrict learning and skill
development; and they are characterized by a lack
of free time and reduced energy, resulting in indi-
vidual isolation, passive, destructive behavior, in-
creased drug use, as well as a decline in partici-
pation in social and political institutions;
5
and
For example, finding that health care workers,
particularly those working in managed care insti-
tutions, are now finding that their job latitude and
control which include their use of personal judg-
ment is being undermined; yet these factors are
critical to job satisfaction and to their own and
their patients health; and
Recognizing that how much control a person
has over his or her work is important because it
affects how well he or she copes with the de-
mands of his job;
6
and that jobs that offer restrict-
ed opportunity to use skills combined with high
job demands result in a high strain situation with
heavy psychosocial costs in physical and mental
health.
7
The so-called job demand-control hy-
pothesis that high decision latitude and low-to-
moderate work demands are good for health and
that high job demands and low decision latitude
are bad; similarly, the effort-reward hypothesis
postulates that the risk of ill-health is increased by
an imbalance between efforts and rewards;
8
such
poorly-designed jobs are associated with negative
health effects, including increased blood pres-
sure;
9
heart disease,
10-14
fatigue and sleep distur-
bance,
15,16
musculoskeletal disorders,
17
absen-
teeism, job turnover, and increased acute injury
rates,
18,19
and adverse effects on family and social
life outside the workplace;
5
and
Realizing that additional types of job strain,
such as lean production, in particular, cutting the
number of workers while at the same time speed-
ing up production, are associated with increased
injury rates;
20
many of these involve non-standard
shifts associated in some studies with adverse
health outcomes including heart disease;
21
and
Whereas APHA has previously recognized
the right to a healthful working environment
22
and
the need to increase occupational disease preven-
tion and increasing worker and union rights;
23
therefore urges that,
1. Reducing job strain and providing quality
jobs are key to improving the health of work-
ers; and
2. Improved job design depends on sustainable
principles of social equity instead of short-
term profitability and lean production.
24
3. That the Congress provide for additional oc-
cupational safety and health funding to:
convene employers and other professional
organizations to develop research strate-
gies and intervention methods to reduce
job stress;
conduct further research on job stress and
the mechanism of the observed increase
in cardiovascular disease;
support investigation into job stress and
its relationship to depression;
evaluate occupational differences and
gender and ethnic differences in preva-
lence of job stress and resulting adverse
health affects.
References
1. Schor, JB. The Overworked American: The
Unexpected Decline of Leisure. New York, NY:
Harper Collins, 1991.
2. Forrant R. Global flexibilityshop floor
flexibility: Whats a worker to do? New Solutions.
1999;9:231-245.
3. World Labour Report: Industrial Relations,
Democracy and Social Stability, 1997-1998. Gen-
eva: International Labour Organization; 1997.
4. Fact Finding Report: Commission on the
future of worker-management relations. Washing-
ton, DC: US Departments of Labor and
Commerce; 1994.
5. Karasek R. The new work organization and
conducive value. Sociolosche Gids [Dutch
Sociological Journal]; 1999;5:310-330.
6. Bonn D, Bonn J. Work-related stress: Can it
be a thing of the past? Lancet. 2000;355:125-128.
7. Karasek R, Theorell T. Healthy Work:
Stress, Productivity and the Reconstruction of
Working Life. New York, NY: Basic Books, 1990.
8. Siegrist J. Adverse health effects of high-ef-
fort/low-reward conditions. J Occup Health
Psychol. 1996;1:27-41.
9. Pieper C, Warren K, Pickering TG. A com-
parison of ambulatory blood pressure and heart
rate at home and work on work and non-work
days. J Hypertens. 1993;11:177-183.
Association News
10. Sokejima S, Kagamimori S. Working
hours as a risk factor for acute myocardial in-
farction in Japan: Case-control study. BMJ.
1998;317:775-780.
11. Theorell T, Rahe RH. Behavior and life
satisfactions of Swedish subjects with myocardial
infarction. J Chron Dis. 1972;25:139-147.
12. Karasek R, Baker D, Marxer F, Ahlbom A,
Theorell T. Job decision latitude, job demands
and cardiovascular disease: A prospective study
of Swedish men. Am J Public Health. 1981;71:
694-705.
13. Siegrist J, Peter R, Junge A, Cremer P,
Seidel D. Low status control, high effort at work
and ischemic heart disease: Prospective evidence
from blue-collar men. Soc Sci Med. 1990;31:
1127-1134.
14. Appels A, Mulder P. Excess fatigue as a
precursor of myocardial infarction. Eur Heart J.
1988;9:758-764.
15. Lauber JK, Kayten PI, Sleepiness, circadi-
an dysththmia and fatigue and transportation sys-
tem accidents. Sleep. 1988;11:503-512.
16. Brown ID. Driver fatigue. Human Factors.
1994;36:298-314.
17. Moon SD, Sauter SL. Beyond Biomech-
anics: Psychosocial Aspects of Musculoskeletal
Disorders in Office Work. London: Taylor and
Francis, 1996.
18. Smith L, Folkard S, Poole CHM. Increased
injuries on night shift. Lancet 1994; 344:1137-
1139.
19. Mitler MM, Carskadon MA, Czeisler CA,
et. al. Catastrophies, sleep and public policy.
Consensus Report. Sleep. 1988;11:100-110.
20. Landsbergis PA, Cahill J, Schnall P. The
impact of lean production and related new sys-
tems of work organization on worker health. J
Occup Health Psychol. 1999; 4:108-130.
21. Kawachi I, Colditz G, Stampfer M, et al.
Prospective study of shift work and risk of coro-
nary heart disease in women. Circulation. 1995;
92:3178-3183.
22. APHA Public Policy Statement 7111: The
right to a healthful work environment. APHA Pol-
icy Statements; 1948-present, cumulative. Wash-
current volume.
23. APHA Public Policy Statement 8509:
Occupational Disease Prevention: Increase Work-
er and Union Rights. APHA Policy Statements;
1948-present, cumulative. Washington, DC: Am-
24. Bartley M, Marmot M. Social class and
power relations at the workplace. Occ Med: State
of the Art Reviews. 2000; 15:73-78.
25. Landsbergis PA, Cahill J. Labor union
programs to reduce or prevent occupational stress
in the United States. In J Health Serv 1994;
24:105-129.
26. Kaminski M, Bertell D, Moye M, Yudken
J (eds). Making change happen: Six cases of
unions and companies transforming their work-
places. Washington, DC: Work and Technology
Institute, 1996, pp. 25-44.
27. Leslie D, Butz D. GM Suicide: Flexi-
bility, space and the injured body. Economic
Geography. 1998;74:360-378.
200019: Public Health Role of the
National Fire Protection
Association in Setting Codes and
Standards for the Built
Environment
Having adopted Policy Statement 9916,
Public Health Role of Codes Regulating the
Design, Construction and Use of Buildings,
1
and
recognizing the need to update and expand the
policy to address other public health issues relat-
ed to housing and other buildings; and
Concerned that the International Code Council
(ICC) continues to compromise its process and its
model codes to the detriment of public health, es-
pecially regarding home safety;
2
* and
Recognizing that the National Fire Protection
Association (NFPA) has a long tradition, begin-
ning in 1896, of reducing the burden of fire on the
quality of life;
3
and
Noting that NFPA develops its standards and
codes using widely recognized American
National Standards Institute (ANSI) consensus
procedures;
3-4
and
Pleased that in 1999, NFPA fundamentally ex-
panded its mission statement to reduce the
worldwide burden of fire and other hazards on the
quality of life by advocating scientifically-based
consensus codes and standards, research, training
and education;
5
and
Noting that, in late 1999 and early 2000, NFPA
announced its intentions to develop a full set of
codes for the built environment, including a model
building code, NFPA 5000;
6
and
Acknowledging that NFPA has taken a lead in
educational efforts directed at prominent injury
hazards for children and elderly persons;
7
** and
Recognizing that in its educational programs,
advocacy, coalition participation, and standards de-
velopment, NFPA has dealt with controversial,
major injury-control issues;
8-22
*** and
Concerned that, in its potential expanded role
in developing a full set of codes and standards for
the built environment, NFPA will be subject to
greater pressure from industry organizations to
compromise requirements to the detriment of
public health;
6,19-23
therefore
1. Encourages NFPA to build on its leadership
role by providing a clear alternative
6
to the
International Codes produced by the ICC; by
including public health professionals on
NFPA consensus committees, by remaining
true to the expanded NFPA mission state-
ment; and by emphasizing the reduction of
hazards on the quality of life through a pub-
lic health approach;
2. Encourages NFPA to expand the scope of its
Life Safety Code, ANSI/NFPA 101, to be
more true to its title by dealing with life safe-
ty in buildings in a comprehensive fashion;
3. Encourages NFPA and other organizations to
develop codes and standards requiring auto-
matic fire sprinkler protection that is cost-ef-
fective for new homes and other build-
ings;****
4. Encourages NFPA and other organizations to
develop codes and standards requiring home
stairways to be designed and constructed so
that steps and railings provide at least the
same level of usability and safety from falls
as do stairs and railings in other buildings;
5. Encourages NFPA, in its development of
codes and standards, to utilize generally a
universal design or inclusive design philos-
ophy, which maximizes safety and usability
for the largest range of people, including el-
derly persons or those of any age with dis-
abilities;
6. Encourages collaboration and support by or-
ganizations sharing NFPAs goals for re-
duction of preventable injuries through scien-
tifically-based consensus codes and standards,
research, evaluation, training, and education;
and
7. Urges federal, state and local government or-
ganizations to adopt progressive, responsive
standards and codes, that make public health
a first priority.
* Unlike the National Fire Protection
Association (NFPA), the ICC has given advan-
tage to industry interest groups, notably the Na-
tional Association of Home Builders (NAHB) in
relation to home safety, for example, by appoint-
ing a significant number of NAHB representa-
tives to committees while rejecting code-develop-
ment committee memberships by persons with a
public health background and perspective.
** Educational programs Risk Watch and
Remembering When deal, respectively, with
children and elderly persons. The latter program,
initiated in 1999, was developed in collaboration
with the Centers for Disease Control and Pre-
vention (CDC).
*** Prominent, in relation to ANSI/NFPA 101
(the Life Safety Code), are deliberations on re-
quirements for sprinklering of homes, life safety
for persons with disabilities, and upgraded design
requirements for home stairways; the latest are
also being considered for ANSI/ NFPA 501,
Standard on Manufactured Housing. The pro-
posed NFPA building code, due out in 2002, will
also deal with these issues.
**** This recommendation is included even
though there are indications of potential oppos-
ing opinions among at least two APHA sections
(Injury Control and Gerontological Health). The
concern is largely over the relationship of cost
and benefit plus the possibility that require-
ments for sprinklering of some residential facil-
ities will make them unaffordable or infeasible.
For this reason, this proposed policy statement
includes the words, that is cost effective. It is
hoped that a discussion on this particular
issueand the import of these four wordswill
occur among APHA sections through 2000 as it
is occurring (and has occurred over many years)
in other organizations.
References
1. APHA. Public health role of codes regulat-
ing design, construction and use of buildings. Am
J Public Health. 2000;90(3):467-469.
2. ICC-NAHB Task Force. Report to the ICC
Board of Directors on the International
Residential Code. International Code Council,
Inc. and National Association of Home Builders,
1997.
Association News
3. NFPA 1999 Directory. Quincy, MA: Na-
tional Fire Protection Association, 1999, 5-8.
4. Procedures for the development and coordi-
nation of American National Standards. New
York, NY: American National Standards Institute,
1995.
5. NFPA 2000 Directory. Quincy, MA:
National Fire Protection Association, 2000.
6. Wolf A. Not just another building code:
NFPA plans a building code to anchor a complete
set of codes for the built environment. NFPA.
2000;94(3):66-71. (Also see the National Fire
Protection Associations Consensus Codes Series,
updated frequently at http:// www.nfpa.org)
7. NFPA Center for High Risk Outreach.
Remembering When: A fall and fire prevention
program for older adults. Quincy, MA: National
Fire Protection Association, 1999.
8. Hall JR. The U.S. experience with sprin-
klers: Who has them? How well do they work?
NFPA, 1993;87(6):44-55.
9. Hall JR. Framing the problem. Solutions
2000: Advocating shared responsibilities for im-
proved fire protection. Washington, DC: United
States Fire Administration, Federal Emergency
Management Agency, 1999:4-9.
10. Home Fire Safety Coalition. Automatic
sprinklers: A ten-year study. Scottsdale, AZ:
Rural/Metro Fire Department, 1997.
11. Rohr KD. U.S. experience with sprinklers.
Quincy, MA: National Fire Protection Associa-
tion, 2000.
12. North American Coalition for Fire and
Life Safety Education. Solutions 2000: Advo-
cating shared responsibilities for improved fire
protection. Washington, DC: United States Fire
Administration, Federal Emergency Management
Agency, 1999.
13. Proulx G, Pineau J. Review of evacuation
strategies for occupants with disabilities. Ottawa:
National Research Council of Canada, Institute
for Research in Construction, Internal Report No.
712, 1996.
14. Alessi D, Brill M et al. Home safety guide-
lines for architects and builders. NBS-GCR 78-
156, Gaithersburg, MD: National Institute of
Standards and Technology, 1978.
15. Archea JC, Collins BL, Stahl FI. Guide-
lines for stair safety. NBS-BSS 120, Gaithersburg,
MD: National Bureau of Standards, 1979.
16. Archea JC. Environmental factors associ-
ated with falls by the elderly. Clinics in Geriatric
Medicine, 1985; 1(3):555-569.
17. Pauls J. Benefit-cost analysis and housing
affordability: The case of stairway usability, safe-
ty, design and related requirements and guidelines
for new and existing homes. Proceedings of Paci-
fic Rim Conference of Building Officials, Maui,
HI, 1998:21-38.
18. Lawrence BA, et al. Estimating the costs
of nonfatal consumer product injuries in the
United States. Proceedings of the 7th Interna-
tional Conference on Product Safety Research,
Bethesda, MD, 1999:48-68.
19. NFPA. 1999 November Association
Technical Meeting Report on Proposals. Quincy,
MA: National Fire Protection Association, 1999:
253-255.
20. NFPA. 1999 November Association Tech-
nical Meeting Report on Comments. Quincy,
MA: National Fire Protection Association,
1999:204-209.
21. NFPA. 2000 May Association Technical
Meeting Report on Proposals. Quincy, MA: Na-
tional Fire Protection Association, 1999: 317-401.
22. NFPA. 2000 May Association Technical
Meeting Report on Comments. Quincy, MA:
National Fire Protection Association, 2000: 138-
191.
23. Dixon RG. Standards development in the
private sector: thoughts on interest representation
and procedural fairness. Quincy, MA: National
Fire Protection Association, 1978.
200020: Raising Income to
Protect Health
Recognizing that APHA supports the right of
all persons to a freely chosen job paying wages
sufficient to support a dignified existence.
[APHA Policy Statement 9508]; and
Finding that US has the second highest preva-
lence of child income poverty (22%) among
wealthy countries, and most poor children live in
families with at least one working parent;
1
and
Understanding that Healthy People 2010 goals
specifically recognize income and educational at-
tainent as determinants of health status; however,
the goals do not identify narrowing disparities in
these economic and educational determinants;
2
and
Realizing that it is unlikely that increasing ac-
cess to health care services or targeting public
health messages to communities in poverty alone
will eliminate health disparities;
3-5
and
Recognizing that data from longitudinal stud-
ies in the United States consistently demonstrate
that low income predicts premature mortality for
all causes across the distribution of income and
independent of other socioeconomic correlates of
income;
6-11
and
Acknowledging that low income is inversely
associated with poor subjective health status and
functional limitations;
12-15
and
Recognizing that socioeconomic factors in
childhood have been shown to predict health sta-
tus in adult life, indicating that socioeconomic in-
fluences may be cumulative, have latent effects,
or set an individual on a particular health trajec-
tory;
16,17
and
Finding that educational attainment is raised
and risk of single parenthood lowered due to in-
creased family income;
18
and
Understanding that increased family income
may support better utilization of primary care,
likely forestalling ambulatory care sensitive hos-
pitalizations.
19-21
Recognizing existing labor and tax policy
tools including the minimum wage and the
Earned Income Tax Credit could be used to
raise income for the working poor; and
Recognizing that the explicit health costs of
poverty are not included in the calculus or public
discourse regarding minimum wage and tax poli-
cy; and
Recognizing that local living wage ordi-
nances have passed in more than 30 municipali-
ties that increase wages to a level providing for
the minimum average familys needs for housing
and utilities, food, transportation, childcare,
health care, and taxes; therefore recommends that
1. The prevalence of low income be an explicit
health status indicator and reducing the
prevalence of low income become a national
public health objective;
2. Federal, state, and local governments should
consider and evaluate labor and tax policies
to increase income to minimum sustenance
levels for the working poor as an explicit
public health intervention; conversely, costs
and benefits to health should be explicitly
considered in policy debates regarding the
minimum wage and eligibility thresholds for
the Earned Income Tax Credit;
3. Epidemiologic studies should be done
specifically to evaluate the effectiveness of
income-supporting policies on public health;
these may include studies that look at the ef-
fect of income dynamics on health out-
comes
7,18
or studies of natural experiments
of public policy such as local living wage or-
dinances or changes in tax or entitlement
laws; and
4. APHA members should initiate and inform a
public dialogue regarding the effect of in-
come on health; an informed public is partic-
ularly important in light of the primary em-
phasis of media and advertising messages on
individual behavior changes, pharmaceutical
interventions, and the importance of health
care services and institutions.
References
1. UNICEF-Innocenti Research Center. Inno-
centi Report Card 1: A league table of child
poverty in rich nations. 2000.
2. Healthy People 2010, http://web.health.gov/
healthypeople/document/tableofcontents.htm
3. Adler N, Boyce W, Chesney M, Folkman S,
Syme S. Socioeconomic inequalities in health.
No easy solution. JAMA. 1993;269 (24):3140-
3145.
4. Anderson GF, Poullier JP. Health spending,
access, and outcomes: Trends in industrialized
countries. Health Affairs. 1999.
5. Geronimus AT. To mitigate, resist, or undo:
Addressing structural influences on the health of
urban populations. Am J Public Health. 2000;
90(6):867-872.
6. Backlund E, Sorlie PD, Johnson NJ. The
shape of the relationship between income and
mortality in the United States. Evidence from the
national longitudinal mortality study. Annals of
Epidemiology 1996; 6(1):12-20; discussion 21-2.
7. Mcdonough P, Duncan GJ, Williams D,
House J. Income dynamics and adult mortality in
the United States, 1972 through 1989 [see com-
ments]. Am J Public Health. 1997;87(9): 1476-
1483.
8. Fiscella K, Franks P. Poverty or income in-
equality as predictor of mortality: longitudinal
cohort study [see comments]. BMJ. 1997;314
(7096):1724-1727.
9. Sorlie PD, Backlund E, Keller JB. US mor-
tality by economic, demographic, and social char-
acteristics: The national longitudinal mortality
Association News
study [see comments]. Am J Public Health. 1995;
85(7):949-56.
10. Lantz PM, House JS, Lepkowski JM, Wil-
liams DR, Mero RP, Chen J. Socioeconomic fac-
tors, health behaviors, and mortality: Results from
a nationally representative prospective study of us
adults [see comments]. JAMA. 1998, 279(21):
1703-1708.
11. Leclere FB, Rogers RG, Peters K. Neigh-
borhood social context and racial differences in
womens heart disease mortality. Journal of
Health and Social Behavior. 1998; 39(2):91-107.
12. Marmot MG, Fuhrer R, Ettner SL, Marks
NF, Bumpass L, Ryff CD. Contribution of psy-
cosocial factors to socioeconomic differences in
health. Milbank Quarterly. 1998; 76(3):403-448,
305.
13. Kennedy BP, Kawachi I, Glass R, Proth-
row-Stith D. Income distribution, socioeconomic
status, and self rated health in the United States:
multilevel analysis. BMJ. 1998; 317(7163):
917-921.
14. Ettner SL. New evidence on the relation-
ship between income and health. J Health Eco-
nomics 1996; 15(1):67-85.
15. Geronimus AT, Bound J. Use of census-
based aggregate variables to proxy for socio-
economic group: Evidence from national sam-
ples. Am J Epidemiology. 1998;148(5): 475-486.
16. Kuh DJ, Wadsworth ME. Physical health
status at 36 years in a British national birth co-
hort. Social Science and Medicine. 1993;
37(7):905-916.
17. Keating DP, Hertzman C. Developmental
Health and the Wealth of Nations. New York, NY.
Guillford Press, 1999.
18. Duncan GJ, Yeung W, Brooks-Gunn J,
Smith JR. How much does childhood poverty af-
fect the life chances of children? American
Sociological Review. 1998; 63(3):406-424.
19. Pappas G, Hadden WC, Kozak LJ, Fisher
GF. Potentially avoidable hospitalizations: In-
equalities in rates between us socioeconomic
groups. Am J Public Health. 1997; 87(5):
811-816.
20. Weissman JS, Stern R, Fielding SL,
Epstein AM. Delayed access to health care: Risk
factors, reasons, and consequences. Annals of
Internal Medicine. 1991; 114(4):325-331.
21. Himmelstein DU, Woolhandler S. Care
denied: US residents who are unable to obtain
needed medical services. Am J Public Health.
1995; 85(3):341-344.
200021: International Trade
Policy and Issues of Improving
Access to Drugs for HIV/AIDS
and Other Life-Threatening and
Disabling Diseases
Noting that of the estimated 50 million men,
women, and children who have been infected
with HIV or AIDS worldwide at the end of 1999,
more than 95 percent now live in the developing
world, and, likewise, that of the estimated 16.3
million individuals who have already died from
the disease, 95 percent have occurred in develop-
ing countries and that 95% of the infected remain
without access to treatment;
1,2
and
Observing that trade and investment policies
in many countries block the ability of developing
nations to use international trade agreements to
combat diseases;
3-5
and
Recognizing that while some developing
countries have had sustained success in reducing
HIV/AIDS risk infection, lowering or stabilizing
HIV/AIDS rates, and improving the health care of
those already infected, the cost of life-prolonging
HIV/AIDS drugs remains a major barrier to
fighting the HIV/AIDS epidemic;
6
and
Observing that international trade agreements
such as the World Trade Organizations agree-
ment on intellectual property rights Agreement
on Trade-Related Aspects of Intellectual Property
Rights (TRIPS), while providing broad protection
for intellectual property rights, also allows coun-
tries to regulate cross-border, parallel import-
ing trade in a product, such as pharmaceuticals,
without permission of the patent holder (Article
6, Exhaustion); that this provision of TRIPS is a
model being proposed by The World Health
Organization (WHO) to help less-developed
countries improve access to pharmaceuticals; and
that the international communities have success-
fully worked together to ensure access to vaccines
and other life-prolonging drugs for developing
countries;
7,8
and
Recognizing that WHO policy World Health
Assembly (WHA) Revised Drug Strategy
EB103/ 4 calls upon member countries to:
9
Ensure that public health interests are para-
mount in pharmaceutical and health policies;
and
Reaffirm their commitment to developing,
implementing, and monitoring national drug
policies and to taking all necessary concrete
measures in order to ensure equitable access
to essential drugs; and;
Explore and review their options under rele-
vant international agreements, including
trade agreements, to safeguard access to es-
sential drugs; therefore
1. Urges public health considerations be
paramount in trade policies regarding ac-
cess to medicines for HIV/AIDS and
other diseases which cause premature
death or disability; and
2. Calls for the international community to
employ demonstrably effective methods
to fight the AIDS epidemic, including
more financial assistance, improved pre-
vention activities, increased voluntary
testing and counseling, more treatment of
sexually transmitted diseases, greater sup-
port of human rights work to decrease the
stigma associated with HIV/AIDS, devel-
opment of health care infrastructure, and
use of international trade agreements to
promote the inexpensive production of
life saving drugs;
3. Urges governments to review trade poli-
cies to ensure that developing countries
do not face trade-related barriers for ac-
cess to essential medicines medical tech-
nologies, in a manner consistent with the
World Health Assembly Revised Drug
Strategy.
4. Encourages the World Health Organ-
ization and UNAIDS to lead the interna-
tional organization of manufacturing and
distribution of drugs for HIV/ AIDS, in-
cluding globally registering products, ob-
taining compulsory licenses were needed,
and organizing efficient procurement of
active ingredients and finished products
for countries that require this assistance.
References
1. UNAIDS 1999 Annual Report, Geneva:
UNAIDS, 1999.
2. Satcher, D. The Global HIV/AIDS Epi-
demic. JAMA, April 28, 1999.
3. Editorial, Drugs for AIDS in Africa. New
York Times, August 1999.
4. Wilson, D. et al Global trade and access to
medicines: AIDS treatment in Thailand. Lancet;
345: pp. 1893-1895.
5. Pecoul, B. et al. Access to essential drugs in
poor countries: A lost battle? JAMA.
6. AIDS not losing momentum. Press Release
WHO/66 23. World Health Organization,
November 1999.
7. Globalization and Access to Drugs:
Perspectives on the WTO/TRIPS Agreement,
World Health Organization, Action Programme
on Essential WHO Medicines Strategy 2000-
2003: Framework for action in essential drugs
and medicines policy, Department of Essential
Drugs and Medicines Policy, World Health
Organization.
8. Towards a strategic agenda for the WHO
secretariat: Statement by the DirectorGeneral to
the Executive Board at its 105th session.
(EB105/2) January 24, 2000.
9. Revised Drug Strategy resolution,
(WHA49.14) Geneva: World Health Organiza-
tion, May 25, 1996.
200022: Joint Resolution in
Support of National Public Health
Performance Standards Program
Noting that the following national professional
organizations: The American Public Health Asso-
ciation (APHA), the Association of State and Ter-
ritorial Health Officials (ASTHO), the National
Association of County and City Health Officials
(NACCHO), the National Association of Local
Boards of Health (NALBOH), the Public Health
Foundation (PHF), and Centers for Disease
Control and Prevention (CDC), the Mental Health
Statistics Improvement Program of SAMHSA, the
American Association of Community Psy-
chiatrists, and workgroups of the Center for Mental
Health Services and the National Institute of
Mental Health, are leading an effort to improve
public health infrastructure by developing gover-
nance and local-state-level performance measures
as part of the National Public Health Performance
Standards Program (NPHPSP); and
Noting that these joint measures are based on
the core functions of public health and the ten
Association News
Essential Public Health Services outlined in
Public Health in America;
1
and
Further recognizing that the assessment of
these functions will depend on the Healthy People
2010 objectives in each disability area; and
Recognizing that the first goal of the NPHP-
SP is to promote quality improvement by defin-
ing best practices and becoming an impetus for
action; and
Recognizing that the second goal of the NPH-
PSP is to improve by accountability by providing
performance expectations and providing data for
benchmarking; and
Recognizing that the third goal of the NPHP-
SP is to build a scientific basis for public health
practice that can be used for better decision-mak-
ing, useful comparative data for evaluation, and
advocating for public health resources and part-
nerships; and
Acknowledging that there is a need for spe-
cialized and appropriate quality management
standards and performance indicators for mental
health services as noted in the recommendations
of the Surgeon Generals Report on mental ill-
ness; and
Aware that the Healthy People 2010
2
contains
Objectives 23-12: (Developmental) Increase the
proportion of state and local public health agencies
that meet national performance standards for essen-
tial public health services; and
Aware that this joint collaborative develop-
ment process with local, state, and governance
input assures that all performance measures ad-
dress and promote the same goals and concepts;
and
Aware that in June 1999, after the unveiling of
the program at the NPHPSP Conference in
Atlanta, Georgia, the Centers for Disease Control
and Prevention asked its partner organizations to
formally endorse the NPHPSP tenets; therefore
1. Advocates the implementation, including ap-
propriate quality management standards and
performance indicators for mental health ser-
vices, of the National Public Health Per-
formance Standards Program nationwide.
References
1. US Public Health Service Public Health
Functions Steering Committee. Public Health in
America. Fall 1994.
2. US Department of Health and Human Ser-
vices. Healthy People 2010, Washington, DC.
1999.
200023: The Need for Continued
and Strengthened Support for
Immunization Programs
Knowing that through past resolutions and
policy statements, it has affirmed the importance
of immunizations, both in the United States and
globally; and
Wishing to update and amplify these policy
statements (Resolutions 7805, 7806, 7906, 8706,
9103); and
Recognizing that great progress has been
made in improving immunization coverage
among infants and young children as a result of
the Childhood Immunization Initiative;
1
and
Recognizing that continued success in con-
trolling vaccine-preventable diseases requires as-
suring that the 11,000 infants born each day re-
ceive needed immunizations on schedule; and
Noting that the National Vaccine Advisory
Committee (NVAC) has recently published a re-
port describing the strategies needed to sustain
success in childhood immunizations;
2
and
Noting that the Surgeon General on April 27,
1999,
3
supported the establishment of a nation-
wide network of state/community population-
based immunization registries to facilitate this
immunization as called for in an NVAC report,
4
and
Noting that the NVAC report called for a five-
year federal grant program to fund development
and implementation of registries while a long-
term financing mechanism was being developed;
and
Noting that recent issues raised regarding vac-
cine safety
5
make it imperative that vaccine safe-
ty monitoring activities be enhanced
6
(immuniza-
tion registries being an important component);
and
Noting further that immunization of adoles-
cents and adults, particularly the frail elderly, lags
significantly behind progress with young chil-
dren; and
Noting that recent cuts in federal funding for
immunizations
9
threaten the continuation of exist-
ing activities and preclude the further develop-
ment of registries and vaccine safety monitoring
or the extension of programs to immunize adoles-
cents and adults; and
And further noting that the Institute of Medi-
cine has recently released a report
10
describing the
U.S. immunization system as a national treasure
that is too often taken for granted and calling for
substantial increases in federal and state alloca-
tion of funds to support immunization infrastruc-
ture; therefore
1. Reaffirms its support for immunization as
one of the most cost-effective means of pre-
venting infectious diseases;
2. Urges the Congress and state legislatures to
fully fund, and CDC and state health depart-
ments to implement, the recommendations
called for by the Institute of Medicine in its
recent report Calling the Shots.
3. Urges CDC and the US Department of
Health and Human Services (DHHS) to de-
velop, and the Congress to approve, a leg-
islative proposal for a five-year grant pro-
gram to support development and implemen-
tation of immunization registries, as called
for by NVAC;
4. Urges the Congress to fund fully the Vaccine
Safety Action Plan developed by the DHHS
Vaccine Safety Working Group;
5. Urges CDC and DHHS to develop, and the
Congress to approve, a legislative proposal to
provide federal support for immunization of
adolescents and adults;
6. Urges CDC and DHHS to develop and fund
additional programs for outreach to those
populations that remain hard to reach and are
underimmunized; and
7. Urges CDC and DHHS to promote
public awareness of the importance of
immunizations.
References
1. The Childhood Immunization Initiative.
HHS Fact Sheet, April 20, 1999. http://waisgate.
hhs. gov/ cgi bi n/ wai sgat e?WAI SdocI D=
8133121002+1+0+0&WAISaction=retrieve
2. National Vaccine Advisory Committee.
Strategies to sustain success in childhood immu-
nizations. JAMA. 1999;282:363-370.
3. Statement of David Satcher addressing the
All Kids Count national conference, St. Paul MN,
April 27, 1999 (same statement presented to
National Immunization Conference, Dallas TX,
June 23, 1999).
4. National Vaccine Advisory Committee. De-
velopment of Community- and State- Based Im-
munization Registries. Approved January 12,
1999. www.cdc.gov/nip/registry/I_recs.htm
5. Committee on Government Reform, US
House of Representatives, hearing on Vaccines:
Finding the Balance Between Public Health and
Personal Choice. August 3, 1999.
6. National Vaccine Advisory Committee.
Resolution: Vaccine Safety Action Plan, January
12, 1999. www.cdc.gov/od/nvpo/ nvr11299.htm
vention. National Vaccination Coverage Levels
Among Children Aged 19-35 MonthsUnited
States, 1998. MMWR. September 24, 1999;
48(37):829-830.
vention. Influenza and pneumococcal vaccination
levels among adults aged greater than or equal to
65 yearsUnited States. MMWR. October 2,
1998; 47(38):797-802.
9. A bill making appropriations for the De-
partments of Labor, Health and Human Services,
and Education, and related agencies for the fiscal
year ending September 30, 2000, and for other
purposes. HR3037; pp. 50-51.
10. Institute of Medicine Committee on
Immunization, Finance Policies, and Practices.
Calling the Shots: Immunization finance policies
and practices. Washington, DC: National
Academy Press. 2000.
200024: International Digest
of Health Legislation
Noting that the World Health Organization
(WHO) decided in the summer of 1999 to end
publication of the International Digest of health
Legislation (IDHL) as a printed quarterly journal
and publish health legislation on the Internet;
1
and
Recognizing that the IDHL has provided since
1948 an invaluable compendium of the health
legislation of the world, by country and subject
matter, in English and French;
2
and
Noting that the IDHL is unique in providing
original texts of health laws and accurate sum-
maries of such legislation, constituting a rich re-
source readily available for development of health
policy and research on comparative legislation;
3
and
Association News
Noting that the IDHL has become an inval-
uable tool for government officials, academics,
industry, and other entities as a source of legisla-
tion on such key issues as HIV/AIDS, bioethics,
environmental health, primary health care, phar-
maceuticals, and food safety; and
Noting also the limited or non-existent access
of many current readers and users, notably in re-
source-poor countries, to the Internet; and
Recognizing the important contribution that
WHO has made in disseminating health legisla-
tion worldwide over the past half-century; and
Appreciating the desire of WHO to make
health legislation more widely available without
cost to the user; and
Understanding WHO recognizes the impor-
tance of legislation as a foundation for public
health programs and as a strategy for developing
health systems; therefore
1. Compliments the World Health Organization
on its unique and outstanding accomplish-
ment over the years in disseminating accurate
legislative information on health to scholars,
public health professionals, and countries
seeking to strengthen their health systems;
and
2. Urges WHO to maintain the same high qual-
ity of its on-line publication of health legisla-
tion as it has long provided in its printed
quarterly, and specifically that legislative
texts and summaries of legislation be pre-
sented by country and by subject matter in
English and French so as to be readily avail-
able globally.
References
1. Information provided by WHO to sponsor
of resolution, September 1999.
2. Health Legislation and the dawn of the
XXIst century, IDHL. 1988; 49(1).
3. Roemer, R. Health legislation as a tool for
public health and health policy, IDHL. 1988;
48(1):89-100.
200025: Eliminating Access
Barriers in Public Health
Meetings
Noting that Congress, in enacting the Am-
ericans with Disabilities Act (ADA), has recog-
nized that persons with mental or physical disabil-
ities have been subjected to a history of purpose-
ful unequal treatment and relegated to a position of
political powerlessness
1
which continue(s) to be
a serious and pervasive social problem
2
in many
realms including health services,
3
and that barri-
ers to participation in such critical areas as educa-
tion, employment, housing, public accommoda-
tions, access to public services,
4
etc., have con-
tributed to the fact that people with disabilities, as
a group, occupy an inferior status in our society,
and are severely disadvantaged socially, vocation-
ally, economically, and educationally;
5
and
Recognizing that some discrimination against
persons with disabilities occurs through intentional
exclusion whether because they are undervalued as
members of society or because of overprotective
rules and policies, and that other discrimination oc-
curs through unintentional discriminatory effects of
architectural, transportation, and communication
barriers;
6
and
Recognizing that persons with disabilities
constitute approximately 20.6% of the total popu-
lation;
7
and
Recognizing that the new paradigm in dis-
ability policy focuses on the interaction of an in-
dividuals characteristics and the environment as
determinants of outcomes;
8-10
and
Recognizing that the health, productivity, and
social integration of our society depends on ad-
dressing the health care needs of the total popula-
tion in an efficient and effective way,
11
and creat-
ing equalization of opportunities for persons with
disabilities;
12-14
and
Recognizing that inclusion of persons with
disabilities is an important public health objective
which must be promoted by universal design
backed up by provision of reasonable accommo-
dations to create more competent healthy com-
munities;
15,16
and
Believing that disability, like gender and race,
is a natural and normal part of human experience
that in no way diminishes a persons right to fully
participate in an organizations activities;
17
and
Recognizing that removing the barriers to par-
ticipation and creating a more accessible society
will be greatly enhanced by the involvement of
persons with disabilities in the formation and im-
plementation of public policy
18-20
through public
health organizations; therefore, urges public
health organizations to begin discussions of ways
to initiate the following or to have policies and
implementation mechanisms in place to promptly
and effectively:
1. Select accessible sites
21
in accessible commu-
nities to hold public health meetings; whereby
accessible facilities
22
include meeting spaces,
exhibit booths, public use areas, sleeping
areas, restaurants, and social events, etc.;
2. Ensure physical accessibility by using rooms
set up to accommodate wheelchair users in
the audience as well as at a speakers table,
and to provide amplification equipment if
needed such as table or lapel microphones
that permit persons with disabilities to speak
without having to hold the microphone;
3. Provide accessible and timely transportation
including accessible buses and vans as well
as accessible parking;
4. Promote accessible communication
23
in the
form of conference materials in accessible
formats, qualified sign language interpreters,
assistive listening devices such as in-
duction/hearing hoops, decoders, and real-
time captioning; and provide guidelines to
speakers for accessible methods of presenta-
tion such as providing handouts in alternative
formats (e.g., large print, Braille, or audio
cassette), providing an oral description if vi-
sual materials are included, and presenting
material in easily understandable language
and at a pace that is suitable to professionals
with cognitive differences as well as to most
meeting participants;
5. Provide personal assistance for meeting site
orientation and other assistance when re-
quested and feasible in the form of a note
taker, reader, etc., enabling persons with dis-
abilities to participate in all scheduled con-
ference activities;
6. Utilizing planning process to promote cost-
effective accessibility by:
Identifying access needs of persons with
disabilities through pre-registration and
membership procedures;
Ensuring that all contracts are sensitive to
needs of persons with disabilities and
comply with ADA standards, including
those for conference arrangements, trans-
portation, audio visual and computer
equipment, exhibit booths, hotels meals,
receptions, etc.;
Conducting site visits with the assistance
of accessibility specialist consultants such
as individuals from Independent Living
Centers in the local community prior to the
meetings to ensure compliance with non-
discrimination standards, provide disability
sensitivity training to public health organi-
zation staff to increase their awareness of
architectural, communication, and attitudi-
nal barriers, and designate knowledgeable
person(s) in the organization as an access
troubleshooter to correct problems as they
arise;
Evaluating effectiveness of accessibility
through targeted surveys, focus groups,
advisory committees, etc., of persons with
disabilities who are members or partici-
pants in the public health organization ac-
tivities; and
Using public health organizations com-
munication channels including newslet-
ters, publications, web site, etc., to inform
membership about an organizations com-
mitment to accessible meetings and orga-
nizational procedures.
7. Ensure that persons with disabilities have an
equal opportunity to participate in all gover-
nance functions and decision-making by the
organization.
References
1. ADA Finding 7, Americans with Disabili-
ties Act of 1990, Public Law 101-336.
2. ADA Finding 2, Americans with Disa-
bilities Act of 1990, Public Law 101-336.
7. McNeil JM. Current Population Reports,
Americans With Disabilities: 1994-1995, Wash-
ington, DC: Census Bureau, US Department of
Commerce.
8. World Health Organization. International
classification of impairments, activities, and par-
ticipation (ICIDH-2). A manual of dimensions of
disablement and functioning. Beta-1 draft for
field trials. Geneva: World Health Organization,
1997.
Association News
tion, Office on Disability and Health 1996/97
Strategic Plan, Atlanta, GA.
10. National Institute on Disability and
Rehabilitation Research (NIDRR) Long Range
Plan: Fed Regist. December 7, 1999; 64, (234):
68575- 68614.
12. Pope AM and Tarlov AR (eds.). Disability
in America: Toward a National Agenda for
Prevention, Washington, DC: National Academy
Press, 1991.
13. Brandt EN and Pope AM (eds.). Enabling
America: Assessing the Role of Rehabilitation
Science and Engineering. Washington, D.:
National Academy Press, 1997.
14. United Nations Standard Rules on the
Equalization of Opportunities for Persons with
Disabilities, in United Nations General Assembly
Resolution 48/46, December 20, 1993.
16. Zola I. Toward the necessary niversalizing
of a disability policy. The Milbank Memorial
Fund Quarterly, 1989; 67 (supplement 2, part 2):
401-428.
17. Silverstein Robert. Federal disability pol-
icy framework reflecting the nations goals relat-
ing to people with disabilities as articulated in
the Americans with Disabilities Act. Iowa Law
Review, 2000; 85(5) Section 2(a)(3) of the
Rehabilitation Act (29 U.S.C. 701(a)(3));
Section 601(1) of the Individuals with Dis-
abilities Education Act (20 U.S.C. 1400 (1));
Section 101(a)(2) of the Developmental Disabil-
ities Assistance and Bill of Rights Act (42
U.S.C.6000(a)(2)).
18. Hahn H. Towards a politics of disability:
definitions, disciplines, and policies. Social
Science Journal, 1985; 22(4):87-106; consider
also cites to Paul Longmore, Richard Scotch, etc.
19. National Council on Disability, Towards
Independence, Washington, DC., 1986.
20. DeJong G. Independent living: from so-
cial movement to analytic paradigm, Archives of
Physical Medicine and Rehabilitation, October
1979;60:435-446.
21. Kailes JI, Jones D. A Guide to Planning
Accessible Meetings, Houston, TX: ILRU Re-
search & Training Center on Independent Living,
The Institute for Rehabilitation and Research
(TIRR), 1993.
22. ADA Accessibility Guidelines. 28 C.F.R.
Part 36, January 1992.
23. Stoddard S., Kasnitz D,. and Wahl L. Mak-
ing conferences accessible: Experiences from 1995
SDS. Disability Studies Quarterly, 1998; 18(1).
200026: International Multilateral
and Bilateral
Debt Relief
The American Public Health Association;
Recognizing that the current burden of debt on
developing nations has been widely recognized as
unsustainable and unpayable by the international
community (52 countries owe a total of $354 bil-
lion to creditor nations, International Finance
Institutions (IFIs), and regional banks);
1,2
and
Recognizing that without debt relief, coun-
tries such as Uganda, which spends $3 per person
on health and $15 per person on debt service, will
be faced with increasing poverty, hunger, disease,
conflict, and environmental destruction;
3
and
Recognizing that since 1987, the International
Monetary Fund (IMF) has received $4 billion
more in debt repayments from Africa than it has
provided in new finance to African nations;
3
and
Recognizing that previous attempts by the
World Bank and IMF to relieve debt with struc-
tural adjustment policies and the 1996 HIPC
Initiative have not significantly reduced total debt
service, and, in some cases, have even increased
debt payments;
4
and
Recognizing that the Jubilee 2000 movement,
currently active in more than 80 countries, is cre-
ating awareness of debt and urging rich nations
and international financial institutions to cancel
or greatly reduce debt owed by the worlds poor-
est countries in the year 2000;
5
and
Recognizing that Congressional legislation
[H.R. 1095, S. 1690], passed in Congress in Nov-
ember 1999, provides debt cancellation specifical-
ly for the purpose of health improvement and
poverty reduction, along with a validated frame-
work of monitoring and evaluation to maintain the
transparency of the debt relief process; legislation
also stipulates that members of civil society be in-
volved in decisions on allocation of funds saved
from debt relief, in order to prevent mismanage-
ment of funds;
6,7
and
Recognizing that the total cost of debt cancel-
lation for the United States is relatively insignifi-
cant in comparison to the tremendous global
health benefits to be gained from such an action
(total cost: $970 million to comply with the US
share of the International G-7 agreement, and
slightly more to fulfill the standards set forth by
H.R. 1095 and S. 1690);
8
therefore
1. Fully supports the debt relief legislation
passed by Congress, and now urges Congress
to take the next necessary steps to fully fund
its portion of international debt cancellation
from the federal budget;
2. Urges Congress to carefully monitor the im-
plementation of debt relief legislation in the
US and internationally, to ensure that the
benefits of debt relief reach the poor and
needy in those nations; and
3. Urges its members and the public health
community to actively advocate for and lend
technical support to cooperation between
IFIs, creditor nations, and relief organiza-
tions in order to ensure a fair and transparent
system of debt relief.
References
1. Wolfensohn JD. President, The World Bank
Group. Coalitions for Change. Address to the
Board of Governors at the Annual Meetings of the
World Bank Group and the International Monetary
Fund, Washington, DC, September 1999.
2. Burgess J. Clinton pledges to forgive poor
nations debt. Washington Post, September 30,
1999, p. A18.
3. Watkins K. The catch-22 of debt [third
world debt problems]. New Statesman and Soci-
ety, March 1, 1996; 9(392):30(2).
4. Walhof TK. Responses to concerns about
the Debt Relief for Poverty Reduction Act (H.R.
1095). Internal Document, Bread for the World,
October 1999.
5. Bunting M. Jubilee 2000: Churches spread
the word on debt. UNESCO Courier, January
2000, p. 31.
6. Representative Jim Leach (R-IA). Com-
prehensive Debt Relief Adopted by the Omnibus
Budget Resolution. Address to the U.S. House of
Representatives, November 1999.
7. Senators Connie Mack (R-FL) and Paul
Sarbanes (D-MD). Debt Relief for Poor Coun-
tries Act of 1999. Statements on introduced bills
and joint resolutions, US Senate, October 1999.
8. Grunwald M. GOPs Bachus makes debt re-
lief his mission. Washington Post, October 9,
1999, p. A03.
200027: Encourage Healthy
Behavior by Adolescents
Recognizing the importance of reducing alco-
hol, tobacco, and other drug use among youth
1
and seeking to update that focus on prevention of
initial risky behavior and the high incidence of in-
juries resulting from risky behaviors by adoles-
cents and evidence-based interventions that pre-
vent and ameliorate further problems; and
Noting that comprehensive approaches are
more effective than programs that focus on a sin-
gle behavior;
2-4
and
Noting that tobacco use,
5
alcohol and drug
abuse,
6
unsafe driving practices, violent behavior
7
including attempting suicide,
8
unprotected sex,
9
poor nutrition,
10,11
and lack of exercise
10-12
threat-
en the healthy development of youth into produc-
tive adults; and
Observing that previous resolutions have con-
sidered specific unhealthy behaviors, their re-
sults, and methods of intervention;
13-26
and
Recognizing that risky behavior is affected by
core social institutions such as education, admin-
istration of justice, and economic opportunities;
27
and
Observing that publicizing adolescent violent
behavior in newspapers,
28-29
television,
30-32
and
other media can lead to copy-cat behavior by
adolescents and enactment of tougher penalties
by voters; and
Noting that the majority of adolescents may
engage in one or more of these behaviors at some
time,
27,33-35
but these behaviors are not normative;
and
Recognizing that youth at high risk for life-
threatening activities tend to engage in multiple
risky behaviors;
36-41
and
Noting that adolescents at high risk for health
and criminal problems also tend to have multiple
predisposing factors,
28,33,36,42,43
including poor aca-
demic achievement, lack a caring adult, and have
access to illegal substances or guns;
37,44
and
Recognizing that these predisposing and en-
abling factors tend to e complex, a more compre-
Association News
hensive approach to prevention and intervention
is required; and
Observing that programs that focus on pro-
moting academic success for all students, devel-
oping positive relationships with peers and adults,
providing family support, and increasing family
and community engagement have been effective
in reducing risky behavior
28,33,36,45-47
and that many
of these programs include school-based health
centers and family resource centers where multi-
agency services can be coordinated; and
Finding that these elements are often present in
programs known as community schools
48,49
that
provide activities outside of school hours for stu-
dents, their families, and community members;
and
Noting that intervention policies requiring ex-
pulsion and suspension drive students from
school and inhibit their development;
41,45,50
and
Recognizing that interventions involving
mandatory minimum sentences and incarceration
of youth with adult criminals encourages devel-
opment of deviant behaviors and inhibits positive
learning, forcing increasing dependence on soci-
ety;
28,51,52
therefore
1. Urges Congress and the states to enact legis-
lation and provide appropriations that pro-
mote collaboration among government agen-
cies to develop comprehensive and integrat-
ed programs and services for prevention of
high-risk adolescent behavior, such as the
Safe Schools/Healthy Students Initiative;
53
2. Urges Congress, the states, and local com-
munities to provide adequate funding for
community schools that include after-school
programs, preferably with community ser-
vice opportunities, health education pro-
grams, family resource centers, and school-
based health centers;
3. Urges Congress to fund collaborative re-
search about the impact of community
schools on prevention of risky behavior by
adolescents, and disseminate the results to
policy makers and professional and lay audi-
ences;
4. Urges wire services and other media to pub-
licize positive activity of adolescents;
5. Urges all states to enact legislation prohibit-
ing media from publicizing names of those
under the age of 18 who commit violent
crimes, or their families;
6. Recommends that school districts implement
alternative educational experiences in lieu of
suspension and expulsion; and
7. Urges Congress and the states to repeal man-
datory minimum sentences for juveniles; and
8. Urges Congress, the states, and local govern-
ments to house incarcerated youth under the
age of 18 with others of similar age, and not
to house them with incarcerated adults.
References
1. Policy Statement 8817(PP): A Public
Health Response to the War on Drugs: Reducing
Alcohol, Tobacco and Other Drug Problems
among the Nations Youth. APHA Policy
Statements; 1948-present, cumulative, APHA:
Washington DC.
2. National Institute for Drug Abuse. Pre-
venting drug abuse among children and adoles-
cents: A research-based guide. National Institute
for Drug Abuse, 1997.
3. National Institute on Drug Abuse. Drug
abuse prevention: What works. Washington, DC:
National Institute on Drug Abuse, 1997, pp. 47-50.
4. Satcher D, et al., Violence prevention is as
American as apple pie. Am J Preventive
Medicine, 1996; 12(5):v-vi.
Services; Preventing tobacco use among young
people: A report of the Surgeon General. Atlanta,
Georgia: US Department of Health and Human
Services, Public Health Service, 1994.
6. Centers for Disease Control; Youth risk be-
havior surveillance survey. Morb Mortal Wkly
Rep, 1996; 45(SS-4):1-85.
7. US Department of Justice, Uniform Crime
Reports 1997, preliminary annual release. Wash-
ington, DC: Federal Bureau of Investigation;
1998.
vention; Youth risk behavior surveillance
United States, 1997. Morb Mortal Wkly Rep,
1998; 47(SS-3).
vention, Trends in sexual risk behaviors among
high school studentsUnited States, 1991-97.
Morbidity and Mortality Weekly Report,
1998;47(36): 749-751.
10. Healthy People 2010. National Health
Promotion and Disease Prevention Objectives,
conference edition, in two volumes. Washington
DC: US Department of Health and Human
Services, Public Health Services, 2000.
11. West P and Farrior E. School Food Service
Research Review. 1991.
vention, Guidelines for school and community
programs to promote lifelong physical activity
among young people. Morb Mortal Wkly Rep,
1997; 46(RR-6).
13. Policy Statement 9808: National Tobac-
co Control Legislation. APHA Policy State-
ments, 1948present, cumulative, APHA:
Washington DC.
14. Policy Statement 7513: Alcoholism.
APHA Policy Statements, 1948present, cumula-
tive, APHA: Washington DC.
15. Policy Statement 7121: Substance Abuse
as a Public Health Problem. 1 APHA Policy
Statements, 1948present, cumulative, APHA:
Washington DC.
16. Policy Statement 9213(PP): Advertising
and Promotion of Alcohol and Tobacco Products to
Youth. APHA Policy Statements, 1948-present, cu-
mulative, APHA: Washington DC.
17. Policy Statement 9610: Elimination of
Outdoor Tobacco Advertising. APHA Policy
Statements, 1948present, cumulative, APHA:
Washington DC.
18. Policy Statement 9611: Linkage of Medi-
cal Services for Low-Income Populations with
Mental Health, Substance Abuse, and Other Sup-
portive Services. APHA Policy Statements, 1948
present, cumulative, APHA: Washington DC.
19. Policy Statement 9210: Homelessness as a
Public Health Problem. APHA Policy Statements,
1948present, cumulative, APHA: Washington
DC.
20. Policy Statement 9818: Handgun Injury
Reduction. APHA Policy Statements, 1948 pre-
sent, cumulative, APHA: Washington DC.
21. Policy Statement 9123: Social Practice of
Mass Imprisonment. APHA Policy Statements,
1948present, cumulative, APHA: Washington DC.
22. Policy Statement 7837: Prevention of Un-
wanted Teenage Pregnancy. APHA Policy State-
ments, 1948present, cumulative, APHA: Wash-
ington DC.
23. Policy Statement 6701: Helping Youth
Achieve Healthy Sexual Adjustment. APHA Pol-
icy Statements, 1948present, cumulative, APHA:
Washington DC.
24. Policy Statement 9309: Sexuality
Education. APHA Policy Statements, 1948 pre-
sent, cumulative, APHA: Washington DC.
25. Policy Statement 6917: Sex Education in
School Systems. APHA Policy Statements, 1948
present, cumulative, APHA: Washington DC.
26. Policy Statement 8205: Endorsement of
the National Nutrition Consortiums Nutrition
Education Policy Guidelines. APHA Policy State-
ments, 1948present, cumulative, APHA: Wash-
ington DC.
27. Elliott D. Youth violence: An overview.
Boulder, CO: Center for the Study and Prevention
of Violence, 1994.
28. Tolan P and Guerra N. What works in re-
ducing adolescent violence: An empirical review
of the field. Boulder, CO: Center for the Study
and Prevention of Violence, 1994.
29. Klein J, et al. Adolescents risky behavior
and mass media use, Comment. Pediatrics, July
1993; (1):146-148.
30. Centerwall B. Television and violence the
scale of the problem and where to go from here.
JAMA, 1992; 26(22):3059-3063.
31. Dorfman L, et al. Youth and violence on
local television news in California. Am J Public
Health, 1997; 87(8):1311-1316.
32. Policy Statement 7622: Television and
Health. APHA Policy Statements, 1948present,
cumulative, APHA: Washington DC.
33. Earls F. Violence and todays youth. The
Future of Children; Critical health Issues for
Children and Youth. 1994; 4(3): 4-23.
34. Moffitt T. Adolescence-limited and life-
course-persistent antisocial behavior: A develop-
mental taxonomy. Psychological Review. 1993;
100(4):674-701.
35. Elliott D, et al. National Youth Survey
General Delinquency Scale. Cumulative risk
across family stressors: Short- and long-term ef-
fects for adolescents. 1998; 26:119-128.
36. Lerner R and Galambos N. Adolescent de-
velopment: Challenges and opportunities for re-
search, programs and policies. Annual Review of
Psychology. 1998;49:413-446.
37. Williams K., Guerra N, and Elliott D.
Human Development and Violence Prevention.
Boulder CO: Center for the Study and Prevention
of Violence; 1997.
38. Ellickson P, Saner H, and McGuigan K.
Profiles of violent youth: Substance use and other
concurrent problems. Am J Public Health. 1997;
87(6):985-991.
Association News
39. Cocozza J and Skowyra K. Youth with
Mental Health Disorders: Issues and Emerging
Responses. Washington, DC: Office of Juvenile
Justice and Delinquency; 2000; p. 3-13.
40. Hawkins J et al. Predictors of youth vio-
lence. Washington, DC: Office of Juvenile Justice
and Delinquency Prevention. 2000;. 1-11.
41. Dryfoos J. Adolescents at Risk: Prev-
alence and Prevention. New York, NY: Oxford
Press; 1990.
42. Jessor R. Successful adolescent develop-
ment among youth in high-risk settings.
American Psychologist. 1993; 48(2):117-126.
43. Hawkins J, Catalano R and Miller J. Risk
and protective factors for alcohol and other drug
problems in adolescence and early adulthood:
Implications for substance abuse prevention.
Psychological Bulletin. 1992;112: 64-105.
44. American Academy of Pediatrics Com-
mittee on Adolescence, Firearms and adolescents.
Pediatrics. 1992; 89(4):784-787.
45. Carnegie Council on Adolescent Develop-
ment, Great Transitions: Preparing Adolescents
for a New Century. New York, NY: Carnegie
Corporation of New York; 1995.
46. Decker L and Decker V. Engaging Fami-
lies and Communities: Pathways to Educational
Success. Fairfax, VA: National Community
Education Association; 2000.
47. Dryfoos J. Full-Service Schools. San
Francisco, CA: Jossey-Bass; 1994.
48. Canada G. Fist, Stick, Knife, Gun. Boston,
MA: Beacon Press; 1996.
49. Melaville A. Learning Together: The De-
veloping Field of SchoolCommunity Initiatives.
Flint, MI: Charles Stewart Mott Foundation; 1998.
50. US Department of Education and US
Justice Department. Safe and smartmaking
after-school hours work for kids. Washington,
DC: Government Printing Office; 1998.
51. Gottfredson D. Choosing punishments:
Crime control effects of sentences, Research
Review. 2000; p. 2.
52. Singer S and McDowall D. Criminalizing
delinquency: The deterrent effects of the New
York juvenile offender law. Law & Society
Review. 1988; 22(3):521-535.
53. US Department of Justice, President
Clinton announces more than $200 million in
community grants to prevent violence among
youth. Washington, DC: US Department of Jus-
tice; 2000.
200028: Ensuring Optimal Vision
Performance in Visually At Risk
Drivers
Observing that traffic crashes remain as one
of the most significant public health problems in
the US,
1-5
and realizing that driving is a complex
dynamic activity, requiring rapid and continuous
integration of cognitive, sensory, and motor
skills;
6,7
and
Recognizing that the average American driver
is becoming older, and that by the year 2020, the
number of elderly drivers is expected to increase
by almost 50%;
8
and that age-related decrements
in driving competency are likely to have impor-
tant implications for traffic safety;
9
and
Observing that elderly drivers have an in-
creased likelihood of vision impairments, and an
increased risk for vision-related crashes;
6,7
and
Observing that roughly 88% of older Ameri-
cans rely on private automobiles for their trans-
portation needs,
10
and that a drivers license is in-
trinsically tied to mobility, independence, and
quality of life; and
Recognizing that most older persons live in
very low density communities where alternative
transportation to the privately owned automobile
is rare, and that a substantial proportion of older
drivers continue to rely on their automobiles and
to drive in their ninth decade of life;
11,12
and
Recognizing that some states require vision
testing for driver license renewal, whereas others
do not, and that among those states requiring vi-
sion testing, the frequency and types of vision tests
performed vary considerably;
13-15
and
Acknowledging that state governments have
the right and responsibility to protect the public
health,
16
but that ineffective policies may adverse-
ly impact the mobility and quality of life of the el-
derly;
17
and
Observing that the Americans with Disa-
bilities Act (ADA) emphasized reasonableness
but does not require that others be placed at risk
in the process of creating opportunities for per-
sons with disabilities;
18
and
Noting that if licensing requirements are ap-
plied in a uniform and non-discriminatory man-
ner, the spirit of the ADA will be satisfied;
16,18
and
Given the scarcity of empirical evidence of a
predictive relationship between vision testing and
traffic safety,
19-23
and recognizing that the elderly
have higher rates of vision impairment,
24,25
and,
therefore, are more likely to be denied driver li-
censes as a result of failing the vision screening
examination;
26,27
and
Noting evidence which is available indicates a
beneficial effect of public policy requiring vision
testing as a condition of driver license renewal;
28-
30
and
Understanding that lawmakers and regulators
must carefully balance societal needs and individ-
ual rights when shaping public policy; therefore
1. Encourages schools of public health, optom-
etry, medicine, occupational therapy, engi-
neering, and other appropriate schools to ex-
pand research in prevention and control of
vision-related traffic crashes, and federal and
state government to fund such programs;
2. Urges increased funding for the National Eye
Institute and the National Institute on Aging,
Agency for Healthcare Research and Quality,
National Highway Traffic Safety Adminis-
tration (NHTSA) and the Centers for Disease
Control and Prevention (CDC) Injury Con-
trol and Prevention Division to investigate
the role of vision function, vision impair-
ment, and vision- related licensing policies
on traffic safety;
3. Urges the motor vehicle administrators and
their medical advisory boards to review the
vision requirements for assessing drivers at
risk for vision impairment;
4. Advocates a system for referring individuals
at risk for functionally impaired vision for
comprehensive eye examination as a condi-
tion for driver license renewal;
5. Urges Medicare funding of vision care for all
seniors;
6. Encourages the development and adoption of
uniform vision function standard for drivers;
and
7. Encourages the research into, and develop-
ment of alternative means of transportation
and mobility for visually impaired drivers who
no longer meet minimal vision standards.
References
1. Fife D, Barancik J, Chatterjee BF. North-
eastern Ohio trauma study: II: Injury rates by age,
sex, and cause. Am J Public Health. 1984;
74:473-478.
2. Evans L. Risk of fatality from physical
trauma versus sex and age. J Trauma. 1988;
28:368-378.
3. Hartunian NS, Smart CN, Thompson MS.
The incidence and economic costs of cancer,
motor vehicle injuries, coronary hearth disease,
and stroke: A comparative analysis. Am J Public
Health. 1980;70:1249-1260.
4. Rice DP, Mackenzie EJ, Associates. Cost of
Injury in the United States: A Report to Congress.
San Francisco, CA: Institute for Health & Aging,
University of California; Baltimore, MD: Injury
Prevention Center, The Johns Hopkins
University; 1989.
5. Mackenzie FD, Hirst LW, Battistutta D,
Green A. Risk analysis in the development of
pterygia. Ophthalmology. 1992;99:1056-1061.
6. Underwood M. The older driverClinical
assessment and injury prevention. Archives of
Internal Medicine. 1992;152:735-740.
7. Lerner N. Giving the older driver enough
perception-reaction time. Experimental Aging
Research. 1994;20:25-33.
8. National Safety Council. Crash Facts 1992.
Chicago, IL, 1992.
9. Crews JE. The demographic, social, and
conceptual context of aging and vision loss. J Am
Optometric Assoc. 1994;65:63-68.
10. Hu PS, Young J. 1990 Nationwide person-
al transportation survey: Demographic special re-
ports: Oak Ridge, TN: Oak Ridge National
Laboratories, 1994.
11. Rosenbloom S. Transportation needs of
the elderly population. Clinics in Geriatric
Medicine. 1993;9:297-310.
12. Jette AM, Branch LG. A ten-year follow-
up of driving patterns among the community-
dwelling elderly. Human Factors. 1992; 34:25-31.
13. Roberts HJ. The Causes, Ecology and
Prevention of Traffic Accidents. Springfield:
Charles C Thomas, 1971.
14. Charman WN. Visual standards for dri-
ving. Ophthalmic and Physiological Optics.
1985;5:211-220.
15. Davison PA. Inter-relationships between
British drivers visual abilities, age and road acci-
dents histories. Ophthalmic and Physiological
Optics. 1985;5:195-204.
16. Wing KR. The Law and the Publics
Health. Ann Arbor, MI: Health Administration
Press, 1990.
Association News
17. Atchley RC. Social Forces and Aging. 4th
ed. Belmont, CA. Wadsworth Publishing Com-
pany; 1985:510.
18. Parmet, WE. Discrimination and disabili-
ty: The challenges of the ADA. Law Medicine &
Health Care. 1991:24:274-281.
19. Burg A. The relationship between vision
test scores and driving record: General findings.
Los Angeles, CA: The Institute of Transportation
and Traffic Engineering, University of California,
1967.
20. Schieber F. High-priority research and de-
velopment needs for maintaining the safety and
mobility of older drivers. Experimental Aging
Research. 1994;20:35-43.
21. Schieber F. Vision assessment technology
and screening older drivers: Past practices and
emerging techniques (1988). Committee on the
Safety and Mobility of Older Drivers, Trans-
portation Research Board, National Research
Council; 1993.
22. Ball K, Owsley C. Identifying correlates
of accident involvement for the older driver. Hu-
man Factors. 1991;33:583-595.
23. Mangione CM, Phillips RS, Seddon JM,
et al. Development of the activities of daily vision
scale. Medical Care. 1992;30:1111-1126.
24. Elliott DB, Yang KCH, Whitaker D. Visual
acuity changes throughout adulthood in normal,
healthy eyes: Seeing beyond 6/6. Optometry and
Vision Science. 1995;72:186-191.
25. Bailey IL, Sheedy JE. Vision and the
aging driver. In: London R (ed.) Problems in
Optometry. Philadelphia, PA: J.B. Lippincott
Company; 1992.
26. Zaidel DM, Hocherman I. License re-
newal for older drivers: The effects of medical
and vision tests. J Safety Research. 1986; 17:
111-116.
27. Rice D, Jones B. Vision screening of dri-
vers license renewal applicants. Salem, OR:
Department of Transportation, Motor Vehicle
Division, 1984.
28. Nelson DE, Sacks JF, Chorba TL. Re-
quired vision testing for older drivers. N Engl J
Med. 1992;326:1784-1785.
29. Levy DT, Vernick JS, Howard KA.
Relationship between drivers license renewal
policies and fatal crashes involving drivers 70
years or older. JAMA. 1995;274:1026-1030.
30. Shipp MD. Potential human and econom-
ic cost-savings attributable to vision testing poli-
cies for driver license renewal, 1989-1991.
Optometry and Vision Science. 1998; 75:103-118.
200029: The Need for Mental
Health and Substance Abuse
Services for the Incarcerated
Mentally Ill
Understanding that the Surgeon Generals re-
port states that one in five adults during a given
year experience a mental disorder,
1
including
adults with serious mental illness, substance use
disorder and co-occurring mental and substance
use disorders, as defined in the Federal Register;
1
and
Recognizing that compared to the general
population, people with mental disorders, sub-
stance use disorders, and co-occurring mental
and substance use disorders are arrested more
frequently for nonviolent crimes or behaviors
committed as a direct result of the mental disor-
ders, substance use disorders, and/or homeless-
ness
2-4
or are arrested on mercy bookings be-
cause of the restrictiveness of psychiatric hospi-
tal admission policies and the lack of communi-
ty based mental health and substance abuse ser-
vices;
5
and
Noting that there are nearly two million peo-
ple incarcerated in the jails and prisons in the
United States,
6,7
with an estimated 10-15% of
people in the prisons suffering from mental ill-
nesses,
8
and an estimated 3-11% of the seriously
mentally ill prison population diagnosed with co-
occurring substance use disorders;
9
and
Further finding that between 140,000 and
400,000
10
people in prisons and jails have a diag-
nosable mental disorder, estimated at 16% of of-
fenders in state prisons, 7% of federal prisoners,
and 16% of detainees in local jails;
11
and more-
over, 6 in 10 mentally ill offenders are more like-
ly to be under the influence of alcohol or drugs at
the time of the offense;
12
and
Understanding that people with mental disor-
ders are vulnerable to deterioration of their men-
tal condition with incarceration;
13
and
Realizing the rate of suicide for the incarcer-
ated population compared to the general popula-
tion is 11 to 14 times greater, with 95% of the sui-
cides within the prisons and jails committed by
those persons with mental illnesses;
14
and
Learning that the rate of criminal justice in-
volvement for people of color is high in urban
areas, with Black and Latino people comprising
more than 50% of the populations of prisons and
jails, and that arrests and convictions for drugs
have accounted for much of this involvement; and
Believing that the mental health status of pris-
oners of color is continually at risk because of the
lack of substance abuse and mental health treat-
ment;
15
and
Recognizing that there is a need for collabora-
tion between the mental health, the substance
abuse treatment, the criminal justice, and the pub-
lic health systems in formulating policies and pro-
grams for the assessment and treatment of these
populations within the criminal justice system; and
Affirming that mental health services are un-
evenly provided in prisons and jails, with less
than half of the detainees or offenders, offered
separate housing, supportive therapies, and sub-
stance abuse treatment;
16,17
and
Acknowledging that those who are incarcerat-
ed and have mental disorders have a right to treat-
ment programs that consist of a minimum set of
assessment and treatment services, including but
not limited to: crisis intervention, psychiatric
screening and assessment, short and long-term
psychotherapy as appropriate, medication evalua-
tion and management, and, special separate hous-
ing,
18
delivered in a culturally competent environ-
ment; and
Recognizing that APHA has adopted as poli-
cy the diversion from jail for non-violent ar-
restees who have serious mental illness,* and
Acknowledging that the increased use of man-
datory sentencing, particularly for drug offenses,
leads to the release of inmates including those
with mental disorders with no parole or post-re-
lease supervision of any kind by the criminal jus-
tice or mental health systems, and that there is a
need for continuity of care through
discharge/transfer planning,
19,20
and linkage to
community mental health and substance abuse
services and continuous aftercare,
21
which can
have the effect of preventing relapse and recidi-
vism; and
Recognizing that the delivery of mental health
and substance abuse services, both within the
larger community and within the prisons and jails
is operating in a managed behavioral health care
environment, which influences the availability of
continuity of care for the mentally ill, including
aftercare placement in housing, rehabilitative ser-
vices, and ongoing therapies; therefore
1. Urges the Administrator of the Substance
Abuse and Mental Health Services Admin-
istration and the Directors of the National
Institutes of Health, the National Institute of
Mental Health, the National Institute on
Drug Abuse, the National Institute of Justice,
and other national health and law enforce-
ment agencies, to study the service needs and
create practice and evaluation guidelines for
a national model of mental health services
and substance abuse treatment services for
the incarcerated mentally ill that include dis-
charge plans for mental health patients being
released from custody;
2. Encourages state mental health and sub-
stance abuse authorities to:
develop collaborations among mental
health, criminal justice, and public health
agencies to examine problems for the
treatment of the incarcerated mentally ill
(by way of example, the most recent col-
laboration with the State of Maryland);
22
Adopt standards specifically created by
the American Public Health Association,
the American Psychiatric Association,
and the National Commission on
Correctional Health Care for the treat-
ment of inmates with mental disorders
and substance use disorders; and
Appropriate sufficient funds within the
budgets of both mental health and cor-
rections agencies and within managed
care contracts, to fund in-house and af-
tercare services for inmates with mental
disorders.
* APHA Policy Statement 9929: Diversion
from Jail for Non-Violent Arrestees with Serious
Mental Illness. APHA Policy Statements: 1948 to
present. Cumulative Washington, DC: American
References
Services. Mental Health: A Report of the Surgeon
General. Rockville, MD: US Department of
Health and Human Services, Substance Abuse
and Mental Health Services Administration,
Center for Mental Health Services, National
Association News
Institutes of Health, National Institute of Mental
Health, 1999; p. 15.
2. The Ad Hoc Working Group on Persons
with Mental Illness in the Criminal Justice Sys-
tem. Double Jeopardy: Persons with mental illness
in the criminal justice system. Report to Congress
from CMHS/SAMHSA, February 24, 1995.
3. Dennis D and Steadman HJ. The criminal
justice system and severely mentally ill homeless
persons: An overview. Report prepared for the Task
Force on Homelessness and Severe Mental Illness.
Dalmar, NY: Policy Research Associates, 1991.
4. Pogebin MR and Poole ED. Deinstitu-
tionalization and increased arrest rates among the
mentally disordered. J Psychiatry and the Law.
Spring 1987.
5. Torrey, EF. Editorial: Jails and prisons -
Americas new mental hospitals. Am J Public
Health. 1995;85:1611-1613.
6. Egan T. Hard time: Less crime, more crimi-
nals. New York Times, March 7, 1999, section 4,
p.1.
7. Goldstrom I, Henderson M, Male A, et al.
Jail mental health services: A national survey. In
Center for Mental Health Services, 1998. Mental
Health United States. Manderscheid RW and
Henderson MJ (eds.). DHHS Pub. No. (SMA)99-
3285. Washington DC:, US Government Printing
Office, 1998; p.176-187.
8. Butterfield F. Prisons replacing hospitals for
the nations mentally ill. New York Times, March 5,
1998, page 1.
9. Lamb HR, and Weinberger LE. Person with
severe mental illness in jails and prisons: A review.
Psychiatr Serv. 1998, 49(4): 483-492.
10. Position Statement of the American Asso-
ciation of Community Psychiatrists. Received by
Email, March 9, 1999.
11. P.M. Ditton. Mental Health and Treatment
of Inmates and Probationers. Washington, DC: US
Department of Justice, Office of Justice Pro-
grams, Bureau of Justice Assistance Special Re-
port, July 1999.
12. Mumola CJ. Substance Abuse and Treat-
ment. Washington, DC: State and Federal Pris-
oners, 1997. US Department of Justice, Office of
Justice Programs, Bureau of Justice Assistance.
Special Report, January 1999.
13. Edens JF, Peters RH, and Hills HA. Treat-
ing prison inmates with co occurring disorders:
An integrative review of existing programs. Behav
Sci Law. 1997; 15(4): 439-457.
14. TenCare Partners Roundtable. A survey of
county jails in Tennessee: A descriptive study to
quantify the number of persons in jails who have
a mental illness or have substance abuse problems.
Nashville, TN, October 1998.
15. Kupers T. Prison Madness: The Mental
Health Crisis Behind Bars and What We Must Do
About It. San Francisco, CA: Josey-Bass Pub-
lishers, 1999, p. 93-94.
16. The Ad Hoc Working Group on Persons
With Mental Illness in the Criminal Justice System.
Double Jeopardy: Persons with Mental Illness in
the Criminal Justice System. Report to Congress
from SAMHSA/CMHS, February 24, 1995.
17. Osofsky HJ. Psychiatry behind the walls:
Mental health services in jails and prisons. Bull
Menninger Clin; Fall 60(4):464-479.
18. National Commission on Correctional
Health Care. Position paper: Mental Health
Services in Correctional Settings, 1992.
19.See 7.
20. Schnapp WB, and Cannedy R. Offenders
with mental illness: mental health and criminal
justice best practices. Admin and Policy in Mental
Health. March 1998; 25(4).
21. Field G (ed.). Continuity of Offender
Treatment for Substance Use Disorders from
Institution to Community. Treatment Improve-
ment Protocol Series 30. Washington, DC: US
Substance Abuse and Mental Health Services
Administration. 1998.
22. Washington Post Center to study inmate
mental health. Washington Post. March 2, 2000,
p. 3.
200030: Preventing Genocide
Recognizing that Genocide and other mass
murders have killed more people in the last 100
years than all wars combined;
1
and
Recognizing that since the world said Never
Again at the end of the Jewish Holocaust, geno-
cide has cost the lives of over 22 million people in
140 different instances of genocide;
2
and
Accepting the definition of genocide in the
Rome Statute of the International Criminal Court
as the intent to destroy, in whole or in part, a na-
tional, ethnical, racial or religious group;
3
and
Understanding that modern genocide is often
a tool for engineering a vision of the ideal society,
as Hitler sought to do;
4
and
Acknowledging that racism and other forms
of discriminatory behavior are necessary precur-
sors for genocidal behavior since they identify the
groups to be exterminated in order to attain the
ideal society;
5
and
Realizing that genocidal behavior is often a
result of political, social or religious leaders ex-
ploiting economic differences between groups of
people in order to gain or hold power;
6
and
Understanding that genocide is almost always
carried out by the nation states military and po-
lice forces in accordance with the orders of the
nations leaders, depriving their citizens of funda-
mental human rights;
7
and
Recognizing that a government with power
concentrated in the hands of leaders rather than
the people is void of checks and balances neces-
sary to keep the body politic away from extrem-
ities and is a potential candidate for genocidal
behavior;
8
and
Realizing that the targeted religious, ethnic,
economic, social, or political groups are regarded
as bereft of human value and dignity and thus, de-
humanized by the oppressor; and, that once the
targeted citizens are dehumanized, non-targeted
citizens are more likely to follow the orders of the
nations leaders, and commit violence against
members of the targeted groups;
9
and
Being aware that this form of violence associ-
ated with economic, political, social, religious
and ethnic differences will likely remain a persis-
tent threat to human life and public health into the
future;
10
and
Further recognizing that international, intra-
national, ethnic and religious conflicts often re-
sult in the destruction of public health and med-
ical infrastructure, the loss of other critical means
for maintaining public health such as water, sani-
tation, fuel, and food sources and delivery mech-
anisms; and
Having considered the existing developments
in biological engineering and the human genome
project that will soon provide the technological
capacity needed to target specific ethnic groups
with designer biological weapons of mass de-
struction;
11
and
Recognizing that some evidence suggests
that efforts to develop an ethnic weapon had
been undertaken by the Apartheid government of
South Africa
12
, and that other govern-
ments
13-15
and racist groups
16
may have been or
may be working to develop such weapons; and
Realizing that the potential for genocide can
be recognized and prevented by monitoring for
eight characteristic genocidal behaviors: classifi-
cation, symbolization, dehumanization, organiza-
tion, polarization, identification, extermination,
and denial;
17
and
Knowing that attempts to mobilize ad hoc mil-
itary responses to crimes against humanity, such
as genocide, can take weeks if not months, result-
ing in the continued slaughter of innocent people
and making future attempts at peace and reconcil-
iation much more difficult;
18
and
Being aware that the existing non-democratic
nature of the UN Security Council and the veto
power
19
associated with permanent member status
of 5 nation states sometimes results in the com-
plete lack of active protection for the non-com-
batants inalienable rights detailed in the
Universal Declaration of Human Rights; and
Acknowledging that a rapid deployment force
could prevent or stop genocides
20
and that the fear
of persecution in an International Criminal Court
as prescribed in the Rome Statute could deter acts
of genocide and other crimes against humanity;
21
and
Recognizing the need and growing support by
US allies for an effective UN rapid deployment
force;
22
and
Recognizing that the cost of establishing such
a force would be far cheaper than dealing with the
consequences associated with the slowness or fail-
ure of existing peacekeeping mobilization efforts.
For example, the world could have saved over
800,000 lives and $2 billion in humanitarian aid if
the United States had sent 5,500 peacekeepers
within the first two weeks after violent uprisings
started in Rwanda for a six-month cost of $115
million;
23
and
Understanding that the existence of such a
force would reduce the need to call US troops to
serve in foreign nations and would reduce the po-
tential for anti-US reactions including terrorism;
24
and
Concluding that failure to take such obvious-
ly needed steps would be a violation of the eco-
nomic, social and cultural rights as well as civil
and political rights and freedom the US agreed
to in the International Covenant on Economic,
Association News
Social and Cultural Rights;
25
Urges that the US
Government fully support the United Nations
and all other efforts to monitor early signs of
genocide.
1. Urges that the US Government address the
conditions of ignorance, poverty and lack of
accountability that enable some leaders to fo-
ment genocide.
2. Urges the US Government to publicly an-
nounce its support for the Covenant on
Economic, Social and Cultural rights and to
actively pursue actualization of economic
and social rights that would help undermine
harmful economic, social or political condi-
tions that are often responsible for armed
conflict.
3. Urges that the US Government fully support
the establishment of a voluntary UN force,
and provide a fair share of funding and sup-
port to its effective operation as prescribed in
HR 4453 whenever innocent human lives or
ethnic groups are specifically targeted by
hostile forces or a sovereign nation
4. Urges the Administration to sign and the
Senate to ratify the Rome Statue on Inter-
national Criminal Court and to pursue the ex-
tradition of any leader actively supporting
war crimes, crimes against humanity or
genocide.
References
1. Rummel, Rudi. The Holocaust in Com-
parative and Historical Perspective, Contemp-
orary Genocides: Causes, Cases, Consequences.
Edited by Albert J. Jongman. Leiden, PIOOM,
1996. See also: Stanton, Greg. World Federalist
Association, Campaign to End Genocide. 10
Jan 2000.
2. The Encyclopedia of Genocide. Charny,
Israel W, chief ed. Rouben Paul Adalian, Jacobs,
Markusen, and Samuel Totten, associate ed.
Sherman, Marc I., bibliographic ed; Forewords by
Archbishop Desmond Tutu and Simon Wiesenthal;
[Santa Barbara, CA: ABC-Clio, 1999, Two vol-
umes, 720p.].
3. United Nations, Rome Statute of the Inter-
national Criminal Court, Article 6: Genocide.
Rome: 17 July 1998.
4. Bauman, Zygmunt, Modernity and the
Holocaust. Cornell University Press, Ithaca, New
York: 1989.
York: 1989.
6. Smith, Dan. The State of War and Peace
Atlas: Trends in a Post-Cold War World. 6
th
ed.
New York: Penguin Book Ltd, 1999. http://
www.prio.no/html/recentpub.asp
7. Stanton, Greg. World Federalist Associa-
tion, Campaign to End Genocide. 10 Jan 2000.
York: 1989.
York: 1989.
10. U.S. Commission on National Security/
21st Century, New World Coming: American
Security In the 21st Century 6 Oct 1999. http://
www.nssg.gov/Reports/reports.htm
11. Hoang, Uy. BMA warns of arrival of
genetic weapons. BMJ 30 Jan 1999. http://www.
bmj.com/cgi/content/full/318/7179/283
12. South Africas Chemical and Biological
Warfare Program, Special Investigation into
Project Coast Truth and Reconciliation Com-
mission FINAL REPORT, Vol. 2 Chapter 6. 29
Oct 1998. http://www.fas.org/nuke/guide/rsa/cbw/
2chap6c .htm
13. Associated Press. Newspaper: Israel
working on biological weapon that targets Arabs,
Athens Daily News 15 Nov 1998. http://www. on-
lineathens.com/1998/111598/1115.a4bio.html
14. Mahnaimi, Uzi and Marie Colvin. Israel
Planning Ethnic Bomb as Saddam Caves in,
Sunday Times 15 Nov 1998. http://www.salam.
org/palestine/bio-arab-bomb.html
15. Reaney, Patricia. Race Specific Weapons
not far away, Washington Times 23 Jan 1999.
16. Lindstedt, Martin, ed. The Biological
War Inevitable. Part II, The Modern Militiamans
Internet Gazette 6 Mar 1998.
17. Stanton, Greg, The Eight Stages of
Genocide, Yale Genocide Studies Paper GS-01,
1998.
18. McGovern, Morella, and Porter intro-
duced, House Resolution 4453: United Nations
Rapid Deployment Force Act of 2000, 106th
Congress, 2nd session 2000.
Rapid Deployment Force Act of 2000 Section 2.
4, 106th Congress, 2nd Session 2000.
21. United Nations, Rome Statute of the In-
ternational Criminal Court, Preamble. Rome: 17
July 1998.
22. United Nations, Progress Report of the
Secretary General on Standby Arrangements for
Peacekeeping. 1 May 2000.
24. Eland, Ivan, CATO Institute. Does U.S.
Intervention Overseas Breed Terrorism?: The
Historical Record, Foreign Policy Briefing No.
50. 17 Dec 1998.
25. United Nations, International Covenant
on the Economic, Social and Cultural Rights
Preamble. 27 Jan 1997.
200031: Criteria for Assessing
the Quality of Health
Information on the Internet
Noting that in 1998 more than 22 million
Americans went to the Internet for health-related
answers, and expecting this number to grow to
33.5 million in 2000;
1
and
Finding that nearly 70 percent of those search-
ing for health care information on the Internet did
so before visiting a doctors office;
2
and
Realizing that the Internet can be a valuable
resource for users seeking health information and
presents a powerful mechanism for helping users
improve their health care decision-making by
providing easy and rapid access, exchange, and
dissemination of enormous amounts of health in-
formation; and
Acknowledging that the quality of health in-
formation is critically important, as it could po-
tentially affect health outcomes for millions; and
Understanding that the quality of health infor-
mation on the Internet is extremely variable and
difficult to assess; and
Recognizing that health information is prolif-
erating on the Internet and that there is a growing
need for objective, reproducible, widely accepted
criteria that can be used to evaluate the quality of
the information; and
Building on APHAs long-standing commit-
ment to accurate health education (Resolution
7320
6
and Position Paper 7742
7
), especially on
controversial topics (Resolution 8524
8
) on
APHAs long-standing belief in preventing health
fraud through provision of accurate health infor-
mation (Resolution 8813
9
), and on APHAs long-
standing concern with the role of the electronic
media health education (Resolutions 5202
10
and
7622
11
); and
Aware that as of June 24, 1999, the United
States Federal Trade Commission had found 800
Internet sites containing inaccurate health claims,
and undertook settlements with four businesses
accused of deceptively marketing health products
on the Internet; and
Noting that incidents relating to health-related
websites demonstrated the blurring of lines be-
tween objective information, advertising, promo-
tional content, and proper disclosure;
3
and
Highlighting the time-sensitive nature of this
issues; and
Understanding that users must be made aware
of the potential for misinformation and recognize
the critical need to assess the quality of the infor-
mation provided; and
Discerning that the choice of appropriate
evaluation criteria for the information is crucial
and that no uniform guidelines for quality assess-
ment of Internet-based health information existed
until the Health Summit Working Group pro-
duced the policy paper,
4
Criteria for Assessing the
Quality of Health Information on the Internet;
5
and
Recognizing that the Health Summit Working
Group selected, defined, ranked, and evaluated
seven major criteria for assessing the quality of
Internet health information: credibility, content,
disclosure, links, design, interactivity, and caveats
(advisories); and
Observing that content providers must be en-
couraged to develop and post high-quality infor-
mation, and policymakers and health care profes-
sionals must be educated on this important health
issue; therefore,
1. Urges individuals and organizations to be-
come involved in promoting the application
of appropriate criteria for assessing health in-
formation on the Internet, whether it be
Association News
Educating consumers and health care pro-
fessionals on how to evaluate Internet
health information,
Using criteria to develop their own Inter-
net health site, or
Promoting the use of educational tools to
help assess quality;
2. Supports continued FTC monitoring and en-
forcement of fraudulent health claims and
deceptive health marketing on the Internet;
3. Endorses the development, publication, and
dissemination of criteria for evaluating
Internet health information that address such
items as those defined by the Health Summit
Working Group:
Credibility: includes the source, currency,
relevance/utility, editorial review process
for the information, and financial disclo-
sure,
Content: must be accurate and complete,
and appropriate disclaimer provided,
Disclosure: includes informing the user of
the purpose of the site, as well as any pro-
filing or collection of information associ-
ated with using the site,
Links: evaluated according to selection,
architecture, content, and back linkages,
Design: encompasses accessibility, logi-
cal organization (navigability), and inter-
nal search capability,
Interactivity: includes feedback mecha-
nisms and means for exchange of infor-
mation among users,
Caveats: clarification of whether the sites
primary function is to market products
and services or to serve as a primary in-
formation content provider.
References
1. Davis R. Miller L. Net Empowering
Patients, USA Today. July 14, 1999.
2. Brown MS: Healthcare information seekers
arent typical Internet users. Medicine on the Net.
February 1998; 4(2):7-18,
3. Noble HB: Hailed as Surgeon General,
Koop Criticized on Web Ethics, New York Times.
September 4, 1999.
4. Members of the Health Summit Working
Group include: Helga Rippen, MD, PhD, MPH,
Health Information Technology Institute, Mitre-
tek Systems; Roger Guard, University of Cincin-
nati and Association of Academic Health
Sciences Libraries; Marshall Kragen, JD; Patricia
Byrns, BSN, MD, University of Colorado Health
Sciences Center; William Silberg, Journal of the
American Medical Association; Denise Silber,
MBA; et al.
5. Criteria for Assessing the Quality of Health
Information on the Internet http://hitiweb.
mitretek .org/docs/ppolicy.html, last visited
November 3, 1999.
6. Res 7320: Increased Efforts in Health
Education.
7. PP 7742: Toward a Policy on Health Edu-
cation Public Health.
8. APHA Resolution 8524: Support for
Accurate Public Information on Abortion.
9. APHA Resolution 8813: Nutrition Fraud
and AIDs.
10. APHA Resolution 5202: Use of Television
in Health Education.
11. APHA Resolution 7622: Television and
Health.
200032: Discontinuation of the
Use of the Island-Municipality
of Vieques, P.R., for the
US Navys Training Exercises
Recognizing the broad consensus among the
people of Puerto Rico regarding the immediate
cessation of the US Navys military exercises in
the Island-Municipality of Vieques, P. R., and the
imminent risks faced by the population in view of
the US Navys resumption of exercises and the re-
cent arrests of nearly three hundred civil dis-
obedients considered as interfering with the mili-
tary maneuvers;
1,2
and
Understanding that although the US Navy has
been in Puerto Rico during the last sixty years,
the extent of the damage caused by the Navys
maneuvers had not been assessed until the
Governor of Puerto Rico commissioned a task
force, which rendered a report in June 1999; and
Acknowledging that the findings of said
Commission were not widely disclosed until
June-July 1999;
3,4
and
Acknowledging that the US Navy permanent-
ly occupies two-thirds of the islands nearly nine
thousand acres and that 180 days per year, they
engage in military exercises that involve shelling
the island with live ammunition, including de-
pleted uranium ammunition without the autho-
rization of the Nuclear Regulatory Commission.
5
launched from the air by the U. S. Air Force attack
planes as well as from naval vessels at sea to areas
eight miles from where the 10,000 inhabitants of
Vieques work and live; and
Realizing that the US Navy assumed res-
ponsibility for the most recent accident that re-
sulted in the death of a civilian employee, who
was killed by a 500 pound Mark 82 missile; and
Acknowledging that officials from Puerto
Ricos Department of Education testified to the
Governors Commission of Vieques that
...bombing practices make school buildings
tremble, affecting the teaching activities and dam-
aging the physical structures,
3
and
Knowing that the Environmental Protection
Agency stated on August 27, 1999, that the US
Navy has violated the norms established for the dis-
posal of contaminated discharges and has, accord-
ing to EPA officials, demonstrated an incapacity to
comply with the agencys regulations;
6
and
Understanding that samples obtained by a
group of marine biologists from the coral reefs in
Vieques located in close proximity to unexploded
leaking bombs reveal highly diseased and discol-
ored coral specimens, and magnetometer studies
performed by the same group reveal unequivocal-
ly that craters on the seaward side of Isla Alcatraz,
which are pock-marking coral reefs and sea grass
beds in the region, were not originated by hurri-
canes but by detonation of ammunition;
7
and
Recognizing that Puerto Ricos Health De-
partments Cancer Registry, published in Nov-
ember 1999,
8
and showing cancer trends for
Vieques and the main Island of Puerto Rico for
1960-1994, demonstrate that, prior to 1979,
Vieques exhibited cancer rates lower than those
of the main Island, whereas the cancer rates for
Vieques subsequently increased, generating stan-
dardized incidence ratios for the periods 1985-
1989 and 1990-1994 that exceed the alert levels
adopted by the surveillance system as defined by
the Agency for Toxic Substances and Disease
Registry of the US Department of Health and
Human Services, prompting the Puerto Rican
Legislature
9
to mandate an epidemiological study
of the cancer rates in Vieques; and
Realizing that the current conditions to which
the people of Vieques are exposed constitute seri-
ous threats to the environment and to their health;
and
Recognizing the right of the people of Puerto
Rico to take the necessary actions to assure their
well-being; therefore
1. Calls upon the President of the United States
to order the permanent cessation of military exer-
cises in the Island-Municipality of Vieques, Puerto
Rico, and transfer of the present occupied land to
the people of Vieques; and
2. Calls upon the President to order the U S
Department of Defense to immediately establish
a clean-up program that will facilitate the
prompt restitution of the Islands environment
and that will include the necessary steps that
must be taken to mitigate the threats to the
health of the people of Vieques for which the US
Navy is responsible.
References
1. Burns, R. Navy: No viable alternative to
Vieques. Associated Press. October 19, 1999,
Washington DC. www.salon.com/news/wire/
1999/10/14/Vieques/
2. WWW.ViequesLibre.com, Articulos de
prensa.
3. Governor of Puerto Ricos Special Com-
mission on Military Operations in Vieques. June
1999.
4. Cronologa: Resumen de los Eventos. El
Nuevo Da, August 2, 1999.
5. Letter from Luis A Reyes, Regional Ad-
ministrator, Nuclear Regulatory Commission to
Dr. Carmen Feliciano, Secretary of Health, P.R.,
February 1, 2000.
6. US Naval Contamination on Vieques,
Puerto Rico. Pacific Studies Center Isiegel@
igc.apc.org, June 1997.
7. Memo from Dr. James W. Porter, Professor
of Ecology and Marine Sciences, University of
Georgia, Athens, Re: Draft statement of findings
on Vieques, P.R. Sent December 6, 1999, to C
Tisdale of King and Spalding, Atlanta, GA, as
representatives of the Government of Puerto
Rico.
8. Zavala-Segarra, D. Incidencia de Cancer en
Vieques, 1960-1964. Registro de Central de
Cancer, Division de Vigilancia Epidemiologica y
Estadisticas, Departamento de Salud de Puerto
Rico, November 1999.
9. Joint Resolution No. 568. Puerto Rico
Legislative Assembly, August 1999.
Association News
Interim Policy Statements
The following interim policy statements were
also adopted by the Governing Council on Wed-
nesday, November 15, 2000 during the 128th an-
nual meeting of the American Public Health
Association in Boston, MA. Introduced as Late-
Breakers, these policy statements have not been
subjected to the APHA policy development
process, which is designed to be open to full par-
ticipation of the membership and to ensure careful
review by appropriate APHA units, including ref-
erence committees, the Joint Policy Committee,
APHA sections, special primary interest groups,
affiliates, and others, and at public hearings during
the annual meeting prior to final voting by the
Governing Council. These interim policy state-
ments are subject to that process during the ensu-
ing year, before they can become official policy of
APHA. Public Policy Statements are used as the
basis of APHAs stand on legislative, legal, and
regulatory issues and may stimulate scientific in-
quiry. They are a record of the nature, character,
and values of the American Public Health Asso-
ciation and its membership.
00-LB-1: Research and
Intervention on Racism as a
Fundamental Cause of Ethnic
Disparities in Health
Understanding that in the United States, eth-
nic disparities in health have persisted during the
20th century and even increased for certain health
outcomes, despite major advances in public
health, biotechnology, and economic prosperity
and wealth;
1-4
and
Understanding that race-associated differ-
ences in health outcomes are routinely document-
ed in this country, but the basis of those differ-
ences remains poorly explained; and
Understanding that race is not a biological
construct that reflects innate differences,
5-11
but a
social construct that precisely captures the social
classification of people in a race- conscious so-
ciety and therefore measures the impacts of
racism;
5
and
Acknowledging that ethnic health disparities
may arise on three levels: 1) Differences in social,
political, economic, or environmental exposures
which result in differences in disease incidence;
2) differences in access to health care including
preventive and curative services; and 3) differ-
ences in the quality of care received within the
health care delivery system;
12-37
and
Acknowledging the importance of identifying
the underlying causes of ethnic health disparities
so that these disparities can be most effectively
addressed; and
Realizing that disparities in health for ethnic
minority populations are rooted in the sociopolit-
ical and economic history of the American soci-
ety;
12,13
and
Understanding that many people in the United
States believe that racism is no longer a problem,
while others deal with its manifestations daily;
12,13,38-40
and
Realizing that the perception of the occurrence
and extent of ethnic disparities in health and health
care differs between white and ethnic minority pop-
ulations in the United States;
41
and
Recognizing that the science on racism as a
risk factor for adverse health outcomes in non-
white populations in the United States is scant;
6-
8,12,13,42-45
and
Recalling that in 1965, the American Public
Health Association passed a resolution of The
Health Minorities and the Relationship of Dis-
crimination Thereto.
46
Further recalling that in
1974, the American Public Health Association
passed a resolution on Racism in the Health
Care Delivery System which states, Minority
health, as affected by institutional racism, can
only improve when efforts from the entire com-
plex of human and public services are purposeful
applied to accomplish that specific goal;
47
and
Association has also previously condemned the
expression of racism in other countries;
48,49
and
Cognizant that Mayor Bob Knight of Wichita,
Kansas has called for a National Campaign
Against Racism as President of the National
League of Cities that challenges and assists city
and town governments in becoming Cities Striv-
ing to Promote Racial Justice;
50
and
Celebrating the Department of Health and
Human Services Initiative to Eliminate Racial
and Ethnic Disparities in Health by the Year 2010
and recognizing this as an opportunity to investi-
gate and address the underlying causes of these
disparities;
51
and
Association has recently joined with the Depart-
ment of Health and Human Services in a national
Campaign to Eliminate Racial and Ethnic Health
Disparities;
51,52
and
Cognizant that the recent Congressional pas-
sage of the Minority Health and Health Dis-
parities Research and Education Act of 2000,
which established a National Center on Minority
Health and Health Disparities at the National
Institutes of Health, provides an opportunity for
coordinated research on the impacts of racism on
health;
53
and
Also cognizant that comments are currently
being solicited on the October 6, 2000 draft of the
National Institute of Healths Strategic Plan to
Reduce and Ultimately Eliminate Health Dispar-
ities;
54
therefore
1. Reaffirms previous American Public Health
Association policies that have condemned
racism and its impacts on health and health
care;
2. Commends the National League of Cities on
their Undoing Racism agenda and their ef-
forts to launch a National Campaign Against
Racism;
3. Calls on the President and the Congress of
the United States to endorse a National Cam-
paign Against Racism;
4. Calls on the Congress of the United States to
convene the Congressional Black Caucus
Foundation and the National Medical Asso-
ciation, along with Institute of Medicine to
prepare a report that summarizes our current
knowledge on the impacts of racism on
health and identifies points of intervention;
5. Calls on the Department of Health and Hu-
man Services to explicitly address racism as
a part of its national Initiative to eliminate
Racial and Ethnic Disparities in Health by
the Year 2010;
6. Calls on the Centers for Disease Control and
Prevention and the National Institutes of
Health to place a high priority on research on
the impacts of racism on the health and well-
being of the nation;
the United States to appropriate funds for in-
vestigating the impacts of racism on the
health and well being of the nation;
the United States to appropriate additional
funds for developing evidence-based pro-
grams to eliminate ethnic health disparities;
and
9. Calls on the President, the Congress, and the
Judicial Branch of the United States to rec-
ognize and promote legal redress for dis-
crimination in health and health care.
References
1. Kington R, Nickens H. Forthcoming, 2001.
Racial and ethnic differences in health: recent
trends, current patterns, future directions. In: Am-
erica Becoming: Racial Trends and their conse-
quences, Volume 2. Smelser and Wilson, eds.
Washington, DC: National Academy Press, 2001
(in press).
2. National Center for Health Statistics.
Health of the nation, annual reports from 1988-
1998. http//www.cdc.gov/nchs
3. U.S. Department of Health and Human
Services. Report of the Secretarys Task Force on
Black & Minority Health. Volume I: executive
Summary. Washington, DC. 1986
4. Healthy People 2010: National Health and
Promotion and Disease Prevention Objectives:
conference edition in two volumes. Washington,
D.C.: U.S. Department of Health and Human
Services; January 2000.
5. Jones CP. Levels of racism: a theoretical
framework and a gardeners tale. Am J Public
Health 2000; 90:1212-1215.
6. DuBois WEB. Morality among Negroes in
cities. Proceedings of the Conference for In-
vestigation of City Problems. Atlanta, GA: At-
lanta University Publications, 1896.
7. DuBois WEB. The health and physique of
the Negro American. A Social Study Made Under
the Direction of the Eleventh Atlanta Conference.
Atlanta, GA: Atlanta University Publications,
1906.
8. Lewis JH. The Biology of the Negro. Chi-
cago, IL: The University of Chicago Press, 1942.
9. Cooper R and David R. The biological con-
cept of race and its application to public health
and epidemiology. J Health Polit Policy Law
1986; 1994:19-20
10. Cavalli-Sforza. LL, Menozzi P, Piazza A.
The History and Geography of Human Genes.
Princeton, NJ: Princeton University Press; 1994:
19-20.
11. Williams DR. Race and health. Basic
questions, emerging directions. Ann Epidemiol
1997; 7:322-333.
Association News
12. Byrd WM, Clayton LA. An American
health dilemma: a medical history of African Am-
ericans and the problem of race, beginnings to
1900, Volume 1. New York, NY: Routledge,
2000.
13. Byrd WM, Clayton LA. Forthcoming. An
American health dilemma: race, medicine, and
health care in the United States: from 1900 to the
dawn of the New Millennium, Volume 2, New
York, NY: Routledge, 2000.
14. Morehouse Medical Treatment Effec-
tiveness Center (MMEDTEC). A Synthesis of the
Literature: Racial & Ethnic Differences in Access
to Medical Care. Menlo Park, CA: The Henry J
Kaiser Foundation, October 1999.
15. Maynard C, Fisher LD, Passamani ER. et
al. Blacks in the coronary artery study (CASS):
race and clinical decision making. Am J Public
Health 1986; 76:1446-1448.
16. Maynard C, Litwin PE, Martin JS, et al.
Characteristics of black patients admitted to coro-
nary care units in metropolitan Seattle: results
from the myocardial infarction triage and inter-
vention registry (MITI). Am J Cardiol 1991;
67:18-23.
17. Johnson PA, Lee TH, Cook EF, et al.
Effect of race on the presentation and manage-
ment of patients with acute chest pain. Ann Intern
Med 1993; 118:593-601.
18. Mirvis DM, Burns R, Gaschen L, et al.
Variation in utilization of cardiac procedures in
the Department of Veterans Affairs health care
system: effect of race. Am J Col Cardiol 1994;
24:1297-1304.
19. Giles WH, Anda RF, Casper ML, et al.
Race and sex differences in rates of invasive car-
diac procedures in US hospitals. Data from the
National Hospital Discharge Survey. Arch Intern
Med 1995; 155:318-324.
20. Ford E, Cooper R, Castaner A, et al.
Coronary arteriography and coronary bypass
surgery among whites and other racial groups rel-
ative to hospital-based incidence rates for coro-
nary artery disease: findings from NHDS. Am J
Public Health 1989; 79:437-440.
21. Wenneker MB, Epstein AM. Racial in-
equalities in the use of procedures for patients
with ischemic heart disease in Massachusetts.
JAMA 1989; 261: 253-257.
22. Hannan EL, Kilburn HJ, ODonnel JF, et
al. Interracial access to selected cardiac proce-
dures for patients hospitalized with coronary
artery disease in New York State. Med Care
1991;29:430-441.
23. Whittle J, Conigliaro J, Good CB, et al.
Racial Differences in the use of invasive cardio-
vascular procedures in the Department of Vet-
erans Affairs medical system. N Engl J Med
1993;329:656-658.
24. Hannan EL, Van Ryn M, Burke J, et al.
Access to coronary artery bypass surgery by
race/ethnicity and gender among patients who are
appropriate for surgery. Med Care 1999; 37:
68-77.
25. Van Ryn M, Burke J. The effect of patient
race and socio-economic status on physicians
perception of patients. Soc Sci Med 2000;50:
813-828.
26. Gillum RF, Gillum BS, Francis CK. Coro-
nary revascularization and cardiac catheterization
in the United States: trends in racial differences.
J Am Coll Cardiol 1997;29:1557-1562.
27. Ramsey DJ, Goff DC, Wear ML, et al. Sex
and ethnic differences in the use of myocardial
revascularization procedures in Mexican Ameri-
cans and non-Hispanic whites: the Corpus Christi
Heart Project. J Clin Epidemiol 1997;50:
603-609.
28. Maxwell JG, Rutherford EJ, Covington D,
et al. Infrequency of blacks among patients hav-
ing carotid endarterectomy. Stroke 1989;20:
22-26.
29. Oddone EZ, Horner RD, Monger ME, et
al. Racial variations in the rates of carotid an-
giography and endarterectomy in patients with
stroke and transient ischemic attack. Intern Med
1993;153:2781-2786.
30. Gillum RF. Epidemiology of carotid end-
arterectomy and cerebral arteriography in the
United States. Stroke 1995;26:1724-1728.
31. Hsia DC, Moscoe LM, Krushat WM.
Epidemiology of carotid endarterectomy among
Medicare beneficiaries 1985-1996 update. Stroke
1998;29:346-350.
32. Peterson ED, Shaw LK, DeLong ER, et al.
Racial variation in the use of coronary-revascu-
larization procedures. Are the differences real?
Do they matter. N Engl J Med 1997;336:480-486.
33. Weitzman S, Cooper L, Chambliss L, et al.
Gender, racial and geographic differences in the
performance of cardiac diagnostic and therapeu-
tic procedures for hospitalized acute myocardial
infarction in four states. Am J Cardiol
1997;79:722-726.
34. Moore RD, Stanton D, Gopalan R, et al.
Racial differences in the use of drug therapy for
HIV disease in an urban community. N Engl J
Med 1994;330:763-768.
35. Graham NM, Jacobson LP, Kuo V, et al.
Access to therapy in the Multicenter AIDS
Cohort Study, 1989-1992. J Clin Epidemiol
1994;47: 1003-1012.
36. Chung H, Mahler JC, Kakuma T. Racial
differences in treatment of psychiatric inpatients.
Psychiatr Serv 1995;46:586-591.
37. Leo RJ, Narayan DA, Sherry C, et al.
Geopsychiatric consultation for African-Ameri-
can and Caucasian patients. Gen Hosp Psychiatr
1997;19(3):216-222.
38. Essed P. Understanding everyday racism:
an interdisciplinary theory. In: Sage Series on
Race and Ethnic Relations, Volume 2. Newbury
Park: Sage Publications, 1991.
39. Yen IH, Ragland DR, Greiner BA, et al.
Racial discrimination and alcohol-related behav-
ior in urban transit operators: findings from the
San Francisco Muni Health and Safety Study.
Publ Health Rep 1999;114:448-458.
40. Feagin JR. The continuing significance of
race: antiblack discrimination in public places.
Am Soc Rev 1991;56:101-116.
41. Perceptions of how race and ethnic back-
ground affect medical care. Menlo Park, CA: The
Henry J Kaiser Family Foundation, October
1999.
42. James S, Harnett SA, Kalsbeek WD. John
Henryism and blood pressure differences among
black men. J Beh Med 1983;6:259-278.
43. Williams D. Racism and health: a research
agenda. Enthicity and Disease 1996;6:1-6.
44. Krieger N, Sidney S. Racial discrimina-
tion and blood pressure: the CARDIA Study of
young black and white adults. Am J Publ Health
1996;6:83-98.
45. Krieger N. Embodying inequality: a re-
view of concepts, measures and methods for
studying the consequences of discrimination. In-
ternational J Health Serv 1999;29:295-352.
46. APHA. Policy Statement 6502: The
Health of Minorities and the Relationship of Dis-
crimination. APHA Public Policy Statements,
1948-present, cumulative. Washington, DC:
American Public Health Association; current
volume.
47. APHA Policy Statement 7424: Racism in
the Health Care Delivery System. APHA Public
Policy Statements, 1948-present, cumulative.
Washington, DC: American Public Health Asso-
ciation; current volume.
48. APHA. Policy Statement 8225: Apartheid
Policy of the Republic of South Africa. APHA
Public Policy Statements, 1948-present, cumula-
tive. Washington, DC: American Public Health
49. APHA Policy Statement 8523: Apartheid
and Its Impact on Health in the Republic of South
Africa. APHA Public Policy Statements, 1948-
present, cumulative. Washington, DC: American
50. National League of Cities. Presidents
Agenda: Undoing Racism. http://www.nlc.org/
pagenda.htm.
51. Department of Health and Human Ser-
vices. Race and Health. http://www.raceand
health.hhs.gov.
52. American Public Health Association. Pro-
grams, projects, and practices. http://www.apha
.org/ppp.
00-LB-2: Opposition to the
CRACK Campaign
Whereas the organization CRACK, Children
Requiring a Caring Kommunity (www. crackster-
ilization.com), is expanding its base of operations
and generating opposition among members of
local and national organizations, such as the
National Black Womens Health Project, the
National Womens Health Network, the Com-
mittee on Women, Population, and the Environ-
ment, National Advocates for Pregnant Women,
and the Center for Women Policy Studies.
CRACK is a non-profit organization that pays
$200 to women with substance abuse problems
who verify that they have been sterilized or use
long-term birth control methods and devices,
such as Norplant, Depo-Provera, or an IUD
(Children, 2000). During the summer of 2000,
CRACK opened a chapter in Washington, DC
and placed subsidized advertisements in public
buses.
Whereas CRACKs mission and operation vio-
lates the policies of the American Public Health
Association that oppose coercing women into ster-
Association News
ilization (APHA Resolution 7317) or Norplant use
(APHA Resolution 9104), and that affirm the
Associations support for expanded drug treatment
facilities for pregnant women who use harmful
drugs (APHA Resolution 9020) and its recognition
that racism and its consequences are dangerous to
health (APHA Resolution 9612).
Whereas unions of government and trans-
portation workers in Washington, DC have passed
resolutions against CRACK and its publicly subsi-
dized ads on DC metrobuses because it is a pro-
gram that is racist and which will alienate us (the
bus drivers) from much of the community that we
seek to serve (Allen, 2000) and because we
would like towork to put into place real provi-
sions of a caring community, such as drug treat-
ment, decent jobs, affordable healthcare,
(AFGE, 2000).
Whereas CRACK violates principles of
human rights, civil rights, and reproductive free-
doms by:
Attacking/addressing the reproductive capac-
ity of women rather than the conditions of op-
pression under which poor women live.
CRACKs approach is misguided because it
does not acknowledge or confront the condi-
tions of poverty, racism, violence and gender
discrimination that give rise to harmful drug
use practices among women. These condi-
tions need to be addressed in order to de-
crease harmful drug use practices among
women (Kearney, 1994; Neuspiel, 1996;
Rosenbaum, 1997).
Targeting communities of color and poor peo-
ple with a racist population control strategy.
CRACK promotes its program only to com-
munities of color and other poor women as
evidenced by their placement of ads, bill-
boards, and outreach activities (Goldstein,
2000; Robinson, 2000) and by their emphasis
on crack cocaine and not on other harmful
substances, such as alcohol or tobacco
(NIDA, 1992), which the public associates
with a broader group of consumers. The small
cash offer would not compel women on mid-
dle to high incomes to choose sterilization or
long-term birth control. CRACKs targeting
and emphasis on permanent or long-term
birth control amount to a strategy of popula-
tion control (CWPE, 2000).
Limiting birth control options. CRACK does
not compensate women for their use of birth
control methods that protect against HIV and
other sexually transmitted conditions, and
encourages birth control drugs and devices
that may increase health risks (CWPE,
2000).
Impeding treatment for illegal drug use.
CRACK does not offer or encourage treat-
ment for drug problems. The director of the
DC Substance Abuse Services office charac-
terized CRACK as ill conceived(and) not
supported by the Department of Health
(Goldstein, 2000). While drug treatment pro-
grams can be successful (Chavkin, 1993;
Humphries, 1992), funding for drug treat-
ment interventions has decreased (Chavkin,
1990; Prendergast, 1995), limiting the op-
tions for pregnant women to get help.
Building the false notion that crack babies
are wasted lives. CRACK ignores the evi-
dence that the teratogenic effects of crack co-
caine are not established scientifically (Neu-
spiel, 1992, 1994; Hadeed, 1989) and exag-
gerates the impact of prenatal exposure to
crack cocaine without addressing the more
prevalent use of alcohol (NIDA, 1992) and
the harmful effects of smoking (Nordentoft,
1996) and alcohol use on the fetus (Streiss-
guth, 1991).
Because of the aforementioned harmful ef-
fects, APHA will:
Oppose the operation of CRACK in existing
and new locations.
Reaffirm its opposition to sterilization and
birth control practices that are coerced.
Endorse programs and services, such as drug
treatment, decent jobs with benefits, educa-
tional opportunities, mental health services,
and childcare services, that help women ter-
minate harmful drug use.
Advocate for increasing the federal budget
for drug treatment programs for pregnant
women.
Oppose publicly subsidized advertisements
for CRACK on public transportation, bill-
boards, and other venues.
References
1. Allen, JW Jr. for the Amalgamated Transit
Union (ATU) Local 689. Letter to Mr. Richard
White (manager of the Washington Metropolitan
Area Transit Authority, WMATA). August 15,
2000.
2. American Federation of Government
Employees (AFGE) Local 12. Resolution to de-
mand removal of all advertising for Crack on
the metrobus system in the Washington, D.C.
area. August 2000.
3. APHA Resolution 9020, Illicit Drug Use by
Pregnant Women, 1990.
4. APHA Resolution 9104, Norplant: Making
it Affordable and Voluntary, 1991.
5. APHA Resolution 9612, Threats to Af-
firmative Action Are Threats to Health, 1996.
6. Chavkin W. Drug addiction and pregnancy:
policy crossroads. Am I Public Health 1990;
80(4):483-487.
7. Chavkin W, Paone D, Friedmann P, Wilets I.
Reframing the debate: toward effective treatment
for inner city drug-abusing mothers. Bulletin of
the New York Academy of Medicine 1993;70:50-
68.
8. Children Requiring a Caring Kommunity
website, http://www.cracksterilization.com, viewed
on October 9, 2000.
9. CWPE, Committee on Women, Population
and the Environment. Fact Sheet on the CRACK
Organization, http://www.cwpe.org/, viewed on
October 9, 2000.
10. Hadeed AJ, Siegel SR. Maternal cocaine
use during pregnancy: effect on the newborn in-
fant. Pediatrics 1989;84:205-21.
11. Goldstein A. Group to Pay Addicts to Take
Birth Control, Washington Post, June 26, 2000,
Metro Section, B01.
12. Humphries D, et al. Mothers and children,
drugs and crack: reactions to maternal drug de-
pendency. Women and Criminal Justice 1992;
1:81-99.
13. Kearney MH, Murphy S, Rosenbaum M.
Learning by losing: sex and fertility on crack co-
caine. Qualitat Health Res 1994;4(2): 147.
14. National Institute on Drug Abuse (NIDA).
National Pregnancy and Health Survey: drug use
among women delivering live births, 1992. Rock-
ville, MD: U.S. Department of Health and Human
Services. National Institutes of Health publica-
tion 96-3819.
15. Neuspiel DR. Behavior in cocaine ex-
posed infants and children: association versus
causality. Drug and Alcohol Dependency
1994;36:101-7.
16. Neuspiel, DR. Cocaine-associated abnor-
malities may not be causally related. American
Journal of Diseases of Children 1992;146:
278-279.
17. Neuspiel, DR Racism and Perinatal Ad-
diction. Ethnicity and Disease 1996;6:47-55.
18. Nordentoft M et al. Intrauterine growth re-
tardation and premature delivery: the influence of
maternal smoking and psychosocial factors.
AJPH. 1996;86:347-354.
19. Prendergast ML, Wellisch J, Falkin GP.
Assessment of and service for substance-abusing
women offenders in community and correctional
settings. Prison J 1995:75(2).
20. Robinson, D. Cracks in the Armor. City
Paper, Washington, D.C., September 2000.
21. Rosenbaum M. Women: Research and
Policy IN Lowinson JH, et al. Substance abuse,
a comprehensive textbook, 3
rd
edition. Baltimore,
MD: Williams and Wilkins, 1997, pages 654-5
and at http://www.lindesmith.org/library/m_
rosenbaum2.html, viewed on October 9, 2000.
22. Streissguth AP et al. Fetal alcohol syn-
drome in adolescents and adults. JAMA 1991;
265:1961-7.
00-LB-3: Restoration of Nutrition
and Health Benefits Eligibility to
Documented Immigrants
Recalling that Congress disqualified docu-
mented immigrants from receiving food stamps
and Medicaid assistance as part of the 1996 wel-
fare legislation and that in 1998 Congress rein-
stated eligibility for a group of the most vulnera-
ble documented immigrants, including many chil-
dren, elderly, and disabled persons; and
Recognizing that the majority of documented
immigrants who meet the means-test require-
ments, including taxpayers working in low-in-
come jobs and parents of young children,
nonetheless remain ineligible for food stamps,
Medicaid, or State Childrens Health Insurance
Program (SCHIP) assistance; and
Noting that the Hunger Relief Act (HRA, S
1805/HR 3192), which included the restoration of
food stamp eligibility to documented immigrants
as one of the bills four major provisions, had
broad, bipartisan support in both houses of
Congress and had been endorsed by large num-
bers of national, state, and local organizations
from across the U.S. but the Agriculture appropri-
ations conference committee chose to include
Association News
only two of the HRA provisions in the final con-
ference report on Agriculture appropriations and
one of the omitted provisions is the restoration of
eligibility for documented immigrants; and
Noting that the Immigrant Childrens Health
Improvement Act (ICHIA, S 1227/HR 4707),
which would have allowed states to receive feder-
al reimbursement if they opt to cover lawfully pre-
sent pregnant women and children in their
Medicaid and SCHIP programs and in states that
opt for such coverage would also eliminate certain
other barriers now faced by lawfully present im-
migrant children and pregnant women in these
programs, also had bipartisan support in both
houses of Congress but was not included in the
$26 billion Medicaid provider bill; therefore,
APHA
1. Congratulates President Clinton on his
strong statement in support of restoring
food stamp, Medicaid, and SCHIP eligibili-
ty to documented immigrants and urges him
to insist that the full restoration of eligibili-
ty for these programs, as found in the
Hunger Relief Act and the Immigrant
Childrens Health Improvement Act, be part
of any end-of-the-year budget agreements
with Congress; and
2. Urges all U.S. Senators and Representa-
tives to make food stamps, Medicaid, and
SCHIP eligibility for documented immi-
grants a top priority in the end-of-the-year
budget legislation.
LB-00-4: Resolution to Improve
the Social Conditions that
Contribute to Health
Whereas, the differences in health outcomes
by socioeconomic position have been recognized
as a persisting and perhaps even increasing public
health problem;
1
and
Whereas, important socioeconomic indicators
such as income and education have been shown to
be inversely associated with various mortality
outcomes including premature mortality, cardio-
vascular mortality, homicide, and death from all
causes;
2
Whereas, the October 7th White House meet-
ing of the National Steering Committees Call to
the Nation to Eliminate Racial and Ethnic
Disparities has given sufficient attention to the
social conditions which determine health; and
Whereas, social and economic deprivation is
not uniformly distributed across the US, and that
there are geographically bound pockets of relative
poverty and inequalities, where exclusion has
contributed to mounting health and social prob-
lems, which require targeted attention;
3
and
Whereas, lower levels of education and in-
come are associated with a significantly higher
prevalence of health risk behaviors, including
smoking, being overweight, not using child safe-
ty seats, and physical inactivity;
4
and
Whereas, lower income leads to a significant
increase in mortality risk yet the influence of
major health risk behaviors explains only a mod-
est proportion of this relationship;
5
and
Whereas, the degree to which health behav-
iors explain or mediate the influence of socioeco-
nomic factors on mortality has important ramifi-
cations for health policy;
6
and
Whereas, the majority of health reform have
tended to concentrate on the reorganization of
health financing systems and on personal health
care;
8
and
Whereas, very few reform initiatives consider
or include the health implications of the social en-
vironment, culture and economy;
9
and
Whereas, economic and social policies over
the proceeding decades have contributed to an
ever-widening gap between rich and poor;
10
and
Whereas, compelling evidence confirms that
the gap is inextricably linked to ever-rising health
and social problems in the United States;
11
and
Whereas, people in positions of authority
have a duty to act with social responsibility, and
must consider the impact of their decisions on
health and the social conditions that contribute to
health;
12
We urge APHA and Affiliates to:
1. Foster an understanding among high-level
decision-makers, including Congress, of the
social conditions that affect health;
2. Advance the development of the Health
Impact Assessment methodology to identify
the potential impact of social and economic
policies on health; and the development of
economic data that support the benefits of re-
ducing health disparities and the costs of not
acting;
3. Advocate for an investment in people and
their social environment in order to maxi-
mize health opportunities for ALL members
of society;
4. Advocate for health and social support sys-
tems which engage communities as full part-
ners in developing health improvement pro-
grams and policies, and which empower peo-
ple to take control over their own lives and
create healthy communities;
5. Advocate for policies and practices, which
dispel the overall pattern of disadvantage and
discrimination that contributes to the health
disparities that exist in the United States.
References
1. Frank, John W, Director of Research Insti-
tute for Work and Health and Fellow, Population
Health Program Canadian Institute for Advanced
Research and Daedalus, J. Fraser Mustard Presi-
dent Canadian Institute for Advanced Research
The Determinants of Health from a Historical
Perspective Journal of the American Academy of
Arts and Sciences, Fall 1995 Vol. 123, No. 4.
http://children.metrotor.on.ca/taskforce/must.html
2. Lantz, Paula M, House, James S, Lepkow-
ski, James M, Wiliams, David R, Mero, Richard P.,
Chen, Jierning: Socioeconomic Factors, Health
Behaviors and Mortality JAMA, June 3, 1998 -
Vol.279, No. 21.
3. Pan American Conference in Public Health
Education Health Sector Reform and Essential
Public Health Functions: Challenges for the De-
velopment of Human Resources. http://www
.americas.health-sector-reform .org/sidorh/docu-
mentos/hsr15e.html.
4. Lantz, Paula M, House, James S, Lepkow-
ski, James M, Wiliams, David R, Mero, Richard
P., Chen, Jierning: Socioeconomic Factors,
Health Behaviors and Mortality JAMA, June 3,
1998 - Vol.279, No. 21.
5. Ibid.
6. http://healthpro.org.uk/facts/charterlocal
.htm, United Kingdom Charter for Health Pro-
motion.
7. Pan American Conference in Public Health
Education Health Sector Reform and Essential
Public Health Functions: Challenges for the
Development of Human Resources. http://ww
w.americas.health-sector-reform.org/sidorh/doc-
umentos/hsr15e.html.
8. Ibid
9. Ibid
10. Collins, Chuck and Betsy Leondar-Wright
and Holly Sklar, Shifting Fortunes, The Perils of
the Growing American Wealth Gap, Copyright
1999 Holly Sklar and United for a Fair Economy.
11. Lynch, John, Kaplan, George, Income
Inequality and Mortality in the Metropolitan Areas
of the United States, Am J Public Health, July
1998.
12. Pan American Conference in Public
Health Education Health Sector Reform and Es-
sential Public Health Functions: Challenges for
the Development of Human Resources. http://
www.americas.health-sector-reform.org/sidorh/
documentos/hsr15e.html.
LB-00-5: Addressing the Use of
Fluoroquinolone Antibiotics
in Agriculture
Recognizing that fluoroquinolone antibi-
otics are the treatment of choice for some human
gastrointestinal infections, particularly severe
food-borne illness caused by Campylobacter or
Salmonellae bacteria; and that fluoroquinolones
also are used to treat urinary tract infections, bone
and joint infections, some types of pneumonia,
and other human illness; and
Further recognizing that Campylobacter, as
the most common cause of food-borne illness in
the U.S., accounts for nearly two million illnesses
and about 100 deaths each year, according to esti-
mates by the Centers for Disease Control;
1
while
Salmonellae bacteria are the leading cause of
food-borne disease in many other countries,
2
and
in the U.S. account for an estimated 1.3 million
food-borne illnesses and around 550 deaths each
year;
3
Understanding that fluoroquinolones closely
related to those used in humans are also used in
poultry, which are a leading source of human
food-borne illnesses,
4
and that use in poultry has
contributed to the generation of fluoroquinolone-
resistant Campylobacter,
5
as well as resistant
Salmonellae;
6
and
Acknowledging that while treatment of hu-
man disease with fluoroquinolones began in
1986, little resistance developed in the U.S. until
the first fluoroquinolone was approved for use in
poultry in 1995, but resistance has since in-
creased rapidly. By 1998, for example, the
Centers for Disease Control found that over 13
Association News
percent of food-borne Campylobacter was resis-
tant to fluoroquinolones, a figure which had risen
to nearly 18 percent by 1999;
7 ,8
Acknowledging that for immuno-compro-
mised and other vulnerable patients, such as chil-
dren and the elderly, antibiotic resistant strains of
Campylobacter and Salmonellae can pose a seri-
ous and potentially fatal problem;
9
also acknowl-
edging that even in otherwise healthy patients, in-
fection by fluoroquinolone-resistant strains of
Campylobacter can lead to longer duration of
symptoms; and
Recognizing that fluoroquinolone resistance
is only part of a more widespread problem that
has resulted in bacterial resistance to all available
antibiotics,
10
and that this widespread problem is
addressed by APHA policy #9908; and
Recognizing that of the two fluoroquinolones
used in poultry over the last five years, Abbott
Laboratories has already requested that FDA
withdraw the authorization for use of one, while
the other, enrofloxacin, manufactured by Bayer
Corporation, remains on the market;
Recognizing that at the time FDA first ap-
proved the application for use of enrofloxacin in
poultry, the potential for antibiotic resistance was
anticipated, and a stipulation was added to the ap-
plication that the drugs sponsor had to agree to
participate in a surveillance program for antibiot-
ic resistance;
11
Recognizing that on October 31, 2000, the
Food and Drug Administrations Center for Veter-
inary Medicine issued a Notice of Opportunity for
Hearing on a proposed withdrawal of authoriza-
tion for use of enrofloxacin;
12
understanding that
the FDA docket for this Notice provides extensive
scientific evidence supporting the proposed ac-
tion;
13
and noting that the Notice provides Bayer
Corporation thirty days to object to the proposed
withdrawal, by requesting a hearing; therefore
1. Strongly supports the FDAs proposed with-
drawal of remaining uses of fluoroquinolones
in poultry as a firm step to meeting recom-
mendations in APHA Policy #9908 that urged
the Center of Veterinary Medicine of the
FDA to work for regulations eliminating the
non-medical use of antibiotics and limiting
the use of antibiotics in animal feeds.
2. Supports the FDA action as being firmly
grounded in existing science and in public
health protection;
3. Calls upon the manufacturers of enrofloxacin
to voluntarily withdraw their product from
world-wide use in poultry, recognizing that
to do so constitutes the quickest, most re-
sponsible way to address the public health
threat.
References
1. Mead, P.S., et al., Food-related illness and
death in the United States, Emerging Infectious
Diseases, 5:607-25, 1999, at http://www.cdc.gov/
ncidod/eid/vol5no5/mead.htm.
2. Malorny B, Schrotter A, Helmuth R, Inci-
dence of Quinolone Resistance Over the Period
1986 to 1998 in Veterinary Salmonella Isolates in
Germany, Antimicrobial Agents and Chemo-
therapy 43: 2278-2282, 1999.
3. Mead et al., 1999.
4. Altekruse, SF, et. al., Campylobacter jeju-
nian Emerging Foodborne Pathogen, 1999 Jan-
Mar 5(1):. Available from: URL: http://www.cdc
.gov/ncidod/eid/vol5no1/altekruse.htm.
5. Smith KE, Besser JM, Hedberg CW, Leano
FT, Bender JB, et al., Quinolone-resistant campy-
lobacter jejuni infections in Minnesota, 1992-
1998, N Engl J Med 1999;340: 1525-32.
6. Malorny et al., 1999.
tion, 1998 Annual Report NARMS National
Antimicrobial Resistance Monitoring System:
Enteric Bacteria, at http://www.cdc.gov/ncidod/
dbmd/narms/annuals.htm
tion, 1999 Annual Report NARMS National
Antimicrobial Resistance Monitoring System:
Enteric Bacteria, at http://www.cdc.gov/ncidod/
dbmd/narms/annuals.htm.
9. Wegener HC (editorial), The Consequences
for Food Safety of the Use of Fluoroquinolones in
Food Animals, N Engl J Med 340(20), May 20,
1999, at http://www.nejm.org/.
10. Levy SB. Clinical Care. Resistant Organ-
isms: Global Impact on Continuum of Care. Inter-
national Congress and Symposium Series 220,
1998.
11. New Animal Drug Application (NADA)
140828, for Baytril 3.23% Concentrate Anti-
microbial Solution, approved by the Food and
Drug Administration, Department of Health and
Human Services, October 4, 1996.
12. Food and Drug Administration, HHS, FR
Notice Vol. 65, No. 211, 64954-64965, docket no.
00N-1571, October 31, 2000, http://www.fda.
gov/OHRMS/DOCKETS/98fr/103100co.htm.
13. Food and Drug Administration, HHS, doc-
ket no. 00N-1571, http://www.fda.gov/ OHRMS/
DOCKETS/.
LB-00-6: Establishment of a
Medicare Prescription Drug
Benefit
Acknowledging that prescription drug cover-
age for Medicare beneficiaries, many of whom
are on fixed incomes, has become a salient poli-
cy and political issue because the cost of pre-
scription drugs is becoming an increasingly sig-
nificant financial burden for many Medicare ben-
eficiaries;
1
Observing that since June 2000 several bills
addressing Medicare prescription drug coverage
have been introduced in Congress;
5
Recognizing that prescription drugs are an es-
sential tool in preventing and managing many
acute care conditions and chronic diseases;
Realizing that almost a quarter (23%) of
Americans under age 65 and almost one in three
(31%) Medicare beneficiaries had no prescription
drug coverage in 1998;
2
Knowing that U.S. spending for prescription
drugs has tripled since 1990 and is estimated to
double from the current level of $112 billion to
$243 billion by 2008;
3
Noting that older adults are disproportionate-
ly affected by rising drug costs as evidence by the
fact that while they comprise 13% of the popula-
tion they account for over a third of the nations
total drug expenditures;
7
Knowing that those without drug coverage
consistently fill fewer drug prescriptions than
their insured counterparts and therefore underuti-
lize prescribed medications, thereby endangering
their health;
3
Recognizing that the continued rapid escala-
tion in prices particularly of newer drugs, the
prodigious expenditures by manufacturers on di-
rect-to-consumer advertising, the resulting ten-
dency of many consumers to prefer higher priced
newer medications, and the growth in the average
number of prescriptions utilized per person are
trends which will continue into the foreseeable
future;
8
Therefore, APHA urges the President and
Congress to enact a Medicare prescription drug
coverage benefit which incorporates the follow-
ing set of principles:
4,6,7
Benefits: Medicare should guarantee access
to a voluntary Medicare prescription drug benefit
as a part of its defined benefit package, similar to
Part B coverage.
Coverage: The Medicare prescription drug
benefit should be available to all Medicare eligi-
ble older adults and individuals with disabilities,
regardless of income or health status.
Affordability: The Medicare prescription
drug benefit should provide extra protection
against premium and out of pocket costs for low
income beneficiaries and provide catastrophic
protection for all beneficiaries.
Administration: The Medicare prescription
drug benefit should be administered by HCFA
and not relegated to private insurers. To include
efficient management, appropriate cost contain-
ment and reflect the purchasing power of the
Medicare beneficiary pool.
Quality: The Medicare prescription drug ben-
efit should have defined quality of care standards,
including appropriate monitoring and quality as-
surance activities.
The Medicare program should work to pre-
vent overuse, under use and misuse of prescrip-
tion drugs.
References
1. Kaiser Family Foundation, Medicare and
Prescription Drugs, March 2000.
2. Kaiser Family Foundation, Prescription
Drug Trends, September 2000.
3. Kaiser Family Foundation, Prescription
Drug Trendsa chartbook, July 2000.
4. Leadership Council of Aging Organiza-
tions, Prescription Drug Benefit Principles, Feb-
ruary 2000.
5. Congressional Research Office Report for
Congress, Medicare: Selected Prescription Drug
Proposals, September 2000.
6. Congressional Research Office Report for
Congress, Medicare: Prescription Drug Cover-
age for Beneficiaries, April 1999.
7. AARP Public Policy Institute, Prescription
Drug Benefits: Cost Management Issues for
Medicare, Peter Fox, August 2000.
8. Protecting and Strengthening Medicare:
Financing and Prescription Drug Issues, APHA
Policy Statement 9934(PP).
Association News
LB-00-7: Support the Framework
for Action on Oral Health in
America: A Report of the Surgeon
General
Recognizing that the Surgeon General has re-
cently released a report on oral health; and
Recognizing that there are profound and con-
sequential disparities of oral health status within
the U.S. population, for example that poor chil-
dren suffer twice as much dental caries as their
more affluent peers; and their disease is more like-
ly to by untreated; and
Recognizing that dental caries is the single
most common chronic disease-five times more
common than asthma and seven times more com-
mon than Hay fever; twenty-three percent of 65 to
75-year-olds have severe peridontal disease. Less
than two thirds of adults report having visited a
dentist in the past 12 months. Those with incomes
at or above the poverty level are twice as likely to
report a dental visit in the past 12 months as those
who are below the poverty level; and
Recognizing there is emerging evidence that
oral diseases and conditions are associated with
other health problems such as diabetes, heart dis-
ease and adverse pregnancy outcomes; and
Recognizing that dental insurance is a strong
predictor of access to dental care, shown by unin-
sured children are 2.5 times less likely than in-
sured children to receive dental care. For each
child without medical insurance, there are at least
2.6 children without dental insurance. For every
adult 19 years or older without medical insurance,
there are three without dental insurance; and
Recognizing that water fluoridation is identi-
fied by the CDC as one of the top ten public
health achievements of the century in the preven-
tion of dental caries, yet over one third of the U.
S. population (100 million people), has no access
to community water fluoridation
Recognizing that oral and pharyngeal cancers
have one of the lowest five-year survival rate
when compared to other major cancers;
Therefore, APHA supports the framework for
action called for in the Surgeon Generals report
and calls on the dental profession and the public
health sector to take actions to:
1. Change perceptions regarding oral health
and disease, so that oral health becomes an
accepted component of general health.
2. Accelerate the building of the science and
evidence base and applied science effective-
ly to improve oral health.
3. Build an effective health infrastructure that
meets the oral health needs of all Americans
and integrates oral health effectively into
overall health.
4. Remove known barriers between people and
oral health services.
5. Use public/private partnerships to improve
oral health of those who still suffer dispro-
portionately from oral diseases.
Reference
U.S. Department of Health and Human Ser-
vices. Oral Health in America: A Report of the
Surgeon General. Rockville, MD: U.S. Depart-
ment of Health and Human Services, National
Institute of Dental and Craniofacial Research,
National Institutes of Health, 2000.
LB-00-8: Trust Fund for
Developing Countries to Meet
National Commitment under the
WHO Framework Convention for
Tobacco Control
Recognizing that the 11th World Conference
on Tobacco or Health, held 6-11 August 2000 in
Chicago, adopted as its first resolution that the
WHO Framework Convention on Tobacco Con-
trol (FCTC) be strong, driven by public health
considerations, not preclude nations from adopt-
ing stronger measures and fully integrate NGOs
in the process;
Realizing that the aggressive marketing of the
multinational tobacco industry in the developing
countries results in an enormous burden of dis-
ease and premature death, with tobacco killing 4
million people worldwide in 2000, a toll predict-
ed to rise, if current smoking patterns persist, to
10 million deaths per year by 2030, of which 7
million will be in developing countries;
1
Further recognizing that many developing
countries do not have the financial resources to
fund tobacco control measures, train personnel in
tobacco control strategies, support monitoring
and implementing of tobacco control measures,
and fund crop substitution programs;
2
Noting that precedents exist for establishing
multilateral trust funds to assist developing coun-
tries, specifically the trust fund established in the
1190 London Amendments to the Montreal
Protocol to the Vienna Convention for the
Protection of the Ozone Layer and the general
fund established by the World Bank in the Global
Environmental facility to aid developing coun-
tries in correcting global environmental prob-
lems;
3
therefore
Urges that the World Health Organization
begin discussions with the international donor
community (governmental agencies and founda-
tions), even in advance of the coming into force
of the FCTC, on the establishment of a global fi-
nancing mechanism or multilateral trust fund to
assist developing countries in strengthening their
tobacco control programs, pursuant to the WHO
Framework Convention on Tobacco Control.
References
1. Curbing the Epidemic: Government and
the Economics of Tobacco Control, The World
Bank, Washington, DC, 1999, pp. ix, 13-18.
2. Ally L. Taylor, An International Regu-
latory Strategy for Global Tobacco Control, Yale
Journal of International Law, 21: 257 at 300-301,
1996.
3. Ibid.
LB-00-9: Participation of Health
Professionals in Capital
Punishment
Noting that there have been 672 executions, of
which 507 have been done by lethal injection,
since 1976 in the 38 states which have capital
punishment
1
; and
Noting that 74 executions have occurred in
this year alone with 32 executions scheduled in
the next 4 months
2
; and
Noting that the majority of executions in the
United States require, by statute or wardens pro-
cedures, health professional participation in the
execution process
3
; and
Noting that the medicalization of the death
penalty by lethal injection particularly employs
the same medical knowledge, devices, and meth-
ods used by health professionals to comfort, to
heal, and to preserve life
3,4,5
; and
Recognizing that the APHA has clear policy
prohibiting the participation of health personnel
in legally authorized executions
6
; and
Recognizing that the American College of
PhysiciansAmerican Society of Internal
Medicine, the American Medical Association,
and the American Nurses Association have simi-
lar clear policies
7,8,9
; and
Recognizing that in March 1994, in response
to concern about the increasing number of execu-
tions requiring health professional participation,
the APHA in collaboration with the ACP-ASIM,
the AMA, and the ANA publicly stated that ethi-
cal codes of health professions forbid participa-
tion in executions and, since these codes are inte-
gral parts of most state medical, nursing, and
other health professional practice and licensing
acts, health professional participation in execu-
tions violates state law; and
Whereas this 1994 statement directed state
professional licensing and discipline boards to
treat participation in executions as grounds for
active disciplinary proceedings, including license
revocation; and
Whereas, this statement also called upon all
health care professional societies to ensure that
their members know and understand that partici-
pation in an execution is a serious violation of
ethical standards, that professional societies
should also impose disciplinary actions on those
members who do participate in execution includ-
ing expulsion from membership and reporting of
these violations to the state licensing and disci-
pline boards
3,4,5,10
; and
Whereas, the World Medical Association in
its October 2000 meeting unequivocally restated
its opposition to physician participation in execu-
tions: RESOLVED, that it is unethical for physi-
cians to participate in capital punishment, in any
way, or during any step of the execution pro-
cess
11
; and
Noting, a recent article in a respected medical
journal indicates that, despite medical society
policies, the majority of surveyed physicians ap-
prove of most disallowed actions involving capi-
tal punishment indicating that they believe that it
is acceptable for physicians to kill by state
order
12
; therefore
Resolves, that the APHA publicly reaffirm its
policy 8521, that health professionals not be re-
quired to participate in capital punishment; and
further
Resolves, that the APHA publicly reaffirm its
March 1994 collaborative statement to all health
professional societies and state licensing and dis-
Association News
cipline boards that health professional participa-
tion in executions is a serious violation of ethical
codes and may be grounds for active disciplinary
proceedings including expulsion from society
membership and license revocation.
References
1. National Coalition to Abolish the Death
Penalty: Death Penalty Profile, November 2000.
2. Halperin, R: Communication from Am-
nesty International in Texas, November 2000.
3. American College of Physicians et al:
Breach of trust: physician participation in execu-
tion in the United States, Philadelphia ACP, 1994.
4. Curran, WJ, Castles, W: The ethics of med-
ical participation in capital punishment by intra-
venous drug injection. N Engl J Med; 1980:
304:226-230.
5. Truog, RD, Brennan, TA: Participation of
physicians in capital punishment. APHA Public
Policy Statement, 1948 to Present, Cumulative.
Current Volume.
6. APHA Resolution 8521: Participation of
health professionals in capital punishment.
APHA Public Policy Statement, 1948 to Present,
Cumulative. Current Volume.
7. American Medical Association Council on
Ethical and Judicial Affairs: Opinion 2.06:
Capital punishment in Council on Ethical and
Judicial Affairs 1992 Code of Medical Ethics:
Annotated Current Opinions. Chicago: American
Medical Association, 1992.
8. American College of Physicians: American
College of Physicians Ethics Manual: Third
Edition. Ann Int Med 1992: 117:947-60.
9. American Nurses Association: Position
statement on the nurses participation in capital
punishment. Kansas City, Missouri: American
Nurses Association, 1983 rev. 1988.
10. APHA et al: Health care professional par-
ticipation in capital punishment: statement from
professional societies regarding disciplinary ac-
tion. press release, March 23, 1994. Published in
Nations Health, November 1994.
11. World Medical Association Resolution,
October 7, 2000.
12. Farber, N, Daviss, EB, et al: Physicians
attitudes about involvement in lethal injection for
capital punishment. Arch Int Med 2000:160:
2912-2916.
LB-00-10: Condemnation of
Pharmaceutical Manufacturers
Retaliatory Tactics
Recognizing that advances in medicine have
made the use of pharmaceuticals an increasingly
important and effective component of the treat-
ment of illness; and
Recognizing that, partly as a result of this,
spending on prescription drugs is an increasing
portion of all spending on medical care;
1,2
and
Recognizing that millions of Americans, in-
cluding those who rely on Medicare, lack ade-
quate insurance coverage for prescription drugs
and cannot afford medicines they need
3
; and
Realizing that the out-of-pocket cost of pre-
scription drugs is a growing burden on low- and
moderate-income Americans
4
; and
Recognizing that American drug companies
sell their products in foreign countries at consid-
erably lower prices than the prices they charge in
the United States and still earn profits that are
higher than those of any other major industry
5
;
and
Recognizing that a number of state govern-
ments are considering steps to contain the price of
drugs and reduce the burden on their citizens
6
;
and,
Recognizing that the State of Maine has
adopted legislation that will seek negotiated dis-
counts and, if this fails within three years to match
cost reductions given to federal agencies in the
State, will impose price controls on pharmaceuti-
cal products
7
; and
Noting that, in an effort to undercut Maines
legislation and intimidate other states that might
be considering similar actions, at least three phar-
maceutical companies, SmithKline Beacham,
Astra-Zeneca, and Bristol-Myers Squibb, have
stopped shipping their products to wholesale drug
distributors in Maine;
8-10
Therefore,
1. Welcomes efforts by the State of Maine to
seek lower drug prices for its residents;
2. Condemns any effort by pharmaceutical
companies to retaliate against a State, its dis-
tributors, another area, or the residents of a
State or area, on the basis of that States or
areas policies;
3. Encourages public health and health organi-
zations not to accept contributions or adver-
tising from any company which boycotts any
area or individual in making available neces-
sary pharmaceuticals.
References
1. Smith S, Heffler S, et al. The next decade of
health spending: A new outlook. Health Affairs.
1999;18(4):86-95.
2. Levit K, Cowan C, et al. Health spending
in 1998: Signals of change. Health Affairs. 2000;
19(1):124-132.
3. Rasell ME. Cost sharing in health insur-
ance: A reexamination. N.Engl.J.Med. 1995;
332(17).
4. Donelan K, Blendon RJ, et al. The cost of
health system change: Public discontent in five
nations. Health Affairs. 1999;18(3):206-216.
5. Public Citizen. Why the pharmaceutical in-
dustrys AR&D scare card does not justify high
and rapidly increasing U.S. drug prices.
http://www.citizen.org/congress/drugs/press/r&d
scarecard.htm. Access June 19, 2000.
6. Freyer FJ. States join to battle prescription
costs. Providence Journal. June 3, 2000.
7. Maine Prescription Drug Fair Pricing Act.
h t t p : / / j a n u s . s t a t e . me . u s / l e g i s / b i l l s /
billtexts/LD259901-1.asp.
8. Maine claims SmithKline dodging drug
discount law, Reuters Aug. 4, 2000, INK http:/
/uk.biz.yahoo.com/000804/80/af4mc.html
http://uk.biz.yahoo.com/000804/80/af4mc.html
Access Oct. 25, 2000.
9. Ed Silverman, Drug makers on attack in
Maine: Pricing law draws apparent retribution.
Newark Star-Ledger. Sept. 24, 2000.
10. Two more drug companies halt shipments
to Maine, Boston Globe, Sept. 27, 2000.
Association News

Epid Yankes

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Epid Yankes

Uploaded by

Copyright:

Available Formats

March 2001, Vol. 91, No.

3 476 American Journal of Public Health

You might also like