ANNUAL SPRING MEETING
Paradise Point Resort - Executive Suite 709 & 711
San Diego, California
February 21, 2003

PROGRAM

1:30PM - 3:30PM : EDUCATIONAL SESSION

WELCOME: History and Mission of AAPHP : Mary Ellen Bradshaw, MD., President AAPHP

PANEL DISCUSSION:

* Public Health Program Implementation:
A Proposal to CDC - A White Paper Presentation
by Joel Nitzkin, MD, MPH, DPA,
Past President AAPHP, Former Director, Louisiana Department of Health
Respondents:
Paul Halverson, Ph.D, CDC , Professional Practice Program Office (Review Requested) and
James R. Allen, MD, MPH, Director, Division of Chronic Disease & Tobacco Control,
Maricopa County Department of Public Health, Past Director of HIV Program at CDC
AMA Vice President for Science, and Director, Arizona Department of Health

* A Rare Public Health Dilemma: Lethal Naeglaria fowleri in a Local Water System
A Case Presentation by Jonathan B. Weisbuch, MD, MPH, Director & Chief Medical Officer,
Maricopa County Department of Public Health, Member AAPHP BOT
Respondent: James Haughton, MD, MPH, Associate Director, Division of Public Health,
Los Angeles County Department of Health Services

Q and A

3:30PM - 4:00PM BREAK (refreshments)

4:00PM - 7:00PM BUSINESS MEETING

REPORTS, POLICY DECISIONS, ELECTION

AGENDA

1. WELCOME & INTRODUCTIONS
2. REVIEW OF MINUTES Fall Meeting 11/10/02
3. REPORTS of AAPHP Executive Committee & Board of Trustees (*action items)

4. ELECTIONS
5. MEMBERSHIP INITIATIVE - NCCHC Contract Expansion
6. ROLES of PREVENTIVE MEDICINE & PUBLIC HEALTH PHYSICIANS
7. ROLE OF AAPHP in PH Physician Education
8. 50th ANNIVERSARY PLANS- 2004 Spring Meeting
9. AAPHP HOME PAGE
10. AMA Committee on Organization of Organizations (COO)
11. AMA RESOLUTIONS for Annual 2003
12. OTHER POLICY - STRATEGIC GOALS
13. OLD BUSINESS
14. NEW BUSINESS
15. NEXT MEETING- in conjunction with APHA - November (15-19) 2003 - San Francisco, California
16. ADJOURNMENT

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Educational Session:  Case Presentation - Abstract

Educational Session - Case Presentation Abstract In October of 2002, in the Peoria region of Maricopa County, Arizona, two
children died on the same day from the same amebic meningitis infection, primary amebic meningoencephalitis. This very rare infection by the ameoba, Naeglaria fowleri, was unusual in many respects. None of the usual causal factors seemed to apply; the children had no history of swimming in lakes or ponds, no common exposure to sources of water spray, and neither had any history of having traveled to areas of the country where the organism is more common than Arizona which has recorded only six cases in the past two decades. The two children had no common contact or association with each other than the deep-well, non-chlorinated water system they shared. The
water system, which serves 6000 individuals, is privately run. Its water sample records filed with the Maricopa County Environmental Services Department have showed no evidence of coliform contamination in the previous two years.

The investigation of the clinical findings, the epidemiologic investigation, and the in depth analysis of the local water system shared by these two victims and their community is a classic public health analysis raising several concerns for the era of bioterrorism. Was the event intentional? Was the management of the public panic and concern carried out correctly? Is the entire deep water aquifer system at risk to natural or intentional infection by parasites for which no standard testing is done, nor most labs equipped to handle. What are the implications for other deep wells currently allowed to provide non-chlorinated water to thousands and possibly millions of people around the world?

These questions and others related to the current problems in the public health infrastructure and its implications for future massive biologic events will be discussed.

 

Educational Session: Public Health Program Implementation Initiative Abstract

This proposal is a recommendation from AAPHP to CDC to initiate a new research agenda and a new initiative to improve the performance, leadership capacity and emergency preparedness capabilities of state and local health departments.
This initiative would address two sets of issues:
1. Policy/politics and organizational culture within professional and governmental agencies as they relate to the roles and leadershipcapabilities of state and local health departments.
2. Decision-support modeling and statistical issues (GIS template and new approach to p value) to optimize program planning, implementation and evaluation

The initial research could be completed in three to five years at a cost not to exceed $1 million per year to the stage where nationwide implementation could begin, as subsidiary research continues to work out selected details and develop additional decision-support modules.

Addressing the second of the two sets of issues within CDC could improve the performance of CDC-funded programming, nationwide.  If AAPHP is correct in its assessment of the root causes of lackluster performance by state and local health departments the stage will be set for quantum improvements in the performance and leadership capabilities of state and local health departments within the three to five years immediately following completion of the initial research.

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AMA DELEGATION REPORT

INTERIM HOUSE OF DELEGATES MEETING – NEW ORLEANS, LA

DECEMBER 7-11, 2002

OVERVIEW

The overarching themes of the 2002 Interim Meeting of the AMA House of Delegates (HOD) in New Orleans were advocacy and legislation with a call to action regarding Medicare payment and medical liability reform. Yank D. Coble, Jr., MD, MPH, AMA President, exhorted all American physicians to" enter the fray and take up the fight" to address the AMA’s priorities and positively impact patients’ access to care. To that end, there was a special session which allowed for venting of concerns and a demonstration appealing to Congress to "Fix the Medicare Mistake" by stopping the proposed physician payment cuts. The action items of this HOD were aimed primarily at Advocacy in physicians’ practice: resolutions relating to other issues were deferred to the Annual 2003 HOD.

NOTEWORTHY EVENTS

There were several important sessions:

Forum on Racial and Ethnic Health Disparities presented by the AMA Minority Affairs Consortium focused on the Institute of Medicine report, "Unequal Treatment: Racial and Ethnic Disparities in Health Care" with Alan R. Nelson, MD, a past AMA President and Chair of the IOM committee, as Keynote Speaker. Panelists included: Regina Benjamin, Member, Council on Ethical and Judicial Affairs; Rodney Hood, MD, Past President, National Medical Association; Elena Rios, MD, President, National Hispanic Medical Association and Carolyn Robinowitz, MD, Member, Council on Scientific Affairs.

"Organization of Organizations Project Status Report", via an open forum, provided information on the ongoing process - initiated by actions of the HOD at A-02 when it adopted the amended BOT Report 23, progress to date, review of the Federation survey results, responsibilities and operational logistics for the Committee on Organization of Organizations (COO), Federation and individual responsibilities and other future plans. First meeting of COO will take place in Los Angeles, CA on February 1-2, 2003.

Speaker to Speaker Meeting with the AMA Speaker and Vice Speaker provided the opportunity of an informal discussion of parliamentary procedure and the proposed change from Davis to 4th edition of Sturgis.

REPORTS AND RESOLUTIONS

Based on the limited thrust of this Interim Meeting, there were five Reference Committees dealing primarily with practice and advocacy issues. Reports and resolutions of import to Public Health and addressed by your delegates are briefly described below. Others are listed for your information. More extensive coverage of all reference committee reports may be accessed through ama_assn.org.

REPORTS

Council on Scientific Affairs (CSA) Report 1 – Racial and Ethnic Disparities in Health Care which examined the racial and ethnic disparities in health care through a systematic review of the literature; defined relevant
terminology; described the evidence for such disparities; discussed linking disparities in health care to health outcomes; considered why health care disparities exist; outlined the role of physicians in eliminating health care
disparities and made several policy recommendations was ADOPTED.

CSA Report 2 - Smallpox: A Scientific Update, which summarized the numerous reviews on smallpox that have been published, provided an update on recent scientific developments in smallpox and smallpox vaccine and presented several recommendations was AMENDED to include, in Recommendation 2, "That our AMA should remain engaged with the Centers for Disease Control and Prevention (CDC), the ACIP, and the Federation on this issue and support a commitment to monitor the current status of smallpox and smallpox vaccination in the world and in the United States. Data on issues such as medical furlough, vaccination site care, and contradictions to vaccination should be monitored, as Phase 1 of the 2002-2003 Department of Human Services smallpox
vaccination program progresses, with particular attention to adverse effects and inadvertent vaccine transmission, and appropriate recommendations developed as necessary. (Directive to Take Action)." The Report was then ADOPTED in lieu of Resolution 728 - Smallpox Vaccination and Resolution 730 – Smallpox Vaccination of Health Care and Public Heath Smallpox Response Teams. Resolution 728- Smallpox Vaccination presented by AAPHP called for our AMA to urge the President, the Department of Health and Human Services and the Centers for Disease Control and Prevention to adopt the very limited pre-event vaccination strategy, and post-event ring strategy recommended by the American Academy of Pediatrics in Pediatrics, 11/02; and urge the Administration to explore with the United Nations, the World Health Organization, the Red Cross and other agencies every possible way to lower the risk of a smallpox release from any location to the lowest possible
level; and support the recommendation that states and local health agencies be prepared for universal vaccination, but not adopt a policy for mass vaccination except under the most catastrophic circumstances.

Council on Medical Service Report 8 – Review of US Health System Financing which reviewed the AMA’s ongoing study of health system financing, as well as various AMA engagements with other key stakeholders to discuss an "enduring health care system that will meet the needs of physicians, hospitals and people of the United States for many years into the future", as requested by Resolution 110 (A-02) ( a composite of AAPHP Resolution 134 & New York State Delegation,110),and highlighted the continued affirmation and refinement of AMA policy in support of individually selected and owned health insurance was ADOPTED. This occurred despite points made by the AAPHP delegate and others indicating that the report did not address the main thrust of the resolutions but merely affirmed existing AMA policy and that a taskforce to study the current health care system was warranted .The Reference Committee, based on other testimony, felt that what was needed was, not new policy, but to "sell"
the current proposal to every Washington "think tank" that works on these issues.

Board of Trustees Report 14 – Crossing the Quality Chasm: A New Health System
for the 21st Century – An American Medical Association Response

Board of Trustees Report 18 – Health Care for the Economically Disadvantaged

Council on Medical Education Report 1 – Preserving Medicaid Funding of Graduate Medical Education

RESOLUTIONS

Resolution 721- Homeland and Global Public Health Security which called for our AMA to encourage our federal government to involve physicians and organized medicine not only in the preparedness planning to deal with the
consequences of weapons of mass destruction but also in the strategic planning of preventing the use of medical knowledge for the development of such weapons; and, cognizant of the homeland and global public health security interdependence, to encourage the World Medical Association, the World Health Organization and other appropriate medical associations to initiate similar actions through the national medical associations of member
nations was ADOPTED. This resolution accomplished the portion of the AAPHP Resolution 728 Smallpox Vaccination not included in the final CSA Report 2.

Resolution 732 – Preservation of HIV and STD Prevention Programs Involving Safer Sex Strategies and Condom Use which called for the AMA to affirm its policy to reiterate that HIV and STD prevention education must be
comprehensive to incorporate safer sex strategies including condom use, not just abstinence, and that these programs be culturally sensitive to sexual-orientation minorities; and that our AMA urge the Centers for Disease
Control and Prevention to re-instate an on-line fact sheet and curriculum on HIV and STD prevention education involving condom use; and that our AMA issue a letter to the Secretary of the U.S. Department of Health and Human Services to express grave concern that funding, promotion, and institutional support for safer sex programs including those that involve condom use are being compromised, and urges the DHHS to ensure that abstinence-only programs are not funded at the expense of funding for safer sex programs involving condom
use was ADOPTED.

Resolution 718 - Strategies for Eliminating Minority Health Care Disparities which called for our AMA to re-affirm Policy H-350.974,"Racial and Ethnic Disparities in Health Care," which advocates a "zero tolerance" for racial and ethnic health disparities; and commends the Institute of Medicine on its report, "Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care," formally review its recommendations and report back to the House of Delegates at the 2003 Interim Meeting with strategies to eliminate minority health care disparities; renew its commitment to support the importance of culturally effective health care in eliminating disparities and explore ways to provide physicians with tools for improving the cultural effectiveness of their practices; and identify and incorporate strategies specific to the elimination of minority health care disparities in its ongoing advocacy and public health efforts, as appropriate was AMENDED to include specific directives for our AMA to make the elimination of racial and ethnic disparities in health care an issue of highest priority and for all applicable AMA Councils to formally review the IOM report and report back to the HOD at I-03 with specific strategies toward the elimination of these disparities was ADOPTED.

Resolution 733 - Achieving Health Care Coverage for All which called for our AMA and interested medical specialty societies and state medical societies to jointly advocate for enactment of a bipartisan resolution in the US Congress establishing the goal of achieving health care coverage for all persons in the United States by January 1, 2009 was AMENDED to eliminate the word" jointly", change the date to "on or before" and add "that is consistent with relevant AMA policy" – so that the language of the resolution not be interpreted as an endorsement of a single payer system – was ADOPTED.

Resolution 901- HIPAA

Resolution 924- Vaccine Safety

Sponsored by AAPHP

Resolution 728 - Smallpox Vaccination is discussed under CSA Report 2. Our Resolution on the Epidemiology of Firearms was deferred to A-03. Our A-02 Resolution On US Health System Review is addressed in the CMS Report 8.

SECTION COUNCIL ON PREVENTIVE MEDICINE

The Section Council on Preventive Medicine (SCPM), currently chaired by the American Society of Aerospace Medicine, met on December 7, 9 and 10. Discussions covered review of pertinent HOD reports and resolutions, SCPM positions and endorsements, strategies for action, as well as a critique of the methodology of the recent Federation survey. The AMA Public Health Update was provided by Claire Callan, MD, AMA Vice President for Public Health and Science, who highlighted activities related to the development of the Clinical Performance Measures for the six conditions to be evaluated – diabetes, CAD, HP,CHF, major depression and osteoarthritis, and shared preliminary results of a survey of AMA and non-AMA physicians regarding their priorities, which reflected positively on public health oriented activities. John Nelson, MD, MPH and Ron Davis, MD, MPH, both AMA BOT members, provided an update on other AMA issues.

WOMEN PHYSICIANS CONGRESS (WPC)

WOMENS’ CAUCUS
A record number of women physicians and students attended the WPC Caucus to hear an outstanding presentation revealing the results of a WPC/American Academy of Pediatrics study on the rising number of physicians – of both genders and in all specialties - working part-time. This phenomenon, if continued and expanded, is anticipated to have significant impact on the future practice of medicine. The remainder of the program provided for a stimulating discussion on the role of the Caucus in identifying and promoting female candidates in the AMA. Tribute was paid to two long-standing, actively contributing AMA delegates on their retirement, Rhoda Posner, MD and Mildred Reardon, MD.

UNDERAGE DRINKING FORUM

AAPHP was a co-sponsor of this excellent session, chaired by J. Edward Hill, MD, Chair , AMA BOT, who spoke on the AMA’s alcohol policy and its next advocacy steps. The distinguished panel included: Norman Wetterau, MD,
American Society of Addiction Medicine, who presented an overview of the problem of underage drinking; David Jernigan, PhD, Center on Alcohol Marketing and Youth at Georgetown University, who spoke on how the alcohol
industry targets youth in its advertising and marketing practices and James Blaine, MD, Missouri State Medical Association, who gave a personal view on the role of the activist physician. One of the most remarkable presentations was by Sandra Brown, PhD, University of California at San Diego on the research findings of the detrimental effects of alcohol on adolescent brain development. Much audience discussion centered on how physicians, in their various roles in the office, medical society and community, can influence young patients, parents, legislators, educators and citizens in general, about the effects of alcohol on the young brain and the measures needed to limit adolescent access to alcohol. The pursuit of comprehensive school health education which has an important focus on the prevention of drug and alcohol use and the activist role of physicians to urge school systems to develop such programs was encouraged.

TOBACCO CONTROL COALITION

The annual Tobacco Control Coalition session, hosted by Steven Hansen, MD, Delegate from CA, featured informative and controvertial presentations on:" Status of Tobacco Control in the United States"; by Rosemarie Henson, MSSW, MPH, Director of the CDC’s Office on Smoking and Health, and "Raising the Legal Age for Tobacco Purchase to 21" by Bob Crane, MD, Department of Family Medicine, Ohio State University and President of "Tobacco to 21. These were followed by a lively but limited, due to time constraints, debate on
" Political Potpourri – An Open Discussion" - a variety of topics including: Lessons from 2002 ballot initiatives in several states; The Karl (Phillip Morris) Rove White House & Tobacco; Gagging of Surgeons General on Tobacco;
Stifling of Public Health provisions in the development of international tobacco policy; Resurgence of tobacco money to, and control of legislators.

COMPREHENSIVE SCHOOL HEALTH INITIATIVE

AAPHP was invited, along with representatives of the American Academy of Pediatrics, to join J. Edward Hill, MD, Chair of the BOT, to discuss the potential AMA role in collaboration with key specialty societies in a
Comprehensive School Health initiative. The aim of such an initiative is to explore bringing health education programs and services to schools lacking such. Extensive experience in this area by the AAPHP Alternate Delegate was pertinent to the discussion and future plans. Follow-up contact by Dr. Hill with identified participants is anticipated.

REPRESENTATION

AAPHP was represented at the HOD by Jonathan B. Weisbuch, MD, MPH, Delegate
and Mary Ellen Bradshaw, MD, Alternate Delegate and in the YPS, by Cheryl Iverson, DO, MPH.

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AMA National Coalition on Adolescent Health
November 14, 2002Washington, DC

AAPHP was invited to participate as a new member of the AMA National Coalition on Adolescent Health which was established in 1987 by the AMA as a forum for multi-disciplinary, coordinated activities on behalf of youth in the United States. The Coalition, which includes twenty national medical specialty organizations concerned with the health of adolescents, meets semi-annually to discuss issues related to adolescent policy development and
S-CHIP enrollment and assists with overseeing the Educational Forum sessions and their evaluation. The Forum addresses positive youth development and topics related to the 21 critical adolescent objectives in the Healthy People 2010. The May 2002 Forum session was on bullying and the current one on physical activity and nutrition

The November 14 2002 morning Coalition meeting featured two informativepresentations on the threats to access to care for adolescents: Medicaid and S-CHIP – Policy Update and The HIPAA Privacy Regulations: Adolescents and the Final Rule, both by representatives from the Center for Adolescent Health and the Law.

The first of these presentations pointed out that millions (8.5 million under 18 in 2001) of adolescents remain uninsured; the states’ ability to meet the coverage needs is severely diminished with 41 states predicting a
shortfall in 2003; Medicaid (4.72 million 13-18yrs ever enrolled in 2001) and S-CHIP (1.46 million 13-18yrs ever enrolled in 2001) must be protected. Challenges for the future included: providing stable finances to support the
ability of Medicaid and S-CHIP to meet projected needs; maintaining Medicaid as an entitlement; ensuring that eligible adolescents enroll and receive services they need and working strategically for universal coverage.

The second presentation on HIPAA covered the history of the "HIPAA Privacy Rule", its provisions for minors and the effects of its modifications from the first proposed rule in 1999 to the final rule in August 2002. The final rule retains the basic framework of the original Privacy Rule with one major exception: Under original Privacy Rule, when minor may consent and state law is silent on disclosure to parents, the minor decides whether parents may have access to the minor’s records; under August 14th modifications, when minor may consent and state law is silent on disclosure to parents, the provider has discretion to determine whether to allow parents access to the minor’s records. It was pointed out that the "provider" or "health care entity" is all institutions and not necessarily the individual physician or other treating professional.Complex situations arise when domestic violence and abuse are suspected or the rule is in conflict with state or other laws providing for access without parental consent or controlling disclosure.

Another item of business for the Coalition was review of the draft Policy and Resource Guide: Adolescence and Violence Prevention. This Compendium, which addresses several adolescent violence objectives of Healthy People
2010, contains existing policy from the Coalition member organizations ,and is a revision of the 1994 AMA Policy Compendium on Violence and Adolescents: Intentional Injury and Abuse. The document addresses such areas as :key facts on violence and adolescence; general statements on violence as a public health problem; legal considerations; physical abuse and neglect; prevention and research; sexual abuse and assault; special populations; suicide; violence and the media; weapons and firearms. The stated aim of the revised Compendium is to enable legislators, policy makers and others to more effectively deal with issues of violence affecting adolescents.

The afternoon session, Educational Forum on Adolescent Health, addressing physical activity and nutrition, focused on adolescent obesity and the resultant increase in diabetes, touched on a variety of contributing factors,
i.e., school vending machines, lunches via contract with fast food chains, humongous sized portions, family eating patterns, proximity of fast food establishments to schools and media advertising ($$$ available and expended
versus $ limited resources from ADA). Remedial actions that each group in its capacity can do were discussed such as schools applying for the comprehensive school health infrastructure grant via CDC Division of Adolescent and School Health, seeking grants for nutrition/exercise programs and curriculum, exploring participation in the President’s Physicial Fitness Program, and physicians and other concerned citizens advocating for more funding for
education to eliminate need to supplement via contracts with fast food vendors, etc.

One of the goals of the Coalition is increasing awareness in member organizations about adolescent health care issues. Since so much of adolescent behavior including school health issues, pregnancy, substance abuse, STD’s, HIV, immunuzations, sports health, etc. are related to public health, AAPHP’s seat at the table is most appropriate. The sharing of information with and soliciting input from our members in their roles as public health practitioners responsible for community health is an important exchange which should contribute greatly to the enhancement of knowledge in both groups.

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Surgeon General's Reception

AAPHP was one of several cosponsors of a welcome reception in honor of the new Surgeon General, VADM Richard H. Carmona, held in Bethesda MD on January 15, 2003. Many Public Health Service Commissioned Officers, were in attendance, as well as Mrs. Carmona, Deputy Surgeon General Ken Moritsugu, and AAPHP representatives Drs. Doug Mack and Marcel Salive. It was clearly a great success, with about 450 guests present. The Commissioned Corps Honor Guard, and the Choral and Brass Ensembles were present. The AAPHP Board has conferred an honorary membership on Surgeon General Carmona.

Other recent press clips have noted the Surgeon General position on prevention and Medical Reserve Corps

Surgeon General Carmona said disease prevention is his "first and most passionate priority" at a recent keynote address. VADM Carmona emphasized the preventable nature of most of the diseases affecting the United States , "I am looking at disease states: asthma, diabetes, trauma, and obesity, the most pressing issue in health facing the country today," he said.

More than 300,000 Americans die every year because of obesity-related diseases and it costs the nation hundreds of billions of dollars in health care costs and in lost productivity. "Obesity is an epidemic. If we don't
do anything about it, we will have a morbidly obese, dysfunctional population whose care we cannot afford," VADM Carmona added

Surgeon General Carmona challenged members of the Medical Reserve Corps (MRC) to work together to find common ground on priorities and guidelines for the MRC. "By bringing local MRC leaders together we can discuss what works and what doesn't work," VADM Carmona said. "Then we can devise a best practices and hopefully recognize a foundation that all MRC responders and volunteers will have."

Last year the Office of the Surgeon General awarded a total of $2 million to 42 communities to help jump-start their local MRC unit. President Bush requested $10 million for fiscal year 2003 to help sustain these 42 units and provide funding to over 100 more.

President Bush, in his State of the Union address in January 2001, announced that he was launching the USA Freedom Corps to foster an American culture of citizenship, service and responsibility. He formed the Citizen Corps initiative, of which the MRC is a part, to give individuals the opportunity to serve their neighbors by making our communities safe from threats of all kinds.

The MRC is led by the Office of the Surgeon General in HHS. For more information including, the MRC guidance document "Medical Reserve Corps -- A Guide for Local Leaders," information on training resources, and the monthly MRC newsletter please log onto www.medicalreservecorps.gov or call the Office of the Surgeon General at (301) 443-4000.

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General Membership Meeting - Philadelphia, PA:  November 10, 2002

Minutes

President Mary Ellen Bradshaw, MD called the AAPHP general membership meeting to order at 8:42 am EST, November 10, 2002, at the Marriott Hotel in downtown Philadelphia, PA.

Members present at the call to order were Drs. Bradshaw; Dave Cundiff; Peter Rumm; Stan Reedy; Jonathan Weisbuch; Camille Dillard; Joel Nitzkin; Art Liang; Marc Safran; and Charles Schade. Ed Harrison represented the National Commission on Correctional Health Care (NCCHC), which provides staff services to AAPHP. Drs. Cheryl Iverson, Arvind Goyal, and John Poundstone joined us during the meeting. Regrets were noted from Drs. Alfio Rausa and Liz Safran. Dr.

Bradshaw called to members' attention the minutes of the February, 2002 meeting in San Antonio, Texas, which were distributed as part of the October 2002 AAPHP Bulletin. Dr. Rumm moved that we make a practice of
approving the previous meeting's minutes at the beginning of each meeting. This motion was approved unanimously. Dr. Weisbuch moved approval of the February 2002 minutes. The minutes were approved unanimously. Dr. Bradshaw noted that the President's Message is in the new Bulletin. This is a special double issue, expected to be the only issue for 2002, and it is the first AAPHP Bulletin to be produced with the assistance of NCCHC
Staff. Dr. Bradshaw distributed the 2001 report of the AAPHP Strategic Planning Committee. Many items from this report have been accomplished, and most others are in progress. The AAPHP is in transition from a volunteer-run organization to a professionally-run organization through the NCCHC national office. We now have a home with address, phone and fax numbers, and assigned staff. Other ongoing initiatives of strategic importance include the Public Health Leadership Forum (which AAPHP hosted and chaired this year); our representation at the AMA; our Job Market Initiative; and our representation on many policy councils and advisory committees.

Dr. Weisbuch noted a need for AAPHP to become more active in Public Health and Preventive Medicine Training and Certification. This was noted in the 2001 plan, but has not been actively implemented yet. Dr. Weisbuch moved re-establishment of AAPHP's Training and Certification Committee. The motion passed without opposition.
Dr. Rumm pointed out that he has begun service on the Residency Review Committee. He will be surveying public health practitioners with respect to the skills needed for successful practice. Dr. Rumm pointed out AAPHP's great success in placing our members in positions of influence. However, in many cases, these individuals are not
formal representatives of AAPHP. AAPHP should work to get formal representation -- a guaranteed "seat at the table" -- on many such bodies, including the Residency Review Committee (RRC) and Accreditation Committee
for Graduate Medical Education (ACGME). Dr. Rumm requested members to serve on the AAPHP Health Access Committee, which he chairs. This committee has included Drs. Liz Safran and Doug Mack in the past. With additional members, the committee can be re-activated.

Dr. Bradshaw noted that Dr. Virginia Dato has stepped down as President-Elect. In accordance with our bylaws, our Vice President, Dr. Goyal, has automatically been named as Interim President-Elect until the February 2003 meeting. Dr. Goyal introduced himself.  Dr. Dato will continue to develop and distribute AAPHP’s electronic
newsletter. She will attend the Executive Committee meetings, as an invited guest, as her schedule permits.
On behalf of the Nominating Committee, Dr. Cundiff reported that most major functions (except the newly re-activated Training and Certification Committee) have adequate leadership between now and the February 2003
meeting. He asked members to volunteer for offices, committees, and task forces. AAPHP has distinguished itself for great accomplishments with few resources, and everyone should consider being part of these initiatives.

There was a brief discussion of potential membership in the Training and Certification Committee.
On behalf of our AMA delegation, Dr. Bradshaw noted that a complete Delegation report is in the new AAPHP Bulletin. At the June 2002 meeting, the House of Delegates accepted the "Declaration of Professional Responsibility" -- a formal statement of the medical profession's social contract with humanity. Dr. Bradshaw has signed this declaration on behalf of AAPHP. The House also is examining health care financing and organizing
systems. Dr. Bradshaw is an elected at-large member of the Congress of Women Physicians. She would like to have another AAPHP member as a formal liaison to the Congress of Women Physicians. Yank Coble, MD, MPH is AMA's current president. More and more AMA officers have public health training, interests, and experience.
Dr. Bradshaw noted that she has compiled a draft "Policy Compendium" for AAPHP. She circulated a copy.

Dr. Nitzkin has researched the early history of AAPHP. The Tulane University library has extensive archives from the estate of Dr. Ben Freedman, who was one of AAPHP's presidents and edited the AAPHP Bulletin for
many years. AAPHP and predecessor organizations lobbied for creation of a federal Department of Health that would have been separate from the then existent Department of Health, Education, and Welfare. Early AAPHP
membership was about 600 members. AAPHP membership began declining sometime in the 1960's and 1970's, though, as others displaced public health physicians as administrators of governmental public health departments.
In preparation for our 50th anniversary in February 2004, Dr. Nitzkin recommends a review of our archives, perhaps by an AAPHP member, and a reconstruction of our history by a professional historian who can do
interviews. Dr. Rausa is seeking funding for such a history. Dr. Rumm pointed out that a newly established Public Health museum in Cleveland is seeking archival materials from all Public Health activities. They may be
interested in working with us.  In discussion, members suggested rapid preparation for AAPHP's fiftieth
anniversary; suggested focusing on a smaller number of crucial goals; and suggested that the best goals are those on which our members are unanimous. The ABPM certification process has its limitations, and AAPHP could offer a
meaningful alternate credential. Credentialing programs have proven to be a membership builder for other specialties. There is an unmet need for rigorous Public Health training for mid-career entrants to our specialty, in
which they could develop and demonstrate competencies without the career interruption and financial sacrifice of a full residency.

Dr. Poundstone gave the treasurer's report. So far this year we have spent a total of $9,817. Our Web site expenses so far this year have been $1,736. NCCHC expenses so far are $3,249. Dues collection expenses are
$1,080. Officers' and delegates' travel is $2,108. Reimbursement for 2001 expenses at APHA was $1,403, but the claim was submitted late and the treasurer paid it in 2002. Miscellaneous expenses include $241 to date, plus
expected expenses for this meeting and Dr. Goyal's travel to CPT. Dues income was $2,460 and our balance is $15,804. Dr. Poundstone estimates that our 2003 maintenance expenses will be approximately $8,400. This will require a minimum of 140 members paying the current dues of $60 per year. Meeting and travel expenses will be additional.  Members commended Dr. Poundstone for his good work. In discussion, members suggested careful consideration of our 2004 dues level, and further investigation into the tax status of additional contributions. Some members were alarmed by our 2002 operating deficit, while others saw opportunities as
exceeding risks. Dr. Rumm moved that we allow Lifetime Memberships to be paid in installments over a period of three years. Dr. Bradshaw pointed out that this would require a bylaws change. Dr. Cundiff moved postponement of this motion to a time certain. Postponement was approved unanimously. Dr. Weisbuch moved that we establish a fund for the 2004 celebration, subject to legal approval. The motion was approved unanimously. President Bradshaw referred this to the Treasurer and the Finance Committee for implementation.

Dr. Goyal reported on activities of the AMA’s CPT Advisory Committee. The Committee's November 2002 meeting, held in New Orleans, focused on the Evaluation and Management (E&M) codes. The AMA expects to incorporate the E&M Guidelines into the coding standards themselves in 2005. Dr. Goyal has been arguing that Preventive Medicine activities are necessary, requiring skills and time, but that they are not adequately presented in the current complexity standards of the E&M codes.

Dr. Weisbuch reported on liaison activities with the National Association of County and City Health Officials (NACCHO). NACCHO continues to be active, and fairly successful, in issues of public health funding and bioterrorism. However, under its previous Executive Director, NACCHO has appeared to have a bias against physicians as public health administrators. It isn't clear whether this bias will continue under the new Executive Director.

Dr. Weisbuch reported on liaison activities with NCCHC. Correctional physicians, and correctional health care administrators, are recognizing their own role in assuring the health status of the larger community. NCCHC
has been quite successful in securing grant and project funding. NCCHC can be a model for us, and NCCHC staff can help guide us, as we seek to expand our own membership and influence.

Dr. Nitzkin reported for the Job Market Initiative (JMI). The Web site has been an important link between employers and Public Health physicians. However, the overall goal of the JMI is to increase the number and quality of job offerings that express a preference for Public Health and Preventive Medicine training. This goal has not yet been achieved. The JMI, which includes AAPHP and ACPM, has defined a variety of job roles for Preventive Medicine physicians. They hope to define training needs and competencies for these roles.

Dr. Bradshaw described AAPHP's advocacy activities at the Preventive Medicine Leadership Forum and other groups. Full reports are in the Bulletin . Dr. Rumm suggested that we communicate our work to the ACGME, which has noted a need for coordination with and within Preventive Medicine. He suggested that ACGME may take action with or without us, and it would be best for them to know what we are doing.

Dr. Weisbuch moved AAPHP approval of the "teaching health department" concept, and commendation of AAPHP members who have been involved in developing this idea. The "teaching health department" recognizes appropriate Health Department staff as teaching faculty at the universities where students are enrolled. It goes beyond models that recognize the Health Department as a placement site for students and trainees whose primary faculty sponsorship is outside the Health Department. Discussion clarified that the motion is an endorsement of the concept, not an endorsement of any specific program. The motion passed unanimously, with Dr. Rumm abstaining.

Dr. Bradshaw moved that we send birthday wishes to our Trustee, Elizabeth Safran, who intended to attend this meeting but was prevented by illness. The motion was seconded, and passed unanimously.

Members pointed out that physicians working for the U.S. Centers for Disease Control and Prevention (CDC) generally have another specialty, but are identifying increasingly with Public Health. These physicians are a
potential market -- but not an easy one to tap. A training and certification program may help -- especially one that develops and documents both technical and organizational competencies, without requiring applicants to complete a full residency in Public Health.

Mr. Harrison commented that NCCHC faced a similar situation in the early 1990's, when a certification process for correctional health professionals was needed. NCCHC moved quickly to meet this need, and gave their
certification committee some independence from the Board of Directors. Within a year, NCCHC began to offer certification as a "Certified Correctional Health Professional" (CCHP) based on experience and on a 30-day
open book exam. There were 200 people certified in the first year, and there are 1800 people certified now. NCCHC continues to modify and strengthen the certification process. There are legal standards that are required in order to assure fairness for any certification process on which someone's employment may depend. Mr. Harrison and Dr. Weisbuch noted that this achievement may be a useful model for AAPHP. Dr. Bradshaw noted that APHA, ASPH, and NACCHO are developing Public Health certification programs, for individuals and organizations, that may not draw any distinctions at all between physicians and non-physicians. One member commented that, faced with the multiplicity of Public Health organizations, some public health physicians might choose to join none at all. It might be helpful to prepare a summary of all organizations, with information about each.

Dr. Goyal recommended that we establish a process for comparing the merits of various AAPHP initiatives that might require resources. He also recommended that we re-examine our meeting schedule to see if it is still optimal to meet with ACPM in the winter. Our bylaws require that one of our annual meetings must be held in conjunction with the annual APHA meeting. APHA and ACPM are now meeting about three months apart. We may wish to seek
a spring or summer meeting venue. The CDC’s EIS conference in April was mentioned as one possibility, as are the NACCHO/NALBOH meetings in the summer and the ASTHO meeting.  Dr. Bradshaw recommended that the final NCCHC contract contain an expanded role for the NCCHC staff in membership development activities. Mr.
Harrison recommended a high priority for activities that increase AAPHP's long-term financial strength.
Dr. Nitzkin moved that AAPHP's Executive Committee and Board be authorized to expand the NCCHC's role, and to contract with NCCHC for additional services, between now and the February meeting. The motion was
seconded. Dr. Weisbuch moved to amend the motion, to approve the currently presented contract and to instruct the Executive Committee and Board to recommend any further modifications to the General Membership Meeting in February 2003. Dr. Nitzkin accepted this as a friendly amendment, requiring
no discussion. The motion itself was approved unanimously.

Dr. Bradshaw requested input on whether to hold our February 2003 General Membership Meeting on Wednesday, February 19th (before the meeting) or on Friday, February 21st (in the mid-meeting time slot reserved by ACPM for affiliated organizations). Members preferred the Friday option. There may be an opportunity for a third annual meeting, perhaps at NACCHO or NCCHC. Members suggested that this be considered. Dr. Nitzkin moved that this evening’s discussion session be designated as an extension of this Business Meeting, at the discretion of the President. Members suggested that any formal business should be conducted with
discretion and dispatch, especially if others are present. The motion was approved unanimously.  After the afternoon meetings were announced, the meeting adjourned at 12:03 pm EST. In subsequent caucus limited to Young Physician members, the Young Physicians selected Cheryl Iverson, DO as their interim AMA Delegate.

       We reconvened at 2:43 pm for educational sessions. Dr. Goyal introduced Hugh Tilson, MD, DrPH, for his talk, "Assuring the Health of the Public in the 21st Century".
This talk is related to an Institute of Medicine report that will be released on November 11, 2002. This report will be released to the press at 10:30 am and presented to APHA attenders at 4:30 pm. The new report is expected to affirm the 1988 and 1996 Institute of Medicine reports on the "Future of Public Health". The 1996 report noted remarkable progress, major changes, managed care, new partnership, and the need for a study to
update the 1988 report.
Dr. Tilson oriented us on the co-chairs and members of the study committee for the 2002 report. Co-chair Jo Ivey Boufford was on Dr. Phil Lee's staff during the Clinton administration, and she brings a Federal perspective to the report. Co-chair Christine Cassel is a geriatrician who serves as president of the Oregon Health Sciences University, and she brings an organized medicine perspective to the report. Dr. Tilson described the rest of the panel with enthusiasm.
It is likely that the report will attempt to set out the "business case" for public health. This may occur by enhancing understanding about the core purposes, functions, and roles of public health in improving health outcomes. The report may crystallize knowledge about the conditions under which population-level improvements can occur, and may help outline a research agenda. The study will provide evidence-based recommendations for improving practice, and for building the capacity and workforce that will be needed.
The report may help to provide the context for more strategic funding decisions, in the context of a bioterrorist war.  The committee and its members met in Washington DC, Irvine CA, and other locations. Committee members visited Los Angeles, where the public healthcare system was supplanted by a private managed care system that has
now collapsed. They visited New Orleans, where the community ownership of clinics has been revitalized under the Turning Point initiative. They visited Baltimore, where African-American women are helping African-American
men to think constructively about their own and their families' health.  The committee will identify drivers of population health, and identify possible scenarios for which communities should be prepared. They will
identify the required infrastructure (related to the AGPALL concept from 1988) and the necessary community-wide systems (including the medical care system, the media, etc.) Goals, competencies, and system performance issues will be addressed.
(Dr. Tilson gave a mnemonic for the Ten Essential Services of public health: "My Day Is Made Pushing Everything Likely to Win Some Resources.") The report is likely to address workforce issues, including the eight
Core Competencies as seen by the Council on Linkages:

Analytic/Assessment Skills; Policy Development and Program Planning;
Communication;
Cultural Competency;
Community Dimensions of Practice;
Basic Public Health Sciences;
Financial Planning and Management; and
Leadership and Systems Thinking.

There is another new report, "Who Will Keep the Public Healthy?", on the future of schools of public health. As this report talks about required competencies, it may provide openings for AAPHP to stress the need for public
health physicians nationwide. The AAPHP may be needed in order to help determine the optimal allocation
of responsibilities among partners, to help determine appropriate staffing and funding formulas, to help advise on the minimum size that is necessary in order to support an efficient and effective infrastructure, to help advise on
the maximum size and distance that can still be considered "local", what is the optimal governance structure for state and local health departments, and what is the optimal governance structure for state-local relationships. To
the extent possible, these determinations must be evidence-based. Almost nothing can be included in an IOM report without evidence. The committee's report will put forth actionable recommendations outlining a visionary framework for assuring the public's health. The report will be broadly disseminated using a multi-layered communications strategy. As the primary responder, Dr. Weisbuch noted Hippocrates' emphasis on
environmental determinants of community health. He outlined the psychosocial, biological, and physical environments that determine health. The medical care system, however complex, is only a tiny subset of the
determinants of health. Dr. Weisbuch noted that public health physicians must interact successfully with the political system. This is sometimes laborious. Despite the obvious life-saving characteristics of automobile safety belts, it took thirty years to get half of Americans to use them.  Who will keep the public healthy? It had better be the PUBLIC who will keep the public healthy! This has an analogy in one-on-one medical care, where the model is that the practitioner and patient work together to meet the patient's needs within the constraints of the atient's culture and beliefs. Dr. Weisbuch hopes that the IOM report will help us to advocate for appropriate resources for our jobs.
Dr. Bradshaw inquired what must be done in order to assure that the report's recommendations are acted on responsibly in a resource-deprived environment, and what must be done to assure AAPHP representation on the
Council on Linkages. A member inquired about possible challenges to the public health physician role, based on the new IOM report. The report appears unlikely to provide direct ammunition for either advocates or opponents of the public health physician role. It is likely to identify competencies directly, allowing interested groups to make their own arguments about the relevance of medical training in Public Health. A more authoritative statement from IOM may have to wait for more definitive evidence.
The first afternoon session ended at 3:48 pm.

***

When we reconvened at 4:04 pm. Dr. Nitzkin introduced Robert (Bobby) Milstein, MPH, to discuss the concept of "Syndemics".
Mr. Milstein presented an analysis of conditions in London, one year after the removal of the Broad Street Pump handle. They hadn't improved much. Dramatic improvements would require social change, which came after
the Industrial Revolution.  Many people assume that the cause of each event will be near to the event
in time and space. That's not always the case.  Picture a community where conditions don't support healthy living; people are either afflicted by or at risk for mutually reinforcing health problems; community leaders try to fight the affliction and improve living conditions, but their capacity to do so is limited; and more could be done with backing from government and philanthropies. That could describe almost every community, not just those described as "poor", "underserved", etc.  The minimum boundary for public health thinking involves three
parameters: Health, Living Conditions, and the Capacity to Act. The latter is the hardest to understand, because it has the most layers. The starting assumptions of syndemics are that
(1) effective responses require system-wide interventions;
(2) most PH agencies target analysis and intervention to individual afflictions;
(3) this compartmentalized approach
is ingrained in financial structures, problem-solving frameworks, statistical models, and criteria for professional prestige. (Discussion suggested that many PH agencies have "swum upstream" to address individual risk factors such as tobacco, exercise, etc., and that bioterrorism response has required integration among large and VERY diverse agencies.)
Merrill Singer is doing social science work on substance abuse with NIDA funding. He recognized that violence, substance abuse, and AIDS are more than concurrent; they are linked and not completely separable. This has
primarily been published in the social science literature, e.g., Free Inquiry in Creative Sociology, 1996; 24(2): 99-110, and Social Science and Medicine 1994; 39(7): 931-948.
A "syndemic orientation" is defined as "a problem solving approach that assesses connections between health-related problems", considers those conditions when designing program, and aligns with other forces of social
change to assure the conditions in which people can be healthy.  The spectrum of prevention includes secondary and tertiary prevention, which focus on Healing Services to make a Biological Change in the Affliction. It also includes primary and secondary, which focuses on Disease Prevention to make a Behavioral Change to change Risk. It can include an Intergenerational approach that focuses on Health Promotion to make a Social Change to change Conditions That Affect Health. The time frame for Intergenerational approaches is decades or centuries. The WHO's Health Promotion Glossary defines Health; Living Conditions; etc. The WHO's Ottawa charter for health promotion (1986) includes peace, shelter, education, food, income, stable ecosystem, sustainable resources,
and social justice and equity as prerequisites for optimum health. These have been endorsed at all five world conferences of health promotion from 1986 to 2000.
How do we study the effect of comprehensive interventions on categorical outcomes? This is a difficult question. The interventions thought to be most "effective" have different characteristics from the most "evaluable" interventions.
Disease prevention seeks to prevent disease and injury. Health promotion seeks additional goals, which often assume that community conditions are immutable and basically OK. Public health seeks to produce conditions in which everyone can be healthy.  Affliction-specific specialization creates inefficiency, competition, coercive power dynamics, neglected feedback, confounded evaluations, and only a limited mandate to address living conditions and capacity.  Paul Weisner's essay, "Four diseases of disarray in Public Health" named, among others, Hardening of the categories; the Tension headache between treatment and prevention; Hypocommitment to training; Cultural incompetence; Political phobia; and Input obsession.  Conventional problem solving identifies diseases, determines causes, develops and tests interventions; implements change; and repeats the cycle in
a single community. Syndemic problem solving identifies communities; cooperates with community members in identifying afflictions and their relationships; examining living conditions and why they differ, devising system-wide policies; implementing them with communities; and spreads the method to other communities.
Under a syndemic orientation, the core functions are still Assessment, Policy Development, and Assurance. Under syndemics, the core functions are implemented with the help of Network Analysis, System Dynamics, and Social
Navigation. Model building, simulated experiments, and real world action and observation can help us in syndemic-related Policy Development. As we shift our examination from Events, to Patterns, to Structure, our analysis
increases sophistication and usefulness. However, it may be harder to communicate these concepts to other stakeholders, whose thinking may be much more concrete and short-term.  Syndemics postulates dynamic feedback among diseases, social conditions, and environmental conditions. Each of these influences the other, so they cannot be studied with a unidirectional model.  A preliminary dynamic hypothesis suggests the many interactions among
components of the system. Mr. Milstein is involved in the System Dynamics Society. He recommends game-based learning, because reality takes years to produce equivalent learning. A "Syndemic Flight Simulator" is at http://broadcast/florio/. Assurance, under syndemics, implements policies by aligning health with
other avenues of social change. It is driven by community leaders in partnership with health professionals. It uses a navigational perspective, guided by community vision and values. It has a forward orientation and
adapts to changing conditions.  NACCHO's MAPP program is brilliant in its use of navigational imagery.
Basic concepts in navigation include Position, Destination, Direction, and about ten others.
"Circular statistics" are the means of analyzing directional (movement) data.
Community benchmarks in Hawaii: http://leahi.kcc.hawaii.edu/org/pvs/malama/voyaginghome.html Nainoa Thompson asked children how they knew that the things they considered special about Hawaii would still be there in twenty years. After everyone understood the question, they realized that all is at risk unless the community identifies and protects what it needs.  Hawaii created SCR 12, which names ten indicators of a healthy natural
environment, etc. [Check slides; must sign in to Syndemics network to get access.] This is, by Hawaii state law, the set of standards against which all state policy initiatives will be judged. Active discussion followed. We adjourned this session at 6:01 pm.

***

We reconvened at 6:26 pm. We discussed the upcoming Federal guidelines for smallpox vaccination. There is significant skepticism about the prerequisites for a responsible vaccination program, and the consequences of
proceeding without careful consideration of all variables. A hasty program poses real, and preventable, danger to contacts and to the public. An unknown number of potential vaccinees and potential contacts have contraindications to vaccinia exposure. Which of the vaccinees and contacts need counseling (and maybe HIV testing) before you can safely offer vaccine to any particular individual?  There are no public data on the potential threat of a smallpox virus release. CSTE and AAP have recently issued strong statements against mass
vaccination. Because of dramatic increases in the prevalence of immunocompromise, it seems likely that the urrent estimate of 1.1 deaths per million doses of vaccine may be a substantial underestimate.  There will be a great need to educate community physicians. Only a minority of community physicians appear to be taking existing information seriously so far.
Despite the many unresolved questions, CDC is instructing states to begin the first phase of their vaccination programs as early as January 2003. Because non-bioterrorism Public Health funds are so lacking, it seems
unlikely that any state will openly defy CDC's instructions. Members discussed the options of (1) vaccinating a small initial cohort, then stopping, or (2) starting slowly, then methodically vaccinating a wider and wider circle of essential community service providers.  Our medical care and public health systems may be unprepared to address
the non-vaccine aspects of smallpox vaccination, such as isolation/quarantine and the control of secretion from coughs and sneezes. After discussion, there was consensus that AAPHP should advocate a very cautious approach to smallpox vaccination. Unless there is strong and specific evidence of an imminent attack, each step of a vaccination program should be planned so as to minimize the risk of complications to vaccinees and to their contacts.
We discussed an approach to establishing an Office of Public Health Science Implementation, or Public Health Program Implementation, within CDC. After discussion, we adjourned at approximately 7:50 pm.

Respectfully submitted,
Dave Cundiff, MD, MPH
Immediate Past President