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HomeMy WebLinkAbout2004-June File Copy • Jefferson County Board of Health Agenda • Minutes June 17, 2004 • • JEFFERSON COUNTY BOARD OF HEALTH Thursday,June 17,2004 2:30—4:30 PM Main Conference Room Jefferson Health and Human Services AGENDA I. Approval of Agenda II. Approval of Minutes of Meetings of May 20,2004 III. Public Comments IV. Old Business and Informational Items 1. Child Profile Landmark 2. Washington State Board of Health 2003 Annual Report V. New Business 40 1. Draft Solid Waste Ordinance—Call for Public Hearing July 15,2004 2. Adverse Childhood Events Study 3. 2004 Washington State Health Report 4. 2003 WIC (Special Supplemental Nutrition Program for Women,Infants, and Children)Annual Report 5. Public Health Priority Setting—Mandated Local Health Services VI. Activity Update VII. Agenda Planning VIII. Proposed Next Meeting: July 15,2004 Main Conference Room Jefferson Health and Human Services • A • JEFFERSON COUNTY BOARD OF HEALTH MINUTES Thursday, May 20, 2004 Board Members: Staff Members: Dan Titterness, Chairman-County Commissioner District#1 Jean Baldwin, Health&Human Services Director Glen Huntingford- County Commissioner District#2 Lary Fay,Environmental Health Director Patrick M Rodgers-County Commissioner District#3 Julia Danskin,Nursing Services Director Geoffny Masci-Port Townsend City Council Thomas Locke,MD, Health Officer Jill Buhler-Hospital Commissioner District#2 Sheila Westerman-Citizen at Large(City) Ex-officio Roberta Frissell, Vice Chairman-Citizen at Large(County) David Sullivan, PUD #1 Chairman Titterness called the meeting to order at 2:30 p.m. in the Health Department Conference Room. All Board and Staff members were present with the exception of Commissioner Huntingford. There was a quorum. APPROVAL OF AGENDA IIIMember Masci moved to approve the agenda as corrected adding under Old Business and Information Items the topic of Animal Control.Vice Chairman Frissell seconded the motion, which carried by a unanimous vote. APPROVAL OF MINUTES Member Masci moved to approve the minutes of April 15,2004.Vice Chairman Frissell seconded the motion,which carried by a unanimous vote. PUBLIC COMMENT Dale Wurtsmith of EnviroCheck, LLC was present to express his concern about the County competing with private industry on EES inspections. He mentioned the County's recent adoption of a$30 filing fee,which he and other companies would have to pass along to their customers in the form of a price increase. Because the County can do inspections at a lesser expense and would soon get more business than it can handle,he recommended the County either raise its fees to be more in line with the private industry or cease doing EES inspections. He noted there are currently four companies in the County licensed to do this work. The Board agreed to revisit this topic after Staff has an opportunity to provide information and make a recommendation.Mr.Wurtsmith asked that Staff notify him when this item is back on the Board's agenda. (This topic to be covered later under Fees.) • HEALTH BOARD MINUTES -May 20,2004 Page: 2 41111 OLD BUSINESS AND INFORMATIONAL ITEMS Cruise Ship Wastewater Discharge Pact Signed: Dr. Tom Locke reported that on April 20,2004 Governor Locke signed the memorandum of understanding to guide environmental practices of cruise ships sailing in Puget Sound. He understands this agreement meets or exceeds Alaska's standards,which are considered the toughest in the industry.Responding to the Board's question about the frequency of monitoring,he said the State Board of Health intends to address this topic after surveying those involved when the cruise season ends, around October. When asked by Member Buhler whether there is any opportunity for collaboration with Canada on this issue,Dr. Locke noted that Canada has regulations in place. If Washington wanted to regulate wastewater discharges by the cruise ship industry,there would need to be enabling federal legislation. Alaska's regulations are a combination of State and Federal laws. Member Westerman questioned how the agreement can go as the press release states,"beyond the very tough Alaska regulations"when it is voluntary and unenforceable? She believes now is the time to begin to get federal regulations in place. When asked by Member Masci if there might be legal grounds to pursue action against the Governor or State,Mr. Locke said this would be challenging in that neither is failing to perform any defined duty. Demonstrating harm from the landfall of cruise ship sewage is the challenge. He noted that when the voluntary regulation failed in Alaska,there was a case for federal legislation. Identifying failures is also difficult. Member Buhler commented that since Alaska has set the precedent, it should be easier for Washington State. Vice Chairman Frissell mentioned that while there was an unsuccessful legislative attempt to address this topic,the issue is expected to come up again. Dr. Locke said he believes that a previous attempt was in Skagit County and said that all coastal counties are concerned about this issue. Follow-Up April 15,2004 Board of Health-City Council Meeting: Member Masci reviewed that since last month's Joint meeting,the City Council had discussed the funding issue and are awaiting a formal request from the County Administrator. Commissioner Rogers said that Staff prepared a formal request on behalf of the Health Board. Member Masci felt that a formal request might also need to come from the Board of County Commissioners. When asked if the specific amount had been determined,Member Masci said the matrix presented at the joint meeting showed the City's utilization share to be somewhere between$130K and$146K,depending on the formula. West Nile Virus Surveillance: Dr. Locke noted the 2004 season has officially started and while there have not yet been reports of any human cases in the U.S.,the virus is expected to reach . Washington this year. After two years of preparedness,detailed response plans and communication • HEALTH BOARD MINUTES -May 20,2004 Page: 3 material are in place. In a few weeks,the County would begin accepting new specimens for bird surveillance. When asked about budgetary limitation on the number of birds that could be tested,Dr. Locke noted that two positive tests would confirm the official arrival of the virus. The availability of field-testing kits in Washington should aid abatement efforts in situations where there might be severe human impact. Animal Control: Member Masci read a communication from City Clerk Pam Kolacy asking that Environmental Health consider taking immediate action to find alternative housing for the seven additional dogs brought to the Jefferson County Animal Services(JCAS) as a result of recent enforcement action against a county resident. The animals are taking up over half of the available kennels and threaten premature euthanization of other dogs. Member Masci suggested Environmental Health Staff work with the Friends of the Shelter on a solution, including a possible fundraising campaign to purchase additional freestanding kennels. Larry Fay then responded to Board questions about solving the problem, such as seeking space in Clallam County's kennel. Charging the accused for kennel fees was suggested,but putting a lien on the property in the hopes of recovering costs was not believed to be an option. Staff is kenneling dogs together when possible and continues to work with a network of foster families and dog placement organizations. Dogs that are available for adoption should be kept on-site rather than in foster care. He would need to inquire whether dogs are being euthanized as a result of this situation. • NEW BUSINESS Introduction: Interim Environmental Health Director: Larry Fay announced that he has accepted a position with Seattle/King County and that Dave Christensen of the County's Department of Natural Resources has agreed to act as Interim Director of Environmental Health until a replacement can be found. Hopefully by July, the County would be on its way to hiring a new director. Volunteers are being sought from the Board for the interview committee. This discussion item was added to the end of the meeting. Clandestine Drug Lab Ordinance—Adoption Hearing: Larry Fay reported that the draft ordinance has been further revised to include the Board of Health changes from the February meeting. Staff is recommending approval of the ordinance as presented. Public Comment: None. Based on a question by Member Masci,Larry Fay confirmed that violations of the ordinance would be enforceable and that Deputy Prosecutor Alvarez, in reviewing the document, found it to be accurate based on the Board's recommendations in February. • Member Masci moved to accept the Ordinance relating to the public health hazards arising from real properties and structures contaminated by illegal drug manufacturing or storage HEALTH BOARD MINUTES-May 20, 2004 Page: 4 • and establishing procedures for minimizing the public risk arising from such contaminated properties and structures.Vice Chairman Frissell seconded the motion,which carried by a unanimous vote. Draft Solid Waste Ordinance—Pre-Adoption and Call for Public Hearing on June 17,2004: Larry Fay reviewed that in 2003 the Department of Ecology adopted new regulations governing solid waste handling practices. Those regulations require health departments to update their regulations to be in compliance with the new rule. The draft,based on the Clallam County regulations,has been under review by the County Solid Waste Advisory Committee and a subcommittee of the Board of Health(Member Westerman and Commissioner Huntingford)with assistance by Melinda Bower. Member Masci moved to accept the Draft Solid Waste regulations with the typographical and grammatical changes submitted by the Board and recorded by Melinda Bower, as well as the following substantive changes,subject to review by Deputy Prosecutor Alvarez.Vice Chairman Frissell seconded the motion,which carried by a unanimous vote. Page 5, definition of Person: Explore legality of defining individual as a`person"and all the others in the list(corporation,company,association, society, firm,partnership,joint stock company, etc) as"entities." Page 7,the last sentence in 6.1 would also be added to 6.2. Page 8,under(a) include title definition after references to Washington Administrative Code • (WAC). Page 10, 8.3.2 the second sentence should read, "Permit shall extend from February 1 through January 31."And again on Page 11—8.6.2,include the term of the permit rather than when it ends. Page 13,delete everything after"...produce records for inspections."Under, 10.2 explore with Deputy Prosecutor whether definition could be added for"pervasively regulated industry." Page 15, investigate language used in Clallam County ordinance to see if they list both Health Officer and Hearing Officer and consider listing"Hearing Officer"in the definitions section—"Health Officer would act as the Hearing Officer or can appoint the Hearing Officer...." The Board confirmed that the document would be redrafted and submitted for legal review. The final draft would be brought back to the Board of Health for the scheduling of an adoption hearing. Public Health Emergency Preparedness and Response Update: Dr. Locke reviewed that planning has been ongoing for the past year. From this point forward,planning would become more intensive and would involve other agencies to a greater degree. In a review of the drills and simulations that would be occurring during the remainder of this year,Dr.Locke pointed out that the emergency preparedness plans are limited disclosure documents. He invited individual Board members to read the plans. • HEALTH BOARD MINUTES -May 20,2004 Page: 5 Using a written matrix of focus areas and deliverables, Response Coordinator Lisa McKenzie provided a few examples of what preparedness and planning work has been done and would be done in the near future on a local and regional basis. She commented that this planning process has helped linkages with other agencies. In talking about possibilities for mounting large clinics, she mentioned Kitsap County has established a pilot medical reserve corps project,which might spill over to Clallam and Jefferson Counties. Dr. Locke noted that we are now preparing for a major training exercise in March 2005. Fees Discussion: Regarding the public comment given earlier in the meeting by Dale Wurtsmith, the Board felt it would be helpful to understand the basis of the County's fees and when they are set, as well as what Clallam charges. Mr. Fay suggested that Linda Atkins be present for the discussion of whether or not the County should be in the business of EES inspections. It was mentioned that the policy issue is whether or not the County charges enough to pay for the service. There was Board support for holding a discussion of this and other fees in July. Interim Environmental Health Director—Interview and Orientation Committee: Jean Baldwin solicited volunteers to sit on the interview committee and to help with orientation. Those who agreed to help were Chairman Titterness,Member Masci, and Vice Chairman Frissell.Member Masci suggested Member Buhler be involved during the orientation phase. • Member Masci recognized Larry Fay's significant contribution to Environmental Health during his tenure.Larry Fay expressed that he has enjoyed working in Jefferson County for 14 years. Cake and an appropriate goodbye is scheduled from 12-2:00 tomorrow. ACTIVITY UPDATE/OTHER ANNOUNCEMENTS—None AGENDA PLANNING/ADJOURN The meeting adjourned at 4:30 p.m. The next meeting will be held on Thursday, June 17,2004 at 2:30 p.m. in the Conference Room of the Jefferson County Health Department. JEFFERSON COUNTY BOARD OF HEALTH Dan Titterness,Chairman Jill Buhler,Member Roberta Frissell,Vice Chairman Sheila Westerman,Member (Excused Absence) Geoffrey Masci,Member Glen Huntingford,Member • Patrick M. Rodgers, Member • Board of Health Old Business Agenda Item # IV., 1 • Child Profile Landmark June 17, 2004 • CHILD Profile landmark • This week, CHILD Profile Health Promotion completes its statewide six- year expansion effort by sending well-child checkup and immunization reminders to parents of children turning six years old. Expansion of the program materials initiated in July 1998 and parents of newborns began receiving reminders to schedule well-child checkups and immunizations. Now, six years later, families of all of Washington's children birth to six years are receiving the materials; 17 age- specific mailings are sent to parents. The materials also provide information and resources on growth, health, development, safety, nutrition, school readiness, and other parenting issues. Parent satisfaction surveys have shown parents read the materials and find them useful. In the last survey, 30 percent of parents indicated the information helped them to change their thinking or behavior. All of the CHILD Profile staff would like to say thanks to local health for your ongoing involvement in developing and revising the materials and support for CHILD Profile, in general. This milestone is great progress in achieving the vision that CHILD Profile be a statewide mechanism for getting information and resources to parents and supporting immunization work. Public Health - Always Working For a Safer and Healthier Washington Please note my name change. . . Janna Bardi, MPH • CHILD Profile Manager Washington State Department of Health PO Box 47880 Olympia, WA 98504-7880 phone: 360-236-3554 FAX: 360-586-7868 email: janna.bardi@doh.wa.gov • • Board of Health Old Business Agenda Item # IV., 2 • WA State BOH 2003 Annual Report June 17, 2004 • — if iiiiiii fi ill ¢¢ 3 � a tilky ; jib i=3 i 111111 qiil 1 1 1 ki d q 11111111,1111111111,J. Jill it,i till li'lll 1 I 1 1 '1111111 ,lip IJIIIIIIii it it 1 �• � s,$,,iiikplii464141 AiliWI ` taw` s I"" � @am ��.� °.. .i-- '� i "�` � ? *fit" '' �-, ,-,,,,..*rit 7,,,,/,k ; -, a ; - 3t� a. m _ ice° E �� , x n,i'F '"' .fid s .tl' as �, r � e eot • � i ,, - ' } a sz 4t ii ,Ari - � 3 � kr y y* rQ %E'j`ify t t s�. CD, 3 �� s ¢ s �� fir, __ may r �.�•+a. �" .- u�" � ��.�; � ��2F5 a� a s, w ' S= s f1:4 ,` n \ `SYS `r F £ �, 4...-;:,-;.„,,'.. r'' '' �. 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C Q Oz .s � LL C' 1�1." w_ �k * " HIA7,A " s :� YB+ T' z iK k ?� ym tai, f�} 9 5. • • • Board of Health New Business Agenda Item # V., 2 • Adverse Childhood Events Study June 17, 2004 i Domestic Violence 0, Sexual Assault Program Confidential and Caring P.O.Box 743,Port Townsend,WA 98368 Phone:385-5291 (24 hour) May 13, 2004 Jean Baldwin, Director I 2004 Jefferson County Health&Human Services 615 Sheridan Street Jefferson County Port Townsend, WA 98368 Health&Human Services Dear Jean: Quen Zorah's presentation today on the Nurse Family Partnership was much appreciated by the VIPST group. The Adverse Childhood Events Study certainly confirms what we in the field have known all along. It is extremely helpful to have this data available in such a credible way. • We applaud you for your agency's proactive response to the county's adverse childhood events data and the positive outcomes you are experiencing. Quen did an excellent job of presenting the material. Her hands-on experiences added to the discussion as questions were asked. Please pass our special thanks to Quen and to your other Public Health Nurses who work in this extremely valuable program. Sincerely, Peggy Thompson Chair, VIPST and Executive Director of DV/SA Program a r 5 u • • 2003 Family Policy Council Network Partners' Summit Red Lion Silverdale Hotel Silverdale, Washington Adverse Childhood Experience & Adult Medical Conditions Vincent Felitd, M.D. November 17, 8:30-9:30 am .POLICY. n 0 iC . The Relationship of Adverse Childhood Experiences to Adult Health: Turning gold into lead The question of what determines adult health and well-being is important to all countries. The Adverse Childhood Experiences(ACE)Study'is a major American research project that poses the question of whether,and how,childhood experiences affect adult health decades later. This question is being answered with the ongoing collaboration of Robert Anda,MD at the Centers for Disease Control(CDC)and the cooperation of 17,421 adults at Kaiser Permanente's Department of Preventive Medicine in San Diego,California. Kaiser Permanente is a multispecialty,prepaid, private health insurance system or Health Maintenance Organization[HMO].The findings from the ACE Study provide a remarkable insight into how we become what we are as individuals and as a nation.They are important medically,socially,and economically2.Indeed,they have given us reason to reconsider the very structure of primary care medical practice in America. The ACE Study reveals a powerful relationship between our emotional experiences as children and our physical and mental health as adults,as well as the major causes of adult mortality in the United States. It documents the conversion of traumatic emotional experiences in childhood into organic disease later in life. How does this happen,this reverse alchemy,turning the gold of a newborn infant into the lead of a depressed,diseased adult? The Study makes it clear that time does not heal some of the adverse experiences we found so common in the childhoods of a large population of middle-aged,middle class Americans. One does not'just get over'some things,not even fifty years latera. The Adverse Childhood Experiences Study is an outgrowth of observations we made in the • mid 1980s in an obesity program that had a high dropout rate. The first of many unexpected discoveries was that the majority of the dropouts actually were successfully losing weight. Accidentally and to our surprise,we learned from detailed life interviews of 286 such individuals that childhood sexual abuse was remarkably common and,if present,always antedated the onset of their obesity.No one previously had sought this kind of medical information from them but many patients spoke of their conscious awareness of an association between abuse and obesity. Some told of instances where they had brought up their history of abuse only to have the information rejected by a physician as being in the distant past and hence of no relevance to current problems. The counterintuitive aspect was that,for many people,obesity was not their problem;it was their protective solution to problems that previously had never been acknowledged to anyone. An early insight was the remark of a woman who was raped at age twenty-three and gained 105 pounds in the year subsequent"Overweight is overlooked and that's the way I need to be." The contrast was striking between this statement and her desire to lose weight. Similarly,two men who were guards at the State Penitentiary became anxious after each losing over one hundred pounds. They said that they felt much safer going to work looking larger than life rather than normal size. In general,we found the simultaneous presence of strong opposing forces to be common in our obese patients. Many were driving with one foot on the brakes and one on the gas,wanting to lose weight but fearful of the change in social and sexual expectations that would be brought about by major weight loss. • Vincent J.Felitti,MI) 2 German ACE article Researchers at the Centers for Disease Control(CDC)recognized the importance of these clinical observations and helped design a large,epidemiologically sound study that would provide definitive proof of our findings and of their significance. The Adverse Childhood Experiences Study was carried out in Kaiser Permanente's Department of Preventive Medicine in San Diego. This was an ideal setting because for many years we had carried out detailed biomedical,psychological,and social(biopsychosocial)evaluations of over 58,000 adult Kaiser Health Plan members a year. Moreover,the patients were from a typical middle class American population. We asked 26,000 consecutive adults coming through the Department if they would be interested in helping us understand how childhood events might affect adult health status. Seventy-one percent agreed. We asked these volunteers to help us study eight categories of childhood abuse and household dysfunction. The abuse categories were:recurrent physical abuse,recurrent severe emotional abuse,and contact sexual abuse. The five categories of household dysfunction were:growing up in a household where someone was in prison;where the mother was treated violently;with an alcoholic or.a drug user;where someone was chra tic ally depressed,mentally ill,or suicidal;and where at least one biological parent was lost to the patient during childhood— regardless of cause. An individual exposed to none of the categories had an ACE Score of 0; an individual exposed to any four had an ACE Score of 4,etc. In addition,a prospective arm of the Study is following the cohort for at least 5 years to compare distant childhood experiences against current Emergency Department use,doctor office visits,medication costs, hospitalization,and death. Dr.Anda,my co-principal investigator atCDC with great skill the massive-data management and retrospective and prospective components of the Study. Because the average • participant was 57 years old,we actually were measuring the effect of childhood experiences on adult health status a half-century later. The full text of our initial report is at http://www.meddevel.com/site.mash?left—/library.exe&rn1=4&na2=1&right=/library.exe&action =search form&search.mode=sirnple&site=AJPM&jcode=AMEPRE Our two most important findings are that these adverse childhood experiences: • are vastly more common than recognized or acknowledged and • have a powerful relation to adult health a half-century later. This combination makes them important to the nation's health and to medical practice. Slightlymore than half of our middle-class population of Kaiser members experienced one or more of the categories of adverse childhood experience that we studied. One in four were exposedto twocategories of adverse experience;-one-in-16 were exposed to four categories. Given an exposure to one category,there is 80%likel'hood of exposure to another category. Of course,all this is well shielded by social taboos against seeking or obtaining this kind of information. Furthermore,one may miss the forest for the trees if one studies the categories individually. They do not occur in isolation;for instance,a child does not grow up with an alcoholic parent or with domestic violence in an otherwise supportive and well-functioning household. The question to ask is:How will these childhood experiences play out decades later in a doctor's office? To study that,we will categorize outcomes into organic disease and emotional disorder. • Vincent I Felitti,MD _ 3 German ACE agile-: • Organic disease: We shall first look at the relationship of adverse childhood experiences to smoking4. Smoking underlies some of the most important causes of death in America;there has been a strong public health effort to eradicate smoking in California. In spite of initial success in significantly reducing the number of smokers,there has been no further net decrease in recent years although the efforts against smoking have continued. Because of this,smoking in the face of California's strong social pressures against it is often attributed to `addiction'. The usual concept of tobacco addiction implies that it is attributable to characteristics that are intrinsic within the molecular structure of nicotine. However,we found that the higher the ACE Score,the greater the likelihood of current smoking. In other words,current smoking is strongly related in a progressive dose-response manner to what happened decades ago in childhood. Finding`addiction' attributable to characteristics that are intrinsic in early life experiences challenges the conventional concept of addiction. The psychoactive benefits of nicotine are well established in the medical literature although they are little remembered. Are smoking and its related diseases the result of self-treatment of concealed problems that occurred in childhood? ACE Score vs. Smoking 20 18 5 16 D 14 CO 12 10 ® • x.0 ® U • d 4 U U • ■ " II U U ■ 0 1 o 2 3 4-3 6 or more ACE Score Chronic obstructive pulmonary disease(COPD)also has a strong relationship to the ACE Score,as does the early onset of regular smoking. A person with an ACE Score of 4 is 260% more likely to have COPD than is a person with an ACE Score of 0. This relationship has the same graded,dose-response effect that is present for all the associations we found. Moreover, all the relationships presented here have a p value of.001 or stronger. ACE Score vs. COPD 20 18 ACE Score: 14 tt 12 � e. $ $ • 6 II III 0 ,.rraa.,..►re coro by.g.u • Vincent J.Fella',MD 4 German ACE article When we compared hepatitis in ACE Score 0 patients with hepatitis in ACE Score 4Pa tients, 111 there was a 240%increase in prevalence. A progressive dose response effect was present with every increase in the ACE Score. Similarly,with regard to sexually transmitted disease, comparison of the adjusted odds ratio for sexually transmitted disease in these same two groups showed a 250%increase at ACE Score 4 compared to ACE Score 0. In the United States,intravenous drug use is a major public health problem with which little progress has been made. It is widely recognized as a cause of several life-threatening diseases. We found that the relationship of iv drug use to adverse childhood experiences is powerful and graded at every step;it provides a perfect dose-response curve. ACE Score vs.Intravenous Drug Use 3S ga 3 ' 023 0 le 1301111.11111.1111.111r ■ 1 ■ ■ ■ 0Si -q - ;• 0 1 2 3 4 or more • In Epidemiology,these results are almost unique in their magnitude. For example,a male child with an ACE Score of 6 has a 4,600%increase in the likelihood of later becoming an iv drug user when compared to a male child with an ACE Score of 0. Since no one injects heroin to get endocarditis or AIDS,why is it used? Might heroin be used for the relief of profound anguish dating back to childhood experiences? Might its psychoactive effects be the best coping device that an individual can find? Is intravenous drug use properly viewed as a personal solution to problems that are well concealed by social niceties and taboo? If so,is intravenous drug use a public health problem or a personal solution? Is it both? How often are public health problems personal solutions? Is drug abuse self-destructive or is it a desperate attempt at self-healing,albeit while accepting a significant future risk? This is an important point because primary prevention is far more difficult than anticipated. Is this because non-recognition of the benefits of health risk behaviors leads them to be viewed as irrational and as solely having damaging consequences? Does this major oversight leave us speaking in platitudes instead of understanding the causal basis of some of our intractable public health problems? Emotional disorders: When we looked at purely emotional outcomes lie self-defined current depression or self- reported suicide attempts,we find equally powerful effects. For instance,we found that an • Vincent J.Felitti,MD 5 Getmaa.ACE_attic* individual with an ACE Score of 4 or more was 460%more hely to be suffering from depression than an individual with an ACE Score of 0. Should one doubt the reliability of this,we found that there was a 1,220%increase in attempted suicide between these two groups. At higher ACE Scores,the prevalence of attempted suicide increases 30-5lfold (3,000-5,100%)! Our article describing this staggering effect was published in a recent issue of the Journal of the American Medical Associations. Overall,using the technique of population attributable risk,we found that between two-thirds and 80%of all attempted suicides could be attributed to adverse childhood experiences. ACE Score vs.Attempted Suicide 0 25 al 20 g Em 15 a 1 5 R I 1 0 l 2 3 4 ACE Score • In addition to these examples,we fo and many other measures of adult health have a strong, graded relationship to what happened in childhood:heart disease,fractures,diabetes,obesity, unintended pregnancy/sexually transmitted diseases7,and alcoholism were more frequent. Occupational health and job performance worsened progressively as the ACE Score increased. Some of these results are yet to be published,as is all the data from the prospective arm of the Study that will relate adverse childhood experiences to medical care costs,disease, and death a half-century later. Clearly,we have shown that adverse childhood experiences are co have an effect that often lasts for a lifetime. They destructive,and They are the most important determinant of the health and well-being of our nation. Unfortunately,these problems are painful to recognize and difficult to deal with. Most physicians would far rather deal with traditional organic disease. Certainly,it is easier to do so,but that approach also leads to troubling treatment failures and the frustration of expensive diagnostic quandaries where everything but nothing is ruled in. is ruled out Our usual approach to many adult chronic diseases reminds one of the relationship of smoke to fire. For a person unfamiliar with fires,it would initially be tempting to treat the smoke because that is the most visible aspect of the problem. Fortunately,fire long ago to distinguish cause from effect;else,they would departments learned to their work. What we have learned in the ACE Study 'fans rather than water hoses represents the underlyingfire in medical practice where we often treat symptoms rather than underlying causes. • Vincent J.Felitti,MD 6 German ACE article we found in the ACE Stud • y the treatment implications of what are far-reaching,the prevention aspects are positively daunting. The very nature of the material is such as to make one uncomfortable. Why would one want to leave the relative comfort of traditional organic disease and enter this area of threatening uncertainty that none of us has been trained to deal with? And yet,literally as I am writing these words,I am interrupted to consult on a 70-year- old woman who is diabetic and hypertensive. The initial description given to me left out the fact that she is morbidly obese(one doesn't go out of one's way to identify what one can't handle). Review of her chart shows her to be chronically depressed,never married,and, because we routinely ask the question of 58,000 adults a year,to have been raped by her older brother six decades ago when she was ten. That brother molested her sister who is said also to be leading a troubled life. We found that 22%of our Kaiser members were sexually abused as children. How does that affect a person later in life? How does it show up in the doctor's office? What does it mean that sexual abuse is never spoken of? Most of us initially are uncomfortable about obtaining or using such information;therefore we find it useful routinely to pose such questions to all patients by questionnaire.`Our Yes response rates are quite high as the ACE Study indicates. We then ask patients acknowledging such experience,"How did that affect"ect you later in lifer This question is easy to ask and is neither judgmental nor threatening to hear. It works well and you should remember to use it. It typically provides profoundly important information, and does so concisely. It often gives one a clear idea where to go with treatment. What then is this woman's diagnosis? Is she just another hypertensive,diabetic old woman or is there more to the practice of medicine? Here is the way we conceptualized her problems: • Childhood sexual abuse Chronic depression Morbid obesity Diabetes mellitus Hypertension Hyperllipidea Coronary artery disease Macular degeneration Psoriasis This is not a comfortable diagnostic formulation because it points out that our attention is typically focused on tertiary consequences,far downstream. It reveals that the primary issues are well protected by social convention and taboo. It points out that we physicians have limited ourselves to the smallest part of the problem,that part where we are comfortable as mere prescribers of medication. Which diagnostic choice shall we make? Who shall make it? And,if not now,when? Vincent J.Felitti,MD 7 German ACE article • Board of Health New Business Agenda Item # V., 3 111 2004 Washington State Health Report June 17, 2004 • • y ` 13 as j ` r y, � �lr "`mob`• g ..k, 1 ^. e •,e :jai" « .F r --,<40 4"- , s 2/ � Yom- b+x .,. 1, . �. kr i .- a F Ka Y' a 5,1� 4s- t Washington State Board of fleaith ° r. -, t Governor's Subcabinet on -lealth „ # *P4',1.7,.: py _,._ ..._.:_; 1889 T STATg :iii' 4 GARY LOCKE a>':ii: t I Governor , STATE OF WASHINGTON OFFICE OF THE GOVERNOR P.O. Box 40002 • Olympia, Washington 98504-0002 • (360)753-6780 • www.governor.wa.gov March 25,2004 Washington State Board of Health and Governor's Subcabinet on Health P.O.Box 47990 Olympia,WA 98504-7990 Ladies and Gentlemen: I am pleased to return the 2004 Washington State Health Report to you with my approval. Every January in an even-numbered year,the state Board of Health is required by RCW 43.20.50(1)(b)to prepare a report outlining health priorities for the ensuing biennium. It further mandates that I approve,modify,or disapprove this document. Your report clearly articulates key challenges in making Washington safer and healthier for all residents. It suggests seven strategic directions for state health policy,all of which echo my Priorities of Government goals: to maintain and improve the public health system;ensure fair access to critical health services; improve health outcomes and increase value; explore ways to reduce health disparities;improve nutrition and physical activity;reduce tobacco use;and,safeguard healthy air and healthy water. I appreciate your collaborative efforts to build upon the Priorities of Government process. I also commend the Washington Health Foundation for convening a broad array of community conversations to foster dialogue in these matters. The 2004 Washington State Health Report provides a superb foundation on which to build discussions for the next biennium. Thank you for your great work. Sinter y, g9(L ary Loc Governor • TA7�• • STATE OF WASHINGTON WASHINGTON STATE BOARD OF HEALTH 1102 SE Quince Street • PO Box 47990 Olympia, Washington 98504-7990 January 29,2004 The Honorable Gary Locke Governor of Washington Olympia,WA 98504 Dear Governor Locke: We are pleased to forward the proposed 2004 Washington State Health Report for your consideration. Since 1990,the Washington State Board of Health has been responsible for producing a biennial State Health Report"that outlines the health priorities of the ensuing biennium."RCW 43.20.50(1)(b)stipulates that the report be produced in January of even numbered years and that it serve as an aid to you in beginning the budget process.It further stipulates that it is up to you to determine whether to approve,modify,or disapprove the report.If approved,the report is to be used by state agency administrators as a guide for preparing agency budgets and executive request legislation—in this case,for the 2005-2007 biennium. • This is the seventh State Health Report and the second produced as a collaboration between the Board and the Governor's Subcabinet on Health.It draws on a wide variety of research and policy development efforts to suggest seven strategic directions for state health policy: > Maintain and improve the public health system > Ensure fair access to critical health services > Improve health outcomes and increase value > Explore ways to reduce health disparities > Improve nutrition and increase physical activity > Reduce tobacco use > Safeguard healthy air and healthy water These strategic directions are just that—they are not intended to be all-encompassing or restrictive.The report contains a summary of why each strategic direction is included,a"for instance"that describes one example of an initiative deserving further consideration,and a list of possible actions that illustrate the scope of the strategic direction.It does not attempt to enumerate action strategies for the 2005-07 biennium.The Board and the Subcabinet concur that decisions about specific health programs should be made by agency heads coordinating efforts through the Subcabinet. The Board and Subcabinet recognize the significant challenges facing public health,health care,and the delivery of government services.In fact,this year's report includes a new section describing some of the fiscal realities facing state health planners.It is our hope that identifying a specific,limited set of strategic directions can inform agency actions and help the state make Washington a safer and healthier place for all residents. Sincerely, • • Pete Cut r,Chair Linda Lake,Chair Governor's Subcabinet on Health Washington State Board of Health The role of state governmentt in health care 110 State government's health responsibilities grow from our State Constitution's commitment to provide for the public health and welfare and care for our most vulnerable populations(Article XIII,Section 1),and to regu- late medicine and pharmacy(Article XX,Section 2).The Legislature has interpreted these duties to entail: Maintaining and Improving Public Health > Keeping records of births and deaths and monitoring illness and injury > Acting swiftly and effectively to control the spread of communicable diseases > Reducing preventable diseases and injuries > Protecting the safety of our food,water, and air > Safeguarding the health of vulnerable populations by assuring that residents have access to health services critical to their ability to lead healthy,independent,and productive lives > Preventing injury and disability within the workforce in the state Purchasing Health Services > Purchasing health services for dependent children,the poor,the disabled,the elderly,injured workers, prisoners and public employees > Ensuring that these public investments return the greatest possible value for our state's taxpayers by working constantly to contain the costs and improve the quality of these health services Regulating Health Facilities, Health Providers, and the Health Insurance Industry > Ensuring that health care professionals and health facilities meet minimum safety standards and encouraging them to strive for the highest level of quality 3 > Ensuring that health insurers remain solvent to meet their commitments to their policy holders and that the private insurance market operates fairly and equitably for our state's health insurance consumers State government must periodically re-examine these duties and strategically focus resources to improve the health of citizens,to respond to new health threats,to take advantage of new health discoveries,and to live within the ever-changing financial and social realities of our state and nation.For that reason,RCW 43.20.50(1)(b)makes the Washington State Board of Health responsible for producing a State Health Report "that outlines the health priorities of the ensuing biennium."The statute stipulates that the report be produced in January of even numbered years and serve as an aid to the governor and agency directors during the budget process.The 2004 report is a collaboration between the Board and representatives of the Governor's Subcabi- net on Health. See the Background section,page 14,for a description of the process that led to this report. • 2004 Washington State Health Report • Introduction Going into the 2003 legislative session,the State of Health Report, but that document focused on Washington faced one of the most serious fiscal emergency preparedness,particularly the ability to challenges in recent history—if the state attempted to respond to a bioterrorism event. The Board's own provide the same level of services that it had provided work,its conversations with local boards of health, in 2001-03 without raising taxes,it would face a and the naturally occurring communicable disease projected revenue shortfall for 2003-05 of roughly threats facing the state suggests the focus needs to $2.4 billion. be on the stability and capacity of the entire public health system. The crisis stimulated innovations in the state's budget- writing process and led to cutbacks in state programs, The other two goals under the Governor's health including health-related programs.Rather than simply priority relate to access to health care: (1)preserve distribute cuts across all state programs when prepar- health care coverage for the state's most vulnerable ing the 2003-05 biennium budget,Governor Gary and needy people; and(2)shore up the safety net to Locke asked his executive leadership to determine help those who will lose health insurance coverage in the state's core responsibilities—those things it must the coming period.These stopped short of the 2002 do and do well to serve the citizens of Washington. State Health Report strategic direction to"maintain They defined these responsibilities in terms of desired and improve access to critical health services." goals and results. Then they asked what it would cost to meet these goals and how spending could best be The final 2003-05 budget largely preserved public allocated to achieve the results desired.Ten priorities health funding,but in light of the bleak fiscal realities emerged from this Priorities of Government(POG) it actually reduced access to critical health services process. The Governor submitted a budget based on for some residents.The budget,for example,reduced these priorities that proposed no new general taxes. Basic Health Plan enrollment to 100,000 subscribers, removing 25,000 by attrition and repealing an increase Other recent events have also shaped this report—in to 175,000.For Medicaid,changes included scaling particular,a series of"Community Conversations" back the caseload by an estimated 25,000 enrollees, convened by the Washington Health Foundation reducing the adult dental program,and requiring (WHF).The terminologies associated with different premium shares of some recipients. activities can be confusing. The POG process produced ten priorities, each with different goals. As the 2004 legislative session approached,the 4 The Community RoundTables produced a prioritized governor again turned to the Priorities of Govern- list of ten values.The priorities and values,developed ment.He proposed a supplemental budget increase of by different players using different processes for $193 million.His request included supplemental different purposes,are not always consistent.This appropriations to improve access to care in rural report also considers other inputs,such as the Board areas,increase Medicaid reimbursements for labor of Health's priorities,legislative actions,local govern- and delivery care,and reduce or eliminate some ment feedback,and the best available science.To add planned Medicaid premium shares. value and further the discussion,it offers seven strategic directions that highlight commonalities and Fiscal and political pressures on state budget makers consistencies between the various disparate inputs. are unlikely to lessen dramatically in 2005.Accord- ingly,this report establishes a more modest and One of the ten POG priorities is"improve the health realistic State Health Report strategic direction of Washingtonians."That priority encompasses three related to access: Ensure fair access to critical goals,the first of which is also the first of this State health services. This change is consistent with the Health Report's strategic directions:Maintain and POG results and is prompted in part by the"Commu- improve the state's public health system. This is nity Conversations"process.Many participants in • similar to a strategic direction in the 2002 State these conversations discussed barriers to access as a 2004 Washington State Health Report • fundamental problem with the current system,and Finally,this report includes a new strategic direction. fairness emerged as an important underlying value. One of the Priorities of Government is"improving the Attendees at the October 2003 Health Leadership state's natural resources."Under that priority are Summit prioritized the values elicited during these goals related to healthy air and clean water.To the conversations.The resolution from the summit,which extent that environmental degradation is damaging to Governor Locke signed,put"assure fairness"at the human health,it becomes a human health issue.The top of the values list. final State Health Report strategic direction,accord- ingly,is:Safeguard healthy air and healthy water. The third State Health Report strategic direction is: Improve health outcomes and increase value. For each strategic direction,this report contains a The concept of value is a function of both the quality summary of why it is included,a"for instance"that of care and the cost of care. For purposes of this describes one example of an initiative deserving report,value applies specifically to the purchase of further consideration,and a list of possible actions health services by the state.This strategic direction that illustrate the scope of each of the strategic relates directly to the three values that followed directions. "assure fairness"in the summit resolution:(1)rede- sign the health system;(2)reallocate existing re- One downside of this structure is that it requires that sources; and(3)improve health system performance each initiative or possible action be placed under a and efficiency. particular strategic direction,when in fact many policies and programs affect more then one strategic The fourth State Health Report strategic direction is: direction.Readers are encouraged to keep in mind Explore strategies to reduce disproportionate the interrelatedness of the various strategic directions disease burdens. This strategic direction is consis- laid out in this report.For example: 110 tent with the value of ensuring fairness and with the Governor's focus on addressing the health needs of > Public health must be part of any solution the uninsured,the needy,and the most vulnerable. to access problems. > Increasing value in the health care system The fifth value that emerged from the Washington might free up resources and improve access. Health Foundation's process is to emphasize personal > Lack of insurance,the greatest barrier to responsibility for healthy living and prevention. access, lessens value by raising costs and Aligned with this value are the next two State Health contributing to poorer health outcomes. 5 Report strategic directions: Improve nutrition and ➢ Poor nutrition and physical activity also increase physical activity and Reduce tobacco drive costs and contribute to poorer outcomes, use.For the 2002 report,these two directions had reducing value. been combined into one,which read,"Encourage > Public health agencies convene efforts to responsible behavior to reduce tobacco use,improve improve nutrition and physical activity and nutrition,and increase physical activity."In this report lead efforts to reduce tobacco use. they are split to devote more space to discuss emerg- > Barriers to access contribute to health ing initiatives to address physical activity and nutrition. disparities, as do greater exposure to unhealthy Also,while the importance of individuals taking air and water and,in some communities, responsibility for correcting unhealthy behaviors tobacco use and poor nutrition and physical cannot be overstated,there are ways that current activity. practices and policies encourage unhealthy behaviors. > Targeting communities with disparities for We know,for example,that children who have access certain health conditions may be an effective to healthy foods in schools are more likely to eat a way to improve value. nutritious diet,and people who live near recreation • trails are more likely to be physically active. 2004 Washington State Health Report • Maintain and improve the public health system Summary As this report was being drafted, the nation was to the task,prepared for the global health threats of experiencing an early influenza season with an the 21st century?"It concluded,"Unfortunately,the unusual number of child deaths.People packed answer is no." emergencies rooms and clamored for immunizations. Though it was too early then to gauge the severity of Many experts and organizations have called for a the 2003-04 flu season,anxiety was widespread. more"robust"public health system in response to Media coverage conveyed something long known to possible bioterrorism threats.They note that public public health experts—we are overdue for the kind of health programs and activities needed to respond to flu pandemic that will overwhelm our health system. an attack—disease surveillance,laboratory testing, risk communication,vaccine distribution,public Public health agencies in Washington State were also education,environmental monitoring,and more—are dealing with several new and re-emerging diseases— the very programs public health uses quietly every a possible resurgence of sudden acute respiratory day to create a safer and healthier nation. syndrome (SARS)and new cases of hantavirus. They were anticipating the arrival of West Nile virus Washington State is regarded among public health as mosquito season approached. The need to react to professionals as having a high-performing network of public concerns about a case of bovine spongiform state,academic,and local public health agencies.The encephalopathy re-emphasized the importance of state,however,is part of the national infrastructure interagency cooperation. Some areas were also and shares both its strengths and its weaknesses. ipcontending with a tuberculosis outbreak among homeless people and increasing numbers of new HIV In 2000,the Department of Health asked 39 counties infections among men who have sex with men.All a series of questions based on the Draft Public Health while ramping up to better respond to health emer- Emergency Standards. "In general,"the Department gencies,including the threat of a possible attack using concluded,"Washington's local public health systems biological,chemical,or radiological weapons. are not adequately prepared for a major biological emergency."A tremendous amount of progress has Public health is being asked to face new and re- been made since;yet,there is much more to be done. 6 emerging diseases,antibiotic-resistant microbes,and When the Trust for America's Health issued a report bioterrorism—what Senator Edward Kennedy has on bioterrorism preparedness in December 2003, called the"Three Horsemen of the Modern Apoca- Washington met only six out of ten key indicators; lypse"—with too few resources.A November 2003 however,it was among only nine states to meet six or report prepared for the Centers for Disease Control seven,and no states met more than that. and Prevention(CDC)documents the challenges the nation must face before it can adequately respond to At an April 2003 meeting,the Board held a forum on a major SARS outbreak. It notes,"The current public health funding.Public health leaders and local shortage of epidemiologists,public health nurses,and elected officials told the Board that funding is Mad- other personnel in the U.S.will reach a crisis stage in equate and unreliable.The system,said one county the event of an epidemic.Budget cuts in state and commissioner,is crumbling.Port Orchard Mayor local health departments have further depleted the Leslie Weatherill,speaking of her local health district, human resources needed to deal with a public health wrote,"I find it disconcerting that we are demanding emergency,and if these positions are not restored an more from them and are not willing to fund the otherwise containable epidemic may spread quickly." numerous requirements." • In 2001,the Centers for Disease Control and Preven- Public opinion polls consistently show broad support tion(CDC)asked,"Is public health's infrastructure up for public health activities. 2004 Washington State Health Report • A 'For Instance' Other Possible Actions Community Assessments > Public Health Funding: In November 2001, Of Environmental Health the Board adopted Response Capacity During a Health Emergency—A Review of Selected Issues. The report made nine recommendations and most Public health departments rely on other agencies, concerned the need to increase the capacity of the organizations,and individuals to help identify and public health system by providing adequate govern- address health issues within their jurisdictions.They ment funding.At the state level,this would mean conduct community health assessments—broadly funding that is both secure and stable. There was participatory processes designed to systematically significant discussion of this issue during the 2003 collect health data,identify community beliefs about legislative session but no long-term,statewide health issues,and involve the community in solutions. resolution.The state cut by 2 percent the non- dedicated funding it has provided to local health since When the Board looked at assessment practices in the passage of Initiative 601.Meanwhile,many Washington State,it found that few community health financially strapped counties substantially cut their assessments include environmental health issues(e.g., funding for public health.Public health funding will on-site sewage and safe food and water). Few envi- be a critical issue during 2005-07 budget discussions. ronmental health programs have the capacity to do community assessments. They are largely fee-driven > Surge Capacity:A study conducted for the and typically their staffs are busy ensuring regulatory CDC,"Quarantine and Isolation:Lessons Learned compliance and responding to urgent problems. from SARS,"made it clear that efforts must continue • to improve"surge capacity"—the ability of state and There are,nonetheless,clear examples of"best local health agencies,laboratories,and health care practices"in environmental health assessment.For facilities to handle increased demand during a major example,Island County Health Department over the disease outbreaks like pandemic flu. years has invested local capacity development funds in assessment,community development,and policy > Isolation and Quarantine: In 2002,the Board development. It received a CDC grant to use the adopted rules that provide a basic legal and enforce- Protocol for Assessing Community Excellence in ment framework for isolation and quarantine.Those 7 Environmental Health to build its assessment capac- rule changes were prompted by concerns about a ity. These funds helped develop the infrastructure possible bioterrorism attack employing smallpox. that allows the department and the community to SARS, however, has renewed awareness that collaboratively develop environmental health indica- isolation and quarantine remain important public tors,collect data,analyze local issues,set community health tools in the modern era.The rule revision was priorities,and develop action plans. just the first step.Work on developing community- specific plans for carrying out isolation and quaran- Without adequate administrative funding and support tine will continue into 2005-07. for environmental health,local and state policy makers run the risk of making decisions that are > Public Health Workforce: During 2003, the based on a limited understanding of community health Public Health Improvement Partnership conducted a issues and are irrelevant to the people they serve.As survey to enumerate the public health workforce. the state looks to maintain and improve public health Results are expected in April 2004.Public health is capacity,it must keep in mind that communicable known to suffer from a shortage of trained workers in disease control is just one way public health keeps some areas(e.g.,epidemiology). The results of the Washington safe.It should promote best practices survey can guide training,recruitment and other • and assure capacity for planning and assessment workforce development efforts in 2005-07. across the system. 2004 Washington State Health Report • Ensure fair access to critical health services Summary Access to quality,affordable health care is a major sions with 15 local boards of health.At its meetings indicator of the health of any community's residents. across the state, it asked to hear from local leaders An Institute of Medicine (IOM)report, Crossing the about the state of public health and health care Quality Chasm, A New Health System for the 21st delivery in their communities.A consistent message Century(March 2002), states that as medical science was the need to increase access,particularly to and technology have advanced,the health care mental health,dental health,and preventive care. delivery system has lost ground in its efforts to provide consistent,quality care to all Americans. A major barrier to access is lack of affordable insurance that covers those preventive and primary In a February 2003 poll of Washington residents interventions most likely to improve Washington's conducted for the Washington Health Foundation, health.According to the Office of Financial Manage- only 42 percent rated the health care system in ment,9.4 percent of the state's non-elderly population Washington State as excellent or good; 52 percent lacked health insurance in 2002. There are several said it was only fair or poor.This was down from 51 subpopulations for which the uninsured rate is 14 percent who gave the system a good or excellent percent or higher-19-to 30-year-olds,members of rating in August 2002.Fifty percent said the system households making less than twice the federal poverty needed major changes or fundamental overhaul, level,people born in other countries,Hispanics and compared to 42 percent who said no new changes or American Indians/Alaska Natives. (The US Census only minor changes were necessary. Bureau,using a different methodology,puts the . nation's uninsured rate for 2002 at 15.2 percent,up During a statewide series of Community Round- from 14.6 percent in 2002,and Washington's at 14.2 Tables hosted by the Washington Health Foundation, percent).Uninsured adults are 30 percent less likely participants often mentioned the lack of consistent to have had a checkup in the last year and 40 percent access as a fundamental problem with the current more likely to have skipped a recommended treat- system.A key value that arose from those discussions ment or test than insured adults,according to the was the need to ensure fairness.A gathering of Kaiser Commission on Medicaid and the Uninsured. hundreds of health leaders and the public in October They are more likely to forgo preventive care,require 8 2003 ranked the values and placed fairness at the top. hospitalization for avoidable conditions,die during The emphasis on fairness was often linked to con- hospitalization,and be diagnosed with cancer during cems about inequities in access. late stages of the disease. The state's recent financial challenges have led to cutbacks in public coverage A 1997 statewide survey by the State Board of and strengthened the impetus to prioritize public Health asked respondents to name the most important investments in health. health area on which government should work.The greatest number,22 percent,said access to health Other factors that limit access to care in this state care. When asked about the seriousness of various include a variety of financial,structural,and personal health issues,the greatest number,79 percent,said barriers.In its conversations with local boards and state government should give access to health care a community leaders,the State Board of Health heard high or very high priority.During its 2001 review of testimony about residents who were having difficul- the literature,the Board found extensive support for ties obtaining timely care even with insurance,about making access a top priority.Key informants fre- provider shortages,the collapse of the health care quently mentioned access as one of the biggest issues delivery system(particularly but not exclusively in facing the state. rural areas),a shortage of mental health programs, and non-English speakers having difficulty obtaining el During 2003,the State Board of Health held discus- access because of the lack of interpretive services. 2004 Washington State Health Report • A 'For Instance' Other Possible Actions Ensure Access to a Core > School Health: The Office of Superintendent Set of Essential Services of Public Instruction has developed a five-year strategic plan, Preparing Washington Students for A discussion about access begs the question:Access the 21st Century. One goal is: "All schools,in to what?And when talk turns to fairness,a second partnership with students,families,and communities, question arises:What is fair?Does fairness require provide safe,civil,healthy,and engaging environ- universal access to all services, or assurances that ments."To further that goal,OSPI is developing a everyone have access to a set of core services plan for"addressing physical,social,and emotional necessary to basic health?Analysts and policy barriers to learning and living healthfully."School makers often debate whether to shorten the line or nurses,student health screenings,school-based thin the soup.An alternative is to determine a recipe clinics,specific health management plans,and clear that includes those ingredients necessary to provide a standards for tending ill children attending school—all healthy meal—and then ensure there is no line. can contribute to improving access to care for children.OSPI's strategy for"learning and living Government's role,in partnership with individuals, healthfully"is not due until 2007,but its ongoing nonprofit organizations,businesses and communities, collaboration with the Board,the Departments of would be to promote universal access to core Health and the Department of Social and Health services.First priority would go to public health Services may suggest strategies for 2005-07. services to prevent health problems before people • require expensive"sick care,"and to personal > Targeted Interventions: One strategy for medical services known to improve the health of the addressing access is to focus currently available community,such as anti-smoking policies,substance resources on increasing the delivery of specific and abuse treatment programs,prenatal care, measurable health services known to promote immunizations,early childhood health screenings and community health.An example would be to concen- other interventions with proven community benefit. trate on increasing the percentage of Washington children who receive their fourth combined immuni- There is broad agreement on which clinical zation for diphtheria,pertussis,and tetanus(DPT). preventive services should be offered,particularly to 9 children.The Board,for example,has developed a > Healthy Aging Plan:Washington State is aging list of recommended"Clinical Preventive Services for even faster than the rest of the nation.An older Children."Assuring that children receive access to population brings with it specific public health,social, proven clinical preventive services should be a high and medical needs,such as mobility problems and a priority for state government,with a focus on greater need for disease management programs,that removing barriers to access.Projects should focus on should be addressed at the community and state level. improving information systems,promoting better clinical practices,working with state and private > Public Health Improvement Partnership: plans to encourage better service delivery,targeting The PHIP should continue to implement standards delivery rates for specific interventions,and pursuing encouraging local health jurisdictions and the Depart- a range of incentives(including financial incentives ment of Health to measure access to critical health for parents).Public benefit plans should explore ways services and mobilize community efforts to close to use the Board's evidence-based"Menu of Critical gaps. Many examples of successful strategies for Health Services"as a starting point for restructuring improving access can be found at the local level.The fmancing for other medical services. state can support these efforts by promoting best practices and ensuring public health has the capacity • to convene community-based efforts. 2004 Washington State Health Report • Improve health outcomes and increase value Summary Americans spent nearly 15 percent of the gross and purchasing and by improving patient safety and national product on health care in 2002,according to overall quality of care. the federal government.Health care,not housing,is now the biggest purchase most of us will make in our Three of the top four values that emerged from the lifetime.According to the World Health Organization, Washington Health Foundation's Community however,the United States ranks first among nearly Conversations speak to this nexus of cost-efficiency 200 member nations in per capita health care and quality:(1)redesign the health system;(2) expenditures but 24th in years of healthy life reallocate existing resources;and(3)improve health expectancy.We spent as a nation$1.55 trillion a year system performance and efficiency. The strong on health care in 2002,a 9.3 percent increase over relationship between these values and the lead value, the previous year's total,but are we buying the right assure fairness,should also be noted;redesigning the things,are receiving what we pay for, and are we system to improve performance and efficiency could getting top quality? allow resources to be reallocated to pay for universal access to a set of core health services. It is not always best to buy the cheapest product. We commonly consider quality when purchasing a car, In 1999,the 50 states spent$238.5 billion on personal yet rarely factor quality into medical purchasing.The health care,27.1 percent of state spending. In Institute of Medicine Report To Err Is Human: Washington State,roughly a third of state Building a Safer Health System found that medical expenditures from the general fund and other state • mistakes cause 44,000 to 98,000 deaths each year— accounts goes to health-related expenditures.If one more than HIV/AIDS, breast cancer, or vehicle includes federal funds appropriated by the state for accidents. These medical mistakes are largely programs such as Medical Assistance,the percent of attributable to poorly integrated services,poor all appropriations that go to provide health insurance, information services,and other types of system direct care,and public health programs is 43 percent. errors. The report estimated the annual costs of preventable errors at$17 billion to$27 billion.A Medical Assistance,the Basic Health Plan,and other follow-up report, Crossing the Quality Chasm, state programs insure more than 20 percent of 10 called for an overhaul of health care to increase Washington residents—roughly 1.3 million of the quality and safety. state's 6 million people.The Public Employee Benefits Board covers approximately 300,000 state Government is the primary funder of health care in employees,retirees,and their dependents(almost 5 the United States,according to the Employee Benefit percent).The Medical Assistance Administration Research Institute and other sources.A major share covers more than 900,000 people(16 percent).The of government health expenditures comes from state Basic Health Plan will cover another 100,000 people funds and federal funds administered by states.It is in January 2004.Other state programs provide health not surprising,therefore,that health care is care services directly(for example,the Department considered the most critical cost driver for state of Corrections provides health care for inmates). government. Health care costs in Washington have been growing As a major purchaser of health care services, at a rate six times inflation.About one-sixth of the Washington State is committed to obtaining value— increase in health care spending from 2001 to 2002 is and it defines value as quality divided by price.Cost- tied to prescription drug costs.Other factors include: containment is only one piece of the health care increased utilization,rising consumer demand, purchasing puzzle.The state recognizes that it can medical advances that provide treatments for more 0 improve value by improving efficiency in contracting conditions,and wage pressures. 2004 Washington State Health Report III A 'For Instance' Other Possible Actions Implement Interagency Process > Substance Abuse Services: One recent for Technology Assessment DSHS study found that when some people received treatment for chemical dependency,they required New medical technologies are being deployed faster $252 less per month in public support than those who than practitioners and policy makers can assess their did not,yet Washington only has treatment slots for efficacy and effectiveness. The state Agency Medi- one in four adults who need such care. Some 1,000 cal Directors Group(AMDG)went through an patients languish on waiting lists. extensive process in 2001 to identify key areas of work where interagency coordination could result in > Preferred Drug List: HCA is developing an increased value in government purchasing.Its third- evidence-based list of preferred drugs based on highest priority was to start doing more evidence- efficacy,cost,likelihood of compliance,and based health technology assessments.Technology,in outcomes.The list will need to be expanded to this instance,refers to surgeries and other proce- include additional drug classes and be reevaluated dures,medical devices,equipment,tests,and experi- continually as new drugs and new research emerge. mental or unapproved("off-label")uses for drugs. > Electronic Recordkeeping: Electronic During the 2003 session,the Legislature approved a medical records can reduce errors by providing bill,ESHB 1299,that charged the Health Care accurate and timely records and increasing the Authority(HCA)with developing and disseminating likelihood that records will travel with the patient. • across state agencies a common process for evaluat- Electronic systems can notify patients who are due ing health technologies.It also called for common for preventive care. They can also contribute to methods for monitoring indicators related to health administrative simplification,contain costs,reduce care quality,making decisions about what to cover, provider burdens,and improve service. and implementing disease state management and management of consumer demand.AMDG has > Demand Improvement: Improve quality by developed an implementation plan that calls for all encouraging consumer choices that improve out- work to be completed by January 2005. comes and reduce costs—often by addressing the overuse,misuse,or underuse of procedures or drugs. 11 ESHB 1299,however,really speaks to developing formal assessment processes that can be shared > Disease State Management: Coordinate across agencies.Actually conducting technology efforts to provide systematic,cost-effective care to assessments using those common processes will people with complex and sometimes progressive require ongoing work.New technologies will emerge disorders,particularly chronic conditions. that will require assessments,and new evidence will emerge that requires reassessment of existing > Track Key Health Outcomes: Try to reduce technologies.HCA and AMDG are scheduled to adverse events and medication errors by identifying present a progress report to the Governor's Subcabi- specific,measurable patient-centered outcomes to net on Health. One of the major issues to be dis- track quality of care and better inform consumers. cussed at that time will be the potential need for new resources in 2005-07 and beyond. III 2004 Washington State Health Report • Explore ways to reduce health disparities Summary The term health disparities describes a dispropor- Disparities affecting people of color were observed tionate burden of disease,disability,and death among for 18 of 24 disease conditions reported in the 1996 a population or group.It encompasses both inequities Health of Washington State. Nationally, health in health status(whether a person or group is in good disparities have been observed for asthma,many health)and in health care. Health care disparities types of cancer, diabetes, heart disease HIV/AIDS, include inequities in having access to care,seeking or low immunization rates,infant mortality,inactivity, being provided with care,and receiving quality care. injuries,mental health issues,obesity,oral health,and tobacco use,and other conditions. Healthy People 2010, the federal strategic health plan,identifies two major goals for improving the Many complex factors interact to produce health nation's health in the next decade—and one is to disparities.Those believed to contribute include reduce health disparities(the other is to increase poverty,housing,behavior and lifestyle,health know- quality and years of healthy life).In December 2003, ledge,nutrition,environment,access to care,genetic the Agency for Healthcare Research and Quality predisposition,education,and employment.Specific released the National Healthcare Disparities findings with policy implications include: Report. It identifies disparities in health care for ➢ The Board's 2001 report demonstrated the "priority populations"—women,children,elderly, connection between disparities in health care people of color,low-income groups,and people with and the diversity of the health care workforce. It special health care needs. For example,people of made several recommendations designed to . lower socioeconomic status and African Americans increase the number of people of color preparing are more likely to die of cancer. for health care careers. ➢ Public Health—Seattle&King County In Washington State, the Board's 2001 Final Report found that for people of color,racism or the on Health Disparities examined the impact of perception of racism in health care settings disparities on communities of color.People of color affects the quality of care received. (those identifying themselves as Hispanic and/or a > Research indicates a provider's lack of member of a race other than white)make up more "cultural awareness"can contribute to biases, 12 than 21 percent of Washington's population.Yet their stereotyping,mistrust of the medical system, share of disease burden is significantly higher than miscommunication and treatment refusal. their proportion of the population.For instance: > The infant mortality rate for American The federal government is focusing on eliminating Indians and African Americans is more than inequities for specific conditions.Healthy People double the rate for Caucasians. 2010 calls for achieving parity in cancer screening > African Americans are more than three and management,cardiovascular disease,diabetes, times as likely as Caucasians to die from HIV/ HIV/AIDS,immunizations,and infant mortality AIDS,while Hispanics are more than 1.5 times across racial,ethnic,gender,and socioeconomic more likely to die from the virus. groups. > The rate of tuberculosis for Asians is more than 15 times greater than it is for Caucasians. The recent cuts in public subsidies for medical care > African Americans are more than three disproportionately affect minorities and potentially times as likely to die from diabetes as could worsen disparities. Caucasians; the death rate for American Indians/Alaska Natives is 2.5 times higher and Key informants interviewed by the Board in 2001 • for Hispanics it is 1.5 times higher. overwhelmingly supported its work on health disparities and said such work should continue. 2004 Washington State Health Report • A 'For Instance' Other Possible Actions Enhance Quality of Care In > Workforce Development: The Board's 2001 Areas Where inequities Occur health disparities report described how improving diversity in the health care workforce can reduce Efforts to address health disparities can target disparities.The Institute of Medicine is due to release specific populations if those populations can be a report and recommendations on workforce diversity identified and communicated in a culturally appropri- in 2004.IOM's recommendations could help shape ate manner.Examples include providing housing to efforts of health professions educational institutions to people with no regular home,or targeting health produce a workforce that reflects the state's growing professions recruitment at schools with a high propor- diversity. The state must ensure that efforts to tion of students of color.Data on race and ethnicity is improve diversity remain at the forefront of attempts often unavailable,however,and reaching specific to address shortages in the health care workforce. communities effectively can be difficult.A comple- mentary approach is to focus quality improvement > Social Determinants: Social factors such as efforts on areas where inequities are found. income,housing and education inequities may under- lie many racial and ethnic disparities.A supplement to A case in point is diabetes care.People of African the 2002 Health of Washington State due in 2004 descent are far more likely to have limbs amputated will focus on race,ethnicity,income,and education.It as a result of diabetes complications than people of may suggest new approaches to reducing disparities. European descent.Washington's Diabetes Collabora- tive is an example of a public/private partnership > Indian Health Care: Support implementation of focused on bringing about across-the-board quality Working Together to Build a Healthy Future: The improvement in the clinical management of a disease 2003 Indian Health Care Delivery Plan, which the that has a disproportionate impact on communities of American Indian Health Commission and the Depart- color.Another example is a state effort to increase ment of Health released in 2003. the proportion of children who receive their fourth combined immunization for diphtheria,pertussis and > Racial/Ethnic Data Collection: Encourage the tetanus.Children are a"priority population"and collection and analysis of racial and ethnic health data children of color have lower immunization rates.Also, to allow for better identification of disparities and 13 the Health Care Authority is building quality improve- more effective design of strategies to eliminate them. ment programs into contracts with health insurance plans, and encourages efforts in areas where dispari- > Interpreter Services: Language barriers ties exist(e.g.,cardiovascular disease). discourage people from seeking care and contribute tomedicalerrors. The state should consider ways to Often these approaches can be combined. Reach increase the availability of medical interpreters. 2010,a federally funded community coalition adminis- tered by Public Health—Seattle&King County, > Cultural Competency: Work with provider promotes diabetes self-care,personal and community groups,health care facilities,health professional awareness,and community support. It targets out- schools,and health care and public health organiza- reach efforts to individuals and communities of color. tions to ensure the health care workforce has the skills needed to work with diverse populations. Effective programs to improve overall access to and quality of health care can be an important component > State Policy Agenda: Analysts at Brandeis of Washington's effort to reduce health disparities. University and Harvard are drafting"A State Policy State agencies should look to involve local communi- Agenda to Eliminate Racial and Ethnic Health ties in identifyingprograms and seeking solutions. Disparities,"which will suggest model state policies. 2004 Washington State Health Report • Improve nutrition and increase physical activity Summary The behaviors most damaging to our health,after > Obesity rates have doubled over the last tobacco consumption,are the interrelated behaviors decade of insufficient physical activity and poor diet and > More than half of all state residents are nutrition.A study of"Actual Causes of Death in the obese or overweight United States"in 1990,published in the Nov. 10, 1993 > Rates of chronic disease and disabling Journal of the American Medical Association, conditions associated with poor diet and lack of found that tobacco accounted for 400,000 out of exercise are escalating steadily roughly 2 million deaths that year.Diet and activity > Medical costs related to obesity are patterns accounted for another 300,000.Combined, straining the state's ability to provide affordable they explained about a quarter of all deaths.No other access to care cause accounted for more than 5 percent. > The percent of the population over 65 years Deaths related to poor diet and too little exercise may of age is increasing faster in Washington than in soon surpass those related to tobacco, according to many other states. (An older population is more the Centers for Disease Control and Prevention. likely to experience higher levels of obesity.) Unfortunately,this prediction is based largely on In addition,73 percent of Washington adults do not increases in the number premature deaths from poor engage in moderate physical activity(at least 30 nutrition,overweight and obesity,and lack of activity, minutes daily on five or more days per week during rather than on a decrease in tobacco consumption.A leisure time),according to data from the 2000 illfederal report, America's Children: Key National Behavioral Risk Factors Surveillance System.Only Indicators of Well Being 2003, noted that, 16.6 percent engage in"vigorous"physical activity. compared to 20 years ago,twice as many of the nation's children are obese or overweight. On average,higher body weight is associated with higher death rates.In children it can lead to diabetes, Surgeon General Richard H. Carmona recently put a national price tag on obesity and being overweight— heart disease, sleep apnea, depression and low self- $117 billion a year in increased medical costs and lost esteem. The incidence of type 2 diabetes mellitus in children has risen tenfold in the past 20 years.In 14 productivity. Healthy People 2010, the federal Washington,diabetes has consistently been the sixth government's strategic plan for health improvement, lists"physical activity"and"overweight and obesity" or seventh leading cause of death during the 1990s. as its top two health indicators. During that time,the percentage of all deaths resulting from it has risen slowly.Physical activity Most state and national health trends are moving in reduces the risk of type 2 diabetes,heart disease, the right direction.One of the few exceptions is colon cancer and high blood pressure. obesity.Americans are getting fatter.According to Even before the current epidemic,Washingtonians data from the National Health and Nutrition were concerned about the lack of activity and the Examination Survey,the prevalence of obesity in number of people obese or overweight. The children ages six to 11 quadrupled in the last quarter respondents to the Board's 1997 public opinion century. For adolescents,the prevalence more than survey listed"lack of exercise and poor eating doubled. habits"second only to drug and alcohol misuse as the most serious health issue facing the state. Obesity The Washington State Nutrition & Physical Activity Plan: Policy and Environmental was one of the items mentioned most often in the key 40 Approaches,lists the following indicators that informant interviews conducted by the Board in 2001. Washington is facing an epidemic: Local health assessments have also identified obesity as an important issue. 2004 Washington State Health Report • A 'For Instance' Other Possible Actions implement State Physical > School Fitness and Nutrition: Since 2000, Activity and Nutrition Plan Washington State has required Essential Academic Learning Requirements for health and fitness. In June 2003,the state Department of Health and its Classroom-based assessments now being developed partners released the Washington State Nutrition & will provide a common basis for determining whether Physical Activity Plan: Policy and Environmental a student has the skills necessary to maintain an Approaches. Thirty-five people—from state and active and healthy life.An example would be under- local agencies,academia,and advocacy organiza- standing the relationship between dietary intake and tions—engaged in a year of strategic planning to help energy expenditure through exercise.Assessments slow the epidemic of obesity,reduce chronic disease are slated for voluntary use during the 2005-06 school rates,and improve the quality of life in Washington. year.Washington law requires schools to dedicate a specific amount of class time for health and fitness, The plan's goals are very specific—increase the but that requirement is not always honored.It may be number of state residents whose lifestyles reflect the beneficial to schools and students to explore out- Dietary Guidelines for Americans and who get 30 come-based measures for school health and fitness minutes of moderate activity at least five days a instruction,rather than measuring"seat time,"then week.It also notes the correlation between obesity in allow local flexibility about how to achieve those children and issues of hunger and food security. outcomes.Also,the Office of Superintendent of Public Instruction recognizes it has an important role . The plan puts forth several objectives and recom- in combating the epidemic of obese,overweight,and mends ways to achieve them. Under the physical out-of-shape children. OSPI has partnered with the activity goal,the objectives are: Washington State Actions for Healthy Kids commit- > Increase the number of people who have tee to develop a model physical activity and nutrition access to free or low-cost recreational policy.The Board,OSPI,DOH,the University of opportunities for physical activity Washington and others are working to identify and > Increase the number of physical activities promote best practices in schools policies.They have available to children launched a Web site (www.healthyschoolswa.org) > Increase the number of active community and the Board is hosting community forums with local 15 school boards and boards of health.Disseminating, environments. deploying,and evaluating model policies and best Under the nutrition goal,the objectives are: practices will be important ongoing work in 2005-07. > Access to health-promoting foods > Nontraditional Partnerships:The causes of > Reduce hunger and food insecurity nutrition and physical activity problems are systemic. > Increase the proportion of mothers who They require creative and collaborative solutions. breastfeed their infants and toddlers Health agencies need to partner with businesses, nonprofits,and government agencies not typically Implementation will require sustained collaboration associated with health promotion.An example of a between state and local agencies,communities,and a public/private partnership is the School Board Chal- host of organizations.DOH will provide leadership lenge issued public health and education associations and work with partners to assess progress. More- with funding from Stonyfield Farms.An example of over,several of the specific recommendations in the nontraditional partnerships is working with the state report will require state government to make choices Department of Transportation to develop transporta- and take action—for example,by providing adequate tion systems that encourage walking,bicycling and • funding for recreation sites and facilities. _otherr healthy forms of transportation. 2004 Washington State Health Report • Reduce tobacco use Summary A 'For Instance' Tobacco is the leading cause of preventable,prema- Continue to Implement the ture death,accounting for approximately 440,000 Prevention and Control Plan deaths in the United States each year—or 20 percent of the 2 million deaths that occur each year.Deaths In December 1999,the Washington State attributable to tobacco use include 90 percent of all Department of Health published A Tobacco deaths from lung disease and lung cancer,45 percent Prevention and Control Plan, a blueprint for of all heart disease deaths in people younger than 65, preventing kids from starting to smoke,helping a third of all cancer deaths,nearly one in five stroke smokers quit,reducing secondhand smoke,and deaths,and one in ten newborn deaths.In Washington reducing tobacco consumption by high-risk groups. State,the death toll is greater than 8,000 people a Implementation began in 2000 with an initial year.The cost in avoidable medical expenses is more investment of$100 million from the$4.5 billion in than$1 billion. tobacco settlement funds the state is scheduled to receive over 25 years. The budget for 2002-2003 After"physical activity"and"overweight and obe- was$29.3 million and included money from taxes on sity,"Healthy People 2010, the U.S. government's tobacco sales,fees paid by tobacco retailers, federal strategic plan for health improvement,lists tobacco funds,and a foundation grant.The majority of the use as its top health indicator.Reducing tobacco use money went to local programs. is the top priority of the state Department of Health. The program has contributed to an 8 percent decline . When asked to rate the seriousness of various health in adult smokers,representing 83,000 fewer smokers. issues in the Board's 1997 public opinion survey, The estimated number of children who start smoking respondents listed"tobacco use and secondhand each day has declined from 65 to 55 and the smoke"third(tied with"sexually transmitted dis- percentage of the state's youth who smoke is down eases"). Local community health assessments have significantly for all age groups.The number of sixth also identified tobacco use and obesity as important graders who had smoked in the last 30 days,for issues,and members of local boards of health reduc- example,dropped by more than half between 1999 ing secondhand smoke as an important issue in and 2002. 16 conversations with members of the State Board of Health. This long-term strategic plan should continue to guide state efforts to reduce tobacco use during 2005-2007. The 2002 Behavioral Risk Factor Surveillance System Future work will include:decreasing workplace and (BRFSS),which reports statewide prevalence of risk in-home exposure to secondhand smoke;reducing factors,reports that 21.5 percent of Washington's tobacco use by high-risk groups;increasing the total population currently smokes.This compares to a number of smokers who successfully quit; national prevalence rate of 23.1 percent. Tobacco use counteracting the impact of tobacco ads that target has been declining steadily,but not at a pace that young adults would allow the nation to reach its 2010 objective of 12 percent. In 2002-03,Washington raised current dollars to cover state spending by selling the rights to future Public opinion polls show increasing support in tobacco settlement funds. It is important that tobacco Washington(60 percent or higher on a county-by- settlement funds continue to be dedicated to tobacco county basis)for tighter restrictions on smoking in prevention and control programs during 2005-07.It is public places,which would reduce exposure to also important that the plan be revisited occasionally secondhand smoke. as scientific information,the legal environment,and social expectations change. 2004 Washington State Health Report Safeguard healthy water and healthy air • Summary A 'For Instance' The Priorities of Government exercise identified Continue to Reduce Persistent several goals that relate to human health but do not Bioaccumulative Toxins appear under the health priority.The goals for "improve the state's natural resources,"for example, In December 2000,the Department of Ecology include increasing the number of days with healthy air published its Proposed Strategy to Continually and improving the cleanliness of the state's surface Reduce Persistent Bioaccumulative Toxins (PBTs) waters.Environmental protection efforts conducted in Washington State. PBTs are elements and by the Department of Ecology and other agencies do chemical compounds that are toxic to humans and more than protect natural ecosystems, create recre- animals,and include metals,pesticides,organic ational opportunities,and improve the quality of life. chemicals,and by-products of fossil fuel combustion. To the degree that polluted air and water(and They linger for decades or centuries and accumulate contaminated food)have an adverse impact on in the food chain. Many are released into the human health,these efforts improve the health of the environment through human activity.They can people of Washington State. damage nervous and reproductive systems in humans and animals,cause developmental and learning Toxic air pollutants can lead to birth defects,cancer problems in children,and interfere with the organ and other forms of illness.Millions of pounds of toxic development in fetuses.The PBT plan lays out a pollutants enter Washington's air each year,primarily long-term strategy for identifying,prioritizing and from diesel exhaust fumes,gasoline vapors,and wood reducing PBT threats in Washington. • smoke.The Puget Sound Clean Air Agency estimates 700 cancer cases a year in Washington are Ecology,working closely with the Department of attributable to airborne toxins.Small airborne par- Health,has established mercury reduction as the top ticks,particularly those less than 2.5 microns across, priority under the PBT strategy,and in 2003 contribute to asthma,sudden infant death syndrome, developed a Mercury Chemical Action Plan that heart disease, lung disease, and cancer. The Harvard seeks to eliminate human use and release of mercury Six Cities study followed 8,000 people for 17 years in the state and minimize human exposure to the and found a 26 percent increase in death rates for mercury that exists.It calls for metal separators in people living in areas with elevated levels of particu- dental offices,for example,and safe disposal of 17 lates.Examples of environmental efforts that benefit products that contain mercury,such as fluorescent health include Ecology's program to keep diesel buses lamps,thermostats,and thermometers. from idling outside schools and the Legislature's decision to fund retrofits for diesel school buses. Many elements of the mercury plan are underway and will be completed by the 2005=07 biennium.But Contaminants are also found in our water.Some,like the Legislature chose not to fund full implementation mercury,persist in the environment for many years of the plan.That means Ecology will not be able to and accumulate in the food supply.They are associ- implement many elements of the plan until 2005-07 at ated with nervous and reproductive system problems, the earliest.Moreover,the mercury plan is just the learning difficulties,and developmental damage. first of several toxin-specific plans that will emerge as part of the PBT strategy. Environmental issues,and their connection to cancer and other illnesses,were frequently mentioned during According to the December 2000 proposed strategy, key informant interviews conducted by the Board in it will take about 20 years"to move our society 2001.During 2003,they arose during the Community beyond and away from our most toxic polluting RoundTables across the state and in discussions activities." 411 between the Board and local boards,of health. 2004 Washington State Health Report • • Background and methodology The Washington State Constitution stipulates that rank the top ten values that emerged from the state government will provide for public health and Community RoundTables.Most summit participants welfare. It requires the establishment of a State then signed a resolution acknowledging those values Board of Health to help lead this effort. and pledging to work for health care improvement in ways that reflect citizen principles and values. Since 1989,the Washington State Board of Health has submitted a state health report each biennium. The statute that established the State Health Report RCW 43.20.50(1)(b)mandates that the report be also requires the Board to consider input from the produced in January of even numbered years so it directors of state health care agencies. This report can aid the Governor at the beginning of the budget was developed in collaboration with the Governor's process by suggesting health priorities for the ensuing Subcabinet on Health,which includes most of those biennium.The statute further stipulates that the directors.Established in January 2001 by Executive Governor must approve,modify,or disapprove the Order 01-02,the Subcabinet is charged with develop- report. If approved,the report is to be used by state ing and coordinating state health care policy and agency administrators as a guide for preparing purchasing strategies,providing a forum for the agency budgets and executive request legislation—in exchange of information between agencies,and this case,for the 2005-2007 biennium. coordinating efforts to provide appropriate,available, cost-effective,quality health care and public health The statute defines the minimum process required. services to the citizens of the state. First,the Board is required to hold public forums every five years and consider public input gathered at The Board feels there are clear synergies and areas • those forums in the preparation of the report.The of complementary responsibilities between the Board Board last held public forums in 2000. and the Subcabinet.To be most effective,this report should align its strategic directions with the goals and The Board augmented these forums in 2001 by intent of the Subcabinet. interviewing 52 key informants,including agency heads,local public health leader,legislators,legislative Board staff members have also worked closely with staff,congressional staff,agency directors,gubema- the Washington State Health Agency Medical Direc- torial policy staff,directors of minority affairs corn- tors Group(AMDG),which supports the Subcabinet's missions,deans at public health and medical profes- work.AMDG enhances collaboration across agencies 18 sional schools,policy directors of professional and and seeks to"identify and assess new opportunities industry associations,and directors of health advo- for state agencies to increase quality,and to promote cacy organizations.Additionally the Board posted on cost effectiveness,access,and affordability in the its Web site a survey instrument based on the script state's medical care fmancing and delivery system." used for the key informant interviews.Twenty-three people completed the survey. The Board wrote letters requesting input to the three state agencies with health-related responsibilities that For this year's report,the Board was able to piggy- are mentioned in RCW 43.20.50(1)(b)but are not back on an extensive series of public forums con- represented on the Subcabinet—the departments of vened by the Washington Health Foundation.The Ecology and Agriculture and the Office of Superin- foundation conducted a public opinion survey and held tendent of Public Instruction.It received detailed and 44 Community RoundTable discussions(at least one thoughtful responses from Ecology and from the in every county),involving more than 1,200 people. Superintendent,and it has tried to incorporated that From these conversations it gleaned a list of common feedback into this report. values that shape people's opinions about health care. Another requirement of the statute is that the Board In October 2003,the foundation convened a Health ask for the assistance of local health jurisdictions.In Leadership Summit and asked some 300 attendees to past years, the Board has solicited assistance from 2004 Washington State Health Report • local health officials.Public health leaders were reports were lengthy(80-120 pages)and included a among the key informants interviewed in 2001,and fairly broad list of health priorities,extensive research for this report Board staff met with the membership findings,lists of priority study projects,examples of of the Washington State Association of Local Public recent successes,and comprehensive listings of Health Officials. action strategies for nine health-related agencies. The current format features a limited number of strategic The Board also did something new this time around: directions.This approach is consistent with RCW It embarked on a series of meetings with local boards 43.20.050(1)(b)since it provides agency heads with of health to improve communication,strengthen local an outline of state health priorities. boards,understand local concerns,and engage local policy makers in public health issues.Board mem- The strategic directions proposed in this report are not bers,accompanied by staff members,met with 15 all-inclusive,nor are they meant to be prescriptive. local Boards in 2003(the Board plans to continue State agencies provide numerous health-related meeting with approximately the same number each services that are not covered by these strategic subsequent year).At each meeting the Board directions,but are important and appropriate.Rather, members discussed this report and asked local board these strategic directions suggest areas of empha- members for their input.The comments received at sis—areas where state efforts to create new activi- those meetings are reflected in this report. ties or preserve existing activities are most likely to be effective. A final statutory requirement is that the Board consider the best data available from the Department Furthermore,this report does not recommended of Health.The department must submit to the Board specific action strategies for the 2005-07 biennium. • a list of high-priority study issues.The Board has The statute does not call for that level of detail and always relied heavily on the department's high-quality the Board and the Subcabinet concur that proposals reports,research and data,but it has always supple- for specific programs should be made by agency mented that information with other research.In 2001, heads coordinating their efforts through the Subcabi- Board staff reviewed more than 40 print and elec- net.For each strategic direction,this report contains a tronic documents,including federal and state govern- summary of why it is included,a"for instance"that ment reports,articles from scientific and medical describes one example of an initiative deserving journals,policy analyses published by foundations and further consideration,and a list of possible actions other nonprofit organizations,public opinion surveys, that illustrate the scope of each of the strategic 19 and local health assessments. Staff members pre- directions. pared a document called the"survey of surveys"that summarized the findings.The Board asked the University of Washington's Northwest Center for Public Health Practice (NWCPHP)to review the— document, he,_document,and the reviewers found it to be complete. The staff of the Board has continually updated this body of research to ensure it remains current,and they relied on this information when preparing this report.In addition,the Board requested and received information from the department about research documents published since the 2002 report and about high-priority study issues. This year's report retains many changes implemented • for the 2002 report.As notedin that document,prior - 2004 Washington State Health Report • About the Washington State Board of Health The State Board of Health serves the citizens of Washington by working to understand and prevent disease across the entire population.Established in 1889 by the State Constitution,the Board provides leadership by suggesting public health policies and actions,by regulating certain activities,and by providing a public forum. The governor appoints ten members who fill three-year terms. Board Members Consumers Linda Lake, M.B.A., Chair, has 25 years of Carl S. Osaki, R.S., M.S.P.H., former director of experience in the field of health and social services. environmental health for Public Health—Seattle& She has directed several community health and social King County,is on the faculty at the University of service organizations,including the Pike Market Washington. Medical Clinic,and currently directs the Tuberculosis Vickie Ybarra,R.N.,M.P.H.,is director of planning Clinic at Harborview Medical Center for Public and development for the Yakima Valley Farm Health—Seattle and King County. Workers Clinic.Much of her work is dedicated to supporting children and families. Vacant. Elected County Officials Local Health Officers Thomas H. Locke, M.D., M.P.H., Vice Chair, is The Honorable Carolyn Edmonds, a former health officer for Clallam and Jefferson counties.He III legislator,is a Metropolitan King County Council Member and chair of the King County Board of is a member of the Washington State Medical Health. Association's Interspecialty Council and is active in several Olympic Peninsula community coalitions seeking Elected City Officials improved access to high quality health care. The Honorable Dave Crump, Ph.D., a child psychologist,is a Liberty Lake City Council Member and member of the Spokane Health District Board. 20 Board Staff Department of Health Don Sloma, M.P.H., Executive Director Mary Selecky is secretary of the Washington Craig McLaughlin, M.J., Senior Health Policy Department of Health and former administrator of Manager Northeast Tri-County Health District. Marianne Seifert, M.A.,Health Policy Advisor Health and Sanitation Tara Wolff,M.P.H.,Health Policy Advisor Charles R.Chu,D.P.M.,a practicing podiatrist,is president of the Washington State Podiatry Desiree Day Robinson, Executive Assistant to the Independent Physician Association. Board Heather Boe,Assistant to the Board Ed Gray,M.D.,is health officer for the Northeast Tri-County Health District and chair of the Basic Health Plan Advisory Committee. • 2004 Washington State Health Report • 2004 Washington State Health Report The Washington State Board of Health and the Governor's Subcabinet on Health submitted this document to Governor Gary Locke, who approved it on March 25, 2004. • For additional copies or mom information Contact the Board staff or visit the Board's Web site: 1102 SE Quince Street PO Box 47990 Olympia,WA 98504-7990 Telephone: 360-236-4100 Fax: 360-236-4088 E-mail: wsboh@doh.wa.gov Web:www.sboh.wa.gov For persons with disabilities,this document is available on request in other formats. To submit a request,please call 360-236-4100. • • 3 • WASHINGTON STATE Board of Health ALWAYS WORKING FOR A SAFER AND HEALTHIER WASHINGTON 1102 SE Quince Street PO Box 47990 Olympia,WA 98504-7990 Telephone: 360-236-4100 Fax: 360-236-4088 E-mail:wsboh@doh.wa.gov Web: www.sboh.wa.gov Board of Health New Business Agenda Item # V., 4 • 2003 WIC Annual Report June 17, 2004 1 Jefferson County ilA/IC agencies and sites Jefferson County Health and Human Services Brinnon Chimacum Port Townsend Quilcene Quileute Tribe Forks Quinault Indian Nation Queets Statewide WIC Facts • WIC served 48.2%of all infants born in Washington state • WIC served 260,000 women and children WIC provides nutritious foods, nutrition education, referrals and breastfeeding information. • WIC contributed $94.5 million to local economies • WIC attracted families to preventive health services In 2003, more than 19,400 calls to the Healthy Mothers, Healthy Babies statewide referral line were from families calling for WIC.2 With this one call, they got help finding WIC and also received information about other preventive health services. • WIC was a gateway to health-related services Over 1.3 million times last year, WIC staff discussed these services with families and provided the information and support needed to access them successfully. • WIC breastfeeding rate reached 83.2%3 Breastfeeding support and education are key parts of WIC because breastfed children have fewer infections and are less likely to develop chronic conditions like obesity and diabetes later in life. 'Washington WIC Client Information Management System(CIMS),household income at or below 105%federal poverty level 'Healthy Mothers Healthy Babies Coalition of Washington State,Quarterly Report,4th Quarter 2003 "Mothers Survey,Ross Products Division,and Abbott Laboratories."©2003-Abbott Laboratories. •ItC ViSit 4l"WW.dod1.racy.govJcfli fas is ufhc re you'll find more information about Washington WIC, copy ofout Amnia' Report, sand t. tlnty-specific fact sheets. You can also call raHeal t 1.801)-8.11 t-110 arid press O, or write 1'0 box 47886, Olympia' A 98504-71i84i. For persons Nvit}1'disabilities, this dOCttInent is ;available on request in other formats. 0,-pa u;ll lt\ p Jefferson County ,w W i WIC Facts 2003IliaMirk r, r ., ollk 1111111111111111 Mil 11 ithi SPI# WIC serves wo infants born served by WIC Total women and children served 940 Infants and young children 653 59.3% Pregnant, breastfeeding, and postpartum women 287 WIC food dollar Diverse families contribution to 82.1% Caucasian local economy Hispanic 6.0% African American/Black 3.0% $316,843 Asian/Pacific Islander 1.8% Native American/American Indian 7.1% WIC foods purchased Working families • 19,620 gallons of milk Percent of WIC households with at least one working family member 65% 12,405 boxes of cereal 8,822 cartons of eggs Families living in poverty Percent of WIC households with income at or below the federal poverty level' 70% (less than $1,336 per month for a family of 3) Prenatal Care immunizations Family Planning Dental Quit Smoking WIC attracts families to preventive health services Over 5,417 times last year, WIC staff discussed health-related services with families and provided the information and support needed to access them successfully. \1\Jr. r> J riJ i J n \i\J J 4iifJpf)'lll)j ,ll JIMJIIg 1J?511:1) Lin a11a,llaill) Jr WJll1 e11i 11)1511)rji 511151 j!!11)J rt')1151fEe11" • Board of Health New Business Agenda Item # V., 5 • Public Health Priority Setting - Mandated Local Health Services June 17, 2004 • .45- cc ° Jefferson County Health and Human Services 40 615 Sheridan Street Port Townsend, WA 98368 \;)+,s - Tel 360-385-9400, Fax 360-385-9401 June 10, 2004 To: Jefferson County Board of Health From: Tom Locke, MD, MPH, Jefferson County Health Officer Re: Mandated Local Public Health Services Local public health jurisdictions across the state are facing a worsening budget crisis. Reduction or discontinuation of program services is being considered by boards of health of the smallest to the largest public health departments. Setting priorities for local public health services inevitably raises the question of which services are truly mandated and which services are not. The following policy paper discusses the issue of mandatory services in Washington State. The Laws: The services provided by a local health jurisdiction can be classified in three different categories: statutory mandates, contractual requirements, and discretionary local programs. With very few exceptions, mandates have been codified into state statute (RCW) or administrative codes (WAC). Statutory mandates should be of particular concern to local health officers and members of local boards of health. Specific penalties exist for failure to enforce the provisions of RCW 70.05 (Local Health Departments, Boards, Officers—Regulations), 70.24(Control of Sexually Transmitted Diseases), RCW 70.46 (Health Districts), or"any of the rules, regulations or orders of the state board of health". RCW 70.05.120 Violations --Remedies -- Penalties. (Effective July 1, 2004.) (1)Any local health officer or administrative officer appointed under RCW 70.05.040, if any, who shall refuse or neglect to obey or.enforce the provisions of chapters 70.05, 70.24, and 70.46 RCW or the rules, regulations or orders of the state board of health or who shall refuse or neglect to make prompt and accurate reports to the state board of health,may be removed as local health officer or administrative officer by the state board of health and shall not again be reappointed except with the consent of the state board of health. Any person may complain to the state board of health concerning the failure of the local health officer or administrative officer to carry out the laws or the rules and regulations concerning public health, and the state board of health shall, if a preliminary investigation so warrants, call a hearing to determine whether the local health • officer or administrative officer is guilty of the alleged acts. Such hearings shall be held pursuant to the provisions of chapter 34.05 RCW, and the rules and regulations of the state board of health adopted thereunder. (2) Any member of a local board of health who shall violate any of the provisions of chapters 70.05, 70.24, and 70.46 RCW or refuse or neglect to obey or enforce any of the rules, regulations or orders of the state board of health made for the prevention, suppression or control of any dangerous contagious or infectious disease or for the protection of the health of the people of this state, is guilty of a misdemeanor, and upon conviction shall be fined not less than ten dollars nor more than two hundred dollars. Financial responsibility for mandated public health services is succinctly addressed in Washington state statute: RCW 70.05.130 Expenses of state,health district, or county in enforcing health laws and rules - -Payment by county. All expenses incurred by the state,health district, or county in carrying out the provisions of chapters 70.05 and 70.46 RCW or any other public health law, or the rules of the department of health enacted under such laws, shall be paid by the county and such expenses shall constitute a claim against the general fund as provided in this section. Rules of the State Board of Health: Washington State's public health system is officially composed of three branches : 35 local health jurisdictions,the state Department of Health, and the State Board of Health(SBOH). RCW 43.20.050(2-4) delegates broad authority to the State Board to adopt regulations dealing with a variety of health issues. The State Department of Health has similar rule making authority that may be binding on local health jurisdiction. The rulemaking authority of the SBOH is defined as follows: RCW 43.20.050(2-4) (2) In order to protect public health, the state board of health shall: (a)Adopt rules necessary to assure safe and reliable public drinking water and to protect the public health. Such rules shall establish requirements regarding: (i) The design and construction of public water system facilities, including proper sizing of pipes and storage for the number and type of customers; (ii)Drinking water quality standards, monitoring requirements, and laboratory certification requirements; (iii)Public water system management and reporting requirements; (iv) Public water system planning and emergency response requirements; 2 . (v)Public water system operation and maintenance requirements; (vi) Water quality, reliability, and management of existing but inadequate public water systems; and (vii) Quality standards for the source or supply, or both source and supply, of water for bottled water plants. (b)Adopt rules and standards for prevention, control, and abatement of health hazards and nuisances related to the disposal of wastes, solid and liquid, including but not limited to sewage, garbage, refuse, and other environmental contaminants; adopt standards and procedures governing the design, construction, and operation of sewage, garbage, refuse and other solid waste collection, treatment, and disposal facilities; (c)Adopt rules controlling public health related to environmental conditions including but not limited to heating, lighting, ventilation, sanitary facilities, cleanliness and space in all types of public facilities including but not limited to food service establishments, schools, institutions, recreational facilities and transient accommodations and in places of work; (d)Adopt rules for the imposition and use of isolation and quarantine; • (e)Adopt rules for the prevention and control of infectious and noninfectious diseases, including food and vector borne illness, and rules governing the receipt and conveyance of remains of deceased persons, and such other sanitary matters as admit of and may best be controlled by universal rule; and (f)Adopt rules for accessing existing data bases for the purposes of performing health related research. (3)The state board may delegate any of its rule-adopting authority to the secretary and rescind such delegated authority. (4)All local boards of health, health authorities and officials, officers of state institutions,police officers, sheriffs, constables, and all other officers and employees of the state, or any county, city, or township thereof, shall enforce all rules adopted by the state board of health. In the event of failure or refusal on the part of any member of such boards or any other official or person mentioned in this section to so act, he shall be subject to a fine of not less than fifty dollars, upon first conviction, and not less than one hundred dollars upon second conviction. So What is Mandatory?: Specific statutory mandates for communicable disease • control (sexually transmitted diseases and tuberculosis) and the SBOH regulations 3 dealing with on-site sewage systems, food safety,public water systems, • communicable disease control,notifiable conditions, conduct endangering public health, school construction, and other codified regulations are"hard"mandates. Standards are very specific and failure to enforce them is relatively simple to identify. Responsibilities that arise from the rule making authority of local boards of health(RCW 70.05.060) comprise an additional level of mandates. Local regulations constitute a form of self-imposed mandate. Local codes must be as stringent as the state code, at a minimum. To the extent they are more stringent, they impose additional mandates on the local health jurisdiction. Other duties of local health officers (RCW 70.05.070) or local boards of health RCW 70.05.060) are less specific (e.g. RCW 70.05.060(5) "Provide for the prevention, control and abatement of nuisances detrimental to the public health"). Many regard these as a kind of"soft"mandate—a level of service to which the public is entitled and may initiate a civil lawsuit if some harm befalls them as the result of the absence of a particular public health service. The chance of prevailing in such a civil action is related to a legal determination of what constitutes a "reasonable" level of public health service. The actions of other local health jurisdictions become important in making a case for a reasonable level of service. If most local health jurisdictions provide a specific service,those that do not could be argued to fall below a reasonable standard. Civil actions of this type,while certainly possible, appear to be very rare. Summary: Most, if not all, of the core public health programs dealing with • communicable disease control, environmental health services, and response to public health emergencies are specific mandates under Washington state statutes. Services that are associated with a specific permit or license are not unfunded mandates—a mechanism for funding is provided in the authority of local boards of health to assess fees up to 100% of the cost of providing a service. Other public health services (e.g. tuberculosis control) do not have a fee-supported base. Prior to 1977 they were funded by a dedicated property tax millage. County governments are statutorily required to support these services if another source of funding (federal, state, or personal health insurance) cannot be found. Improving community health is far more complicated than just controlling communicable diseases and enforcing environmental health regulations. A fully functional local health jurisdiction should have a wide array of program services targeting high risk populations and seeking to prevent costly illnesses and injuries. If these are discretionary(non-mandatory)programs,they are at risk of ending up on the budgetary chopping block throughout Washington state. In contrast, failure to provide mandated services is grounds for dismissal for a health officer. For individual board of health members the remedy is different. Non-enforcement of state statutes or codes is a criminal violation punishable by a monetary fine. • 4 e GOL1I1�r A David Goldsmith pti 4‘ 1820 Jefferson Street R.1 ��gsorr coG PO Box 1220 OPort+� o Townsend, WA 9836 .—; 8 9`S.4t4?NG.S9 May 19, 2004 Dear Elected Officials and Department Heads: I have been out in the community speaking about our fiscal `train wreck' which will begin with the 2005 budget. And as you know Mr. Eyman's latest initiative is picking up steam. In my discussions with the Board we have talked about how to get a jump on these issues. I have enclosed two scenarios as a"heads up"for what is to come. Scenario 1: 2%growth in revenues. In this scenario,your 2004 budget has been increased by 2%, or your transfer from the General Fund has been increased by 2%. All increases in program costs, i.e. labor contracts, internal service charges, and contract increases must be contained within this dollar amount. Obviously they can't, so you will need to make program or service level adjustments to compensate. Be prepared to identify how you will meet this challenge. If you assume your expenses will go up by 4%,you will be in the ballpark and the net result is a 2% decrease. Scenario 2: A disaster budget. In this scenario,your budget is cut by 15%over this year's level 410 or your transfer from the General Fund will be 15%less than last year. While I don't believe it will come to this, it is important to identify whatpro grams if your department were to receive 15% less from the General Fudnd. I fully expect to see some reduced, drastic measures to meet this goal. Please be specific and realistic, as what you produce will no doubt be of interest to Press and other members of our community. The Board of Commissioners will be reviewing this information in light of"Priorities of Government"information in order to 'cut and paste' a service delivery system within defined resources. Many of the program cuts options will have not only an expenditure side component,but also a revenue side component. In your proposals, format it so that it is clear what the savings will be on the expenditure side and what the costs will be on the revenue side. This information will be helpful for the Commissioners in discussing the merits of a four-year levy shift from the Road Levy to fill the gap. Also provide a short narrative on what the impact means to your operation. Here is an example that is not a proposal or based on real numbers: Department: Assessor Program: Cut new construction assessment Expenditure Savings: $40,000 Lost Revenue: $80,000 This is a net loss to the County, as new construction would not be added to the tax rolls until the four-year appraisal cycle. In addition,by not picking up new construction until the regular assessment cycle there will be unequal treatment among taxpayers, as new residents will lag as gomuch as four years behind from paying their fair share of property taxes, even though their demand and use of services begins with their residency. Phone (360)385-9100 Fax (360)385-9382 dgoldsmith@co.jefferson.wa.us ft Budget Issues Page: 2 I know the above represents a lot of work,however,I'd rather have you look at what is possible or • not possible rather than having someone from outside your department review it. The budget call is a month away. This letter is intended to make you aware of what is being discussed and for you to begin the thought process of what you may be asked to do. The Commissioners, in their budget message,will formally establish the budget goals for 2005, as well as any format specific ways in which they would want the information provided. Feel free to give me a call should you have any questions. David Gold ith, County Administrator CC. Board of Commissioners John Fischbach • • BUD_SUM_05_PROJECTED 2005 BUDGET TARGETS 05/13/04 NOTE: FOR TYPE,A=ACTUAL; OB=ORIGINAL BUDGET; RB=REVISED BUDGET;TARG =TARGET . FOR ROLE, M=MUNICIPAL; R=REGIONAL; S=AGENT OF STATE; U=UNDESIGNATED 2.00% TARGET -15.00% TARGET R T FUND 0 Y TOTAL TOTAL OR L P DEPT# NAME E YEAR E EXPENSE CHANGE EXPENSE CHANGE ASSESSOR 001 010-OPERATIONS S 2002 A $531,988 $531,988 2003 OB $552,423 $552,423 2003 RB4 $610,744 $610,744 2003 A $544,461 $544,461 2004 OB $591,913 $591,913 2004 RBO $591,913 $591,913 2004 RB1 $591,913 $591,913 2005 TARG $603,751 $11,838 $503,126 -$88,787 AUDITOR 001 020-OPERATIONS S 2002 A $376,816 $376,816 2003 OB $376,211 $376,211 2003 RB4 $421,981 $421,981 2003 A $378,297 $378,297 2004 OB $390,778 $390,778 2004 RBO $390,778 $390,778 2004 RB1 $390,778 $390,778 • 2005 TARG $398,594 $7,816 $332,161 -$58,617 001 021 -ELECTIONS S 2002 A $162,258 $162,258 2003 OB $172,286 $172,286 2003 RB4 $182,618 $182,618 2003 A $160,997 $160,997 2004 OB $207,251 $207,251 2004 RBO $207,251 $207,251 2004 RB1 $207,251 $207,251 2005 TARG $211,396 $4,145 $176,163 -$31,088 • PAGE 1 OF 11 BUD SUM 05 PROJECTED 2005 BUDGET TARGETS 05/13/04 NOTE: FOR TYPE,A=ACTUAL; OB=ORIGINAL BUDGET; RB=REVISED BUDGET;TARG =TARGET FOR ROLE, M =MUNICIPAL; R=REGIONAL; S=AGENT OF STATE; U =UNDESIGNATED 2.00% TARGET -15.00% TARGET • R T FUND 0 Y TOTAL TOTAL OR L P DEPT# NAME E YEAR E EXPENSE CHANGE EXPENSE CHANGE COUNTY ADMINISTRATOR 001 059-OPERATIONS M 2002 A $243,059 $243,059 2003 OB $187,180 $187,180 2003 RB4 $202,402 $202,402 2003 A $189,825 $189,825 2004 OB $203,363 $203,363 2004 RBO $203,363 $203,363 2004 RB1 $203,363 $203,363 2005 TARG $207,430 $4,067 $172,859 -$30,504 001 067-SAFETY&SECURITY M 2002 A $116,971 $116,971 2003 OB $123,795 $123,795 2003 RB4 $174,830 $174,830 2003 A $152,880 $152,880 2004 OB $190,416 $190,416 2004 RBO $190,416 $190,416 2004 RB1 $190,416 $190,416 2005 TARG $194,224 $3,808 $161,854 -$28,562 001 261 -TRANSFERS M 2002 A $1,297,928 $1,297,928 0 2003 OB $2,221,405 $2,221,405 2003 RB4 $2,655,302 $2,655,302 2003 A $3,023,177 $3,023,177 2004 OB $2,022,136 $2,022,136 2004 RBO $2,022,136 $2,022,136 2004 RB1 $2,073,055 $2,073,055 2005 TARG $2,062,579 $40,443 $1,718,816 -$303,320 001 270-NON-DEPARTMENTAL M 2002 A $1,281,304 $1,281,304 2003 OB $1,282,634 $1,282,634 2003 RB4 $1,313,892 $1,313,892 2003 A $1,285,310 $1,285,310 2004 OB $1,321,237 $1,321,237 2004 RBO $1,321,237 $1,321,237 2004 RB1 $1,321,237 $1,321,237 2005 TARG $1,347,662 $26,425 $1,123,051 -$198,186 • PAGE 2OF11 BUD_SUM_05_PROJECTED 2005 BUDGET TARGETS 05/13/04 NOTE: FOR TYPE,A=ACTUAL; OB=ORIGINAL BUDGET; RB= REVISED BUDGET;TARG=TARGET • FOR ROLE, M =MUNICIPAL; R=REGIONAL; S=AGENT OF STATE; U=UNDESIGNATED 2.00% TARGET -15.00% TARGET R T FUND 0 Y TOTAL TOTAL OR L P DEPT# NAME E YEAR E EXPENSE CHANGE EXPENSE CHANGE COUNTY COMMISSIONERS 001 060-OPERATIONS S 2002 A $346,376 $346,376 2003 OB $351,698 $351,698 2003 RB4 $359,005 $359,005 2003 A $332,476 $332,476 2004 OB $365,242 $365,242 2004 RBO $365,242 $365,242 2004 RB1 $365,242 $365,242 2005 TARG $372,547 $7,305 $310,456 -$54,786 001 061 -BOE S 2002 A $6,215 $6,215 2003 OB $5,769 $5,769 2003 RB4 $6,138 $6,138 2003 A $4,687 $4,687 2004 OB $7,821 $7,821 • 2004 RBO $7,821 $7,821 2004 RB1 $7,821 $7,821 2005 TARG $7,977 $156 $6,648 -$1,173 J01 062-CIVIL SERVICE COMM S 2002 A $2,392 $2,392 2003 OB $3,803 $3,803 2003 RB4 $3,803 $3,803 2003 A $2,758 $2,758 2004 OB $3,803 $3,803 2004 RBO $3,803 $3,803 2004 RB1 $3,803 $3,803 2005 TARG $3,879 $76 $3,233 -$570 001 063-PLANNING COMM M 2002 A $10,883 $10,883 2003 OB $10,972 $10,972 2003 RB4 $11,588 $11,588 2003 A $9,303 $9,303 2004 OB $13,347 $13,347 2004 RBO $13,347 $13,347 2004 RB1 $13,347 $13,347 2005 TARG $13,614 $267 $11,345 -$2,002 • PAGE 3 OF 11 BUD SUM 05 PROJECTED 2005 BUDGET TARGETS 05/13/04 NOTE: FOR TYPE,A=ACTUAL; OB=ORIGINAL BUDGET; RB= REVISED BUDGET;TARG=TARGET FOR ROLE, M=MUNICIPAL; R= REGIONAL;S=AGENT OF STATE; U=UNDESIGNATED • 2.00% TARGET -15.00% TARGET R T FUND 0 Y TOTAL TOTAL OR L P DEPT# NAME E YEAR E EXPENSE CHANGE EXPENSE CHANGE COURT CLERK 001 050-OPERATIONS S 2002 A $319,403 $319,403 2003 OB $332,287 $332,287 2003 RB4 $372,297 $372,297 2003 A $344,222 $344,222 2004 OB $357,820 $357,820 2004 RBO $357,820 $357,820 2004 RB1 $357,820 $357,820 2005 TARG $364,976 $7,156 $304,147 -$53,673 • PAGE 4 OF 11 BUD_SUM_05_PROJECTED 2005 BUDGET TARGETS 05/13/04 NOTE: FOR TYPE,A=ACTUAL; OB=ORIGINAL BUDGET; RB =REVISED BUDGET;TARG=TARGET 0 FOR ROLE, M=MUNICIPAL; R=REGIONAL;S=AGENT OF STATE; U =UNDESIGNATED 2.00% TARGET -15.00% TARGET R T FUND 0 Y TOTAL TOTAL OR L P DEPT# NAME E YEAR E EXPENSE CHANGE EXPENSE CHANGE DISTRICT COURT 001 080-OPERATIONS S 2002 A $591,814 $591,814 2003 OB $610,483 $610,483 2003 RB4 $678,138 $678,138 2003 A $625,366 $625,366 2004 OB $642,650 $642,650 2004 RBO $642,650 $642,650 2004 RB1 $642,650 $642,650 2005 TARG $655,503 $12,853 $546,253 -$96,397 • PAGE 5OF11 BUD_SUM 05_PROJECTED 2005 BUDGET TARGETS 05/13/04 NOTE: FOR TYPE,A=ACTUAL; OB=ORIGINAL BUDGET; RB=REVISED BUDGET;TARG =TARGET FOR ROLE, M=MUNICIPAL; R=REGIONAL; S=AGENT OF STATE; U=UNDESIGNATED 5.00% TARGET 2.00% TARGET • R TTOTAL FUND 0 Y TOTAL OR L P DEPT# NAME E YEAR E EXPENSE CHANGE EXPENSE CHANGE PROSECUTING ATTORNEY $606,075 001 150-OPERATIONS S 2002 A $606,0752003 OB $642,512 $642,512 2003 RB4 $735,173 $735,173 2003 A $673,561 $673,561 2004 OB $676,155 $676,155 2004 RBO $676,155 $676,155 2004 RB1 $676,155 $676,155 2005 TARG $689,678 $13,523 $574,732 -$101,423 001 151 -CORONER S 2002 A $20,878 $20,878 2003 OB $24,350 $24,350 2003 RB4 $28,984 $28,984 2003 A $26,649 $26,649 . 2004 OB $24,350 $24,350 2004 RBO $24,350 $24,350 2004 RB1 $24,350 $24,350 2005 TARG $24,837 $487 $20,698 -$3,652 0 0 PAGE6OF 11 BUD_SUM_05_PROJECTED 2005 BUDGET TARGETS 05/13/04 NOTE: FOR TYPE,A=ACTUAL; OB =ORIGINAL BUDGET; RB=REVISED BUDGET;TARG =TARGET • FOR ROLE, M=MUNICIPAL; R=REGIONAL;S =AGENT OF STATE; U =UNDESIGNATED 2.00% TARGET -15.00% TARGET R T FUND 0 Y TOTAL TOTAL OR L P DEPT# NAME E YEAR E EXPENSE CHANGE EXPENSE CHANGE SHERIFF 001 180-OPERATIONS S 2002 A $2,566,652 $2,566,652 2003 OB $2,719,110 $2,719,110 2003 RB4 $3,115,609 $3,115,609 2003 A $2,926,643 $2,926,643 2004 OB $3,088,622 $3,088,622 2004 RBO $3,088,622 $3,088,622 2004 RB1 $3,088,622 $3,088,622 2005 TARG $3,150,394 $61,772 $2,625,329 -$463,293 s s PAGE 7 OF 11 BUD_SUM_05_PROJECTED 2005 BUDGET TARGETS 05/13/04 NOTE: FOR TYPE, A=ACTUAL; OB=ORIGINAL BUDGET; RB=REVISED BUDGET;TARG=TARGET FOR ROLE, M=MUNICIPAL; R=REGIONAL; S=AGENT OF STATE; U =UNDESIGNATED 2.00% TARGET -15.00% TARGET • R T FUND 0 Y TOTAL TOTAL OR L P DEPT# NAME E YEAR E EXPENSE CHANGE EXPENSE CHANGE SUPERIOR COURT 001 240-OPERATIONS S 2002 A $339,109 $339,109 2003 OB $369,241 $369,241 2003 RB4 $369,241 $369,241 2003 A $361,867 $361,867 2004 OB $359,951 $359,951 2004 RBO $359,951 $359,951 2004 RB1 $359,951 $359,951 2005 TARG $367,150 $7,199 $305,958 -$53,993 001 110-JUVENILE COURT SER S 2002 A $723,374 $723,374 2003 OB $759,871 $759,871 2003 RB4 $790,578 $790,578 2003 A $724,510 $724,510 2004 OB $725,776 $725,776 2004 RBO $725,776 $725,776 2004 RB1 $725,776 $725,776 2005 TARG $740,292 $14,516 $616,910 -$108,8 66•S PAGE 8 OF 11 BUD_SUM 05_PROJECTED 2005 BUDGET TARGETS 05/13/04 NOTE: FOR TYPE,A=ACTUAL; OB=ORIGINAL BUDGET; RB=REVISED BUDGET;TARG=TARGET • FOR ROLE, M=MUNICIPAL; R=REGIONAL;S=AGENT OF STATE; U=UNDESIGNATED 2.00% TARGET -15.00% TARGET R T FUND 0 Y TOTAL TOTAL OR L P DEPT# NAME E YEAR E EXPENSE CHANGE EXPENSE CHANGE TREASURER 001 250-OPERATIONS S 2002 A $254,058 $254,058 2003 OB $263,815 $263,815 2003 RB4 $291,192 $291,192 2003 A $270,551 $270,551 2004 OB $275,404 $275,404 2004 RBO $275,404 $275,404 2004 RB1 $275,404 $275,404 2005 TARG $280,912 $5,508 $234,093 -$41,311 • • PAGE 9 OF 11 BUD SUM 05 PROJECTED 2005 BUDGET TARGETS 05/13/04 NOTE: FOR TYPE,A=ACTUAL; OB=ORIGINAL BUDGET; RB=REVISED BUDGET;TARG =TARGET FOR ROLE, M =MUNICIPAL; R=REGIONAL; S=AGENT OF STATE; U =UNDESIGNATED • 2.00% TARGET -15.00% TARGET R T FUND 0 Y TOTAL TOTAL OR L P DEPT# NAME E YEAR E EXPENSE CHANGE EXPENSE CHANGE RECAP BY FUND TYPE 001 GENERAL FUND 2002 A _ o-' ® _:wer _ 2003 OB $11,009,845 $11,009,845 2003 RB4 $12,323,515 $12,323,515 2003 A1001 ,' : 2004 OB $11,468,035 $11,468,035 2004 RBO $11,468,035 $11,468,035 2004 RB1 $11,518,954 $11,518,954 2005 TARG $11,697,395 $229,360 $9,747,832 -$1,720,203 PAGE 10OF11 BUD SUM 05 PROJECTED 2005 BUDGET TARGETS 05/13/04 NOTE: FOR TYPE,A=ACTUAL; OB =ORIGINAL BUDGET; RB= REVISED BUDGET;TARG=TARGET • FOR ROLE, M=MUNICIPAL; R=REGIONAL; S=AGENT OF STATE; U =UNDESIGNATED 2.00% TARGET -15.00% TARGET R T FUND 0 Y TOTAL TOTAL OR L P DEPT# NAME E YEAR E EXPENSE CHANGE EXPENSE CHANGE Transfer Out Detail 108 Extension 2004 OB $212,422 $212,422 2005 TARG $216,670 $4,248 $180,559 -$31,863 112 Community Services 2004 OB $161,518 $161,518 2005 TARG $164,748 $3,230 $137,290 -$24,228 120 Crime Victims 2004 OB $22,850 $22,850 2005 TARG $23,307 $457 $19,423 -$3,427 122 E911 2004 OB $242,932 $242,932 2005 TARG $247,791 $4,859 $206,492 -$36,440 127 Health Dept. 2004 OB $450,000 $450,000 2005 TARG $459,000 $9,000 $382,500 -$67,500 127 Substance Abuse 2004 OB $32,431 $32,431 • 2005 TARG $33,080 $649 $27,566 -$4,865 128 Natural Resources 2004 OB $109,760 $109,760 2005 TARG $111,955 $2,195 $93,296 -$16,464 129 Animal Control 2004 OB $101,698 $101,698 2005 TARG $103,732 $2,034 $86,443 -$15,255 140 Law Library 2004 OB $2,500 $2,500 2005 TARG $2,550 $50 $2,125 -$375 143 Community Development 2004 OB $175,041 $175,041 2005 TARG $178,542 $3,501 $148,785 -$26,256 174 Park&Recreation 2004 OB $346,255 $346,255 2005 TARG $353,180 $6,925 $294,317 -$51,938 302 Capital Improvement 2004 OB $99,729 $99,729 2005 TARG $101,724 $1,995 $84,770 -$14,959 506 GIS 2004 OB $65,000 $65,000 2005 TARG $66,300 $1,300 $55,250 -$9,750 TOTAL 2004 OB $2,022,136 $2,022,136 • 2005 TARG $2,062,579 $40,443 $1,718,816 -$303,320 PAGE 11 OF 11 • Board of Health Media Report • June 17, 2004 • • Jefferson County Health and Human Services MAY — JUNE 2004 NEWS ARTICLES 1. "Coloradoan to become administrator", Peninsula Daily News, May 19, 2004 2. "Prosecutor investigating dog cruelty complaint",PT Leader, May 19, 2004 3. "Peer-In program rewarded",PT Leader, May 19, 2004 4. "New Clallam health board organizes",Peninsula Daily News,May 20,2004 5. "Study: Water quality in Jefferson better", Peninsula Daily News, May 26, 2004 6. "Adolescent rage",PT Leader, May 26, 2004 7. "Dogs taken from landowner cause kennel shortage at shelter" PT Leader, May 26, 2004 • 8. "Marrowstone water foes suing PUD",PT Leader,May 26,2004 9. "State's kids have lost health care", Peninsula Daily News, May 27,2004 10. "Health cuts hitting home: Program makes a difference" (2 pages) PT Leader, June 2, 2004 11. "Health help line aims to link service agencies", Peninsula Daily News,June 7,2004 12. "Sullivan to challenge Huntingford",PT Leader, June 9,2004 13. "Prevention is key with West Nile Virus", PT Leader, June 9,2004 14. "New `view' bench a memorial to mothers",PT Leader, June 9,2004 • PENINSULA DAILY NEWS Coloradoan to become admini strator New Jefferson chief takes F hefty pay cut m BY JIM MANDERS - PENINSULA DAILY NEWS . Jefferson County commis- Fischbach Titterness sioners ended their search for a are very decent people." county administrator Tuesday Rodgers said he was when they named John L. impressed with Fischbach's Fischbach to the position. overall track record. Fischbach,who has been city "I liked that he has direct manager in Fort Collins, Colo., management experience," for the past nine years will be Rodgers said. "He has accom- paid $81,670 annually, accord- fished s ing to Commissioner Pat p pecific goals." Rodgers,R-Brinnon. Excellent reviews Although Fischbach is tak- ing a salary cut of nearly Rodgers said the commis- $67,000 from the $148,000 sioners received excellent • annually he makes in Fort reviews from people he works Collins, he said quality of life with in Fort Collins and also issues are more important than from Vancouver, Wash., where salary. he was city manager for five Fischbach, 58, will succeed years before moving to Fort David Goldsmith, who is retir- Collins. ing in late June after 21/2 years Fort Collins City Council- as administrator. Goldsmith woman Karen Weitkunat also has been employed by the had positive thoughts about county since 1975. Fischbach. It's the Pacific Northwest, "Your city manager is city and that's where I want to be," government," Weitkunat told Fischbach said of his decision, the Coloradoan. pay cut and all. "He is a workhorse, and he Fischbach's mother lives in really has his hands around Albany, Ore., and a sister lives everything." in Bremerton. Titterness, R-Port Mayor not surprised Townsend, said Fischbach was the most qualified candidate. Fort Collins Mayor Ray Mar- Experience with budgeting tinez said he wasn't surprised during tight economic times that Fischbach took a salary cut was a big part of the reason to live in the Pacific Northwest. why Huntingford, R-Chi- "It wouldn't surprise me if macum,favored Fischbach. he took an offer that was maybe "His past experience with less money,less benefits,"Mar- budgeting issues will help us tinez said in an interview with out in the future,"Huntingford • the Fort Collins Coloradoan said. that appeared Tuesday. Huntingford also said Fis- "We know he's been trying chbach's strength during the to get closer to home.He hasn't in-person interviews figured in tried to keep that a secret." his part of the decision-making The three county commis- process. sioners—Rodgers,Glen Hunt- Other finalists for the posi- ingford and Dan Titterness— tion were Nancy McDaniel, 50, also were an attraction for Fis- who recently moved back to • chbach. Chimacum after retiring from "I felt confident in their the U.S.Air Force;Allen Sartin, leadership," Fischbach said 55, Jefferson County's current during a telephone interview assistant administrator and 5-/ q--0 ti shortly after accepting the posi- director of central services;and tion. Michael Pence, 56, city admin- "The three commissioners istrator of Kemmerer,Wyo. Prosecutor investigating dog cruelty complaint often enough to feed the dogs,they County officials have previously By Barney Burke were all well-nourished,she noted. viewed a video taken by neigh- Leader Staff Writer It's unclear when or if Rooks bors showing continuous rat ac- will get his dogs back from the tivity in broad daylight. Jefferson County Prosecutor shelter. Environmental Health Juelie Dalzell said Tuesday that Director Larry Fay, who leaves she expects to file a charge of ani- the county for a new job Friday, mal cruelty in the second degree said he met with Rooks on Mon- against dog owner J.D.Rooks. day,May 17 to discuss the situa- For months, residents of tion. "We will hold those dogs Rooks'neighborhood,located one until I have other instructions," block from State Route 20 near the he said. Port Townsend city limits, have Dalzell said that the ongoing complained that his dogs were concerns about rats and accumu- being neglected. Neighbors have lated junk are issues that are be- also said that the accumulation of ing handled by the health junk and garbage on the property department,not her office. was contributing to a growing rat Fay said that prior to the war- problem. rant,county officials were never One of the dogs apparently ran allowed onto the property. He away from the property on May said that the conditions there 4110 14 and was taken to a local veteri- were"deplorable,",but be did not narian, said.,T Dalze}1 he veterinar- see any'i•ats on the property dur- ian called her office to report ing the execution of the search concerns about the dog's condi- warrant;however,he wasn't spe- tion,she said,and that became the cifically looking for rats when basis for a warrant to search the the dogs were being removed. property.The other six dogs were removed during the execution of that warrant, and all are now housed at the county animal shel- ter. Only one dog appears to have been abused, Dalzell suggested. Despite neighbors' concerns that Rooks might not visit his property • Wednesday,May 19,2004•D 3 Peer-Inprogram rewarded • • A panel of grantmakers seii".„.; zit 7;a1.41 - - r T ' lected the "Peer-In" youth pro- gram to receive a $1,000 grant $ � e from the Jefferson County Com- .' y $ �� �` munity Network.The award was 1 made at the network's first-ever _ grantmakers'forum on May 5. "We'll be using the grant money to put on a full-day edu- �t �� cational retreat for 50 Jefferson '* County kids;" said registered a z nurse Hilary Metzger,coordina- �. "`,, " .w tor of the Peer-In program for A panel of seasoned grantmakers awarded a$1,000 Community Network grant to the Peer-In program. ofs County Healthraand Pictured are(from left)Kris Mayer of the Stuart Foundation,Suzanne Lagoni of Nexus Northwest,Pete Human Services. "We're think- Helsell of the Satterburg Foundation,Scott Waller of the Department of Alcohol and SubstanceAbuse, ing of a `Youth Survivor'theme, and Greg Coy of the Discuren Foundation. Submitted photo addressing youth concerns in a neglect. 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N�N N S O_ � - . .w O N a; N m 'n'Y .1 C.D w / L - R C "° n ti-,* N O m ° 0 a• o ODE "'1 1 ' Il N Ul LI 1W CJ L WEDNESDAY,MAY 26, 2004 A9 • Study: in Jefferson better Chimacum, Tarboo creeks, loses for nearly wateritsntirnto e length e into Quilcene rivers improving Hood therlstudies will exam- ine how much water is being BY LUKE BOGUES ment in the area, Jefferson recharged from the rivers into PENINSULA DAILY NEWS County Natural Resources the aquifers and vice versa, Manager Dave Christensen Simonds said. CHIMACUM — There's said. The aquifers appear to be good news for the health of It has been found to be par doing well, he said. water systems in East Jeffer- ticularly important to salmon. There is only a few feet of son County, a recent study "The study was meant to variance in well water levels affirms. throughout the year, the study The quality of the water in find that when we put in a found. the Big and Little Quilcene well, how that is going to con At the headwaters of Chi- nect or not connect to the I rivers and Chimacum and Tar- water in Chimacum Creek," macum and Tarboo creeks boo creeks is improving, U.S. he said. there is a lot of iron and man- Geological Survey geologist The creek is fed by under- ganese — but that's naturally Bill Simo Resulsdssaid from Tuesday.ederal ground springs, Simonds said. mint Simonds ansaidnot caused by study that examined the Water enters the creek until it gets to Chimacum near streams and underground the high school. There, the Iron problems4111 water from Irondale to water starts dissipating out of Quilcene were presented at a p g Iron problems are rampant meeting Tuesday night at Cha the creek and going back into in water wells throughout the ground. Puget Sound, Geological Sur- . macum High School. As the creek travels toward g vey hydrologist Gary Turney The study did not include Irondale, it begins taking said. Marrowstone Island; which water out of theground a ain has been at the center of a g , Along with future studies, he said. Simonds hopes the data can feud over water. The water fluctuations point well-drillers to areas Many wells on the island seem normal, Simonds said. they can good water and not experience seawater intru• affect the ecosystem by drain- sion. A public water system Other watercourses ing important aquifers. was approved for the island, but some residents have Tarboo Creek gets its start The study didn't get to sur- appealed the decision by Jef- near Center from the ground. vey aquifers deep under ferson County Public Utility Its levels remain constant all ground, Simonds said. Most District No. 1. the ay into Hood Canal. wells in Jefferson County are The Big Quilcene River is only a couple hundred feet Chimacum Creek healthier fed out of a gorge in the deep at most. bedrock in mountains south of Drilling to test water deep Chimacum Creek, espe- Quilcene. It gains water out of underground is expensive, cially, is getting healthier as the ground until it passes by Turney said. The recent sur- salmon habitat restoration the town, where it starts feed- vey was conducted using exist- projects take place and pollu- ing water into aquifers. ing wells. tants are cleaned up, Simonds A main reason for that Copies of the study are said. could be manmade influences available online at The creek, which travels on the river, like dikes, pubs.water.usgs.gou/sir200450 from Center to Irondale, is a Simonds said. 58, or by contacting Chris- major piece of the environ- The Little Quilcene River tensen at 360-385-9444. i Rap: Emm. em aeAdolescent r Continued from Page Al Soaked my clothes in blood, accepted by the status quo;'said grabbed me, and choked my herapist analyzes rap music Bottomley."The message is not throat." 'kill the world.'It's saying don't Eminem's underground poetry, believe everything the government the graduate student argues,is part By Janet Huck do white music/I do fight music/For tells. Don't believe everything of a historic lineage that reaches Leader Staff Writer high school kids."JEminem, "Who your parents or your teachers tell back to the poets that Plato had Knew 200 ") you.Racism,sexism and classism thrown out of the republic. are a reality.The message is things "Athenians found Socrates' Encased in headphones, Lisa have to change." positions sacrilegious and threat- Madelle Bottomley painstakingly Like it or not ening to the established order,just • transcribed the lyrics for radical rap Bottomley chose. Eminem be- Rile up aswefindragefulrapthreatening Bottomley has ••tried to in this day and age,"she wrote. artist Eminem. Hour after hour, she cause he is the crossover'artist whodeconstruct the rapp sew olt,..,.'•'''•,.•',,.. slogged through the seemingly brought hard-core street rap to sub- the razor's edge of controversy" Steal your soul warped violence and vulgarity to urban and rural white teens.As An- for parents, teachers and other Bottomley, who provides adults.At separate meetings of therapy to adolescents and chil- write down Eminem's"furious med- thony Bozza wrote in his book Jefferson County'sHealthyYouth dren suffering from trauma, ley of lyrics"that has wowed teens— Whatever You Say I Am,"the rapper's Coalition and public health nurses, abuse or chemical dependency at urban,suburban and rural—through- neatly cropped,blond hair blue eyes, she tried to persuade adults to Port Townsend and Chimacum move beyond their preconceived schools, suggests in her thesis out America. cute earrings and boy band good ideas to consider the teenagers' that therapists should pay atten- "I felt like I was opening a trea- looks were too normal to be ignored." fierce attraction. tion to what"pisses"teens off. sure box,"said Bottomley. Nonetheless, well-meaning and "I was an adult who originally "As therapists, we hope for Though many parents shudder at loving parents have been shocked by thought rap was vulgar,violent progress out of the angry ques- rap artists' misanthropy and mi- the white rapper's vitriolic message. and misogynistic,"said public boning of adolescence," wrote health nurse Hilary Metzger,who Bottomley."The question'what sogyny, Bottomley, 40, wanted to Bottomley quotes one mother's la- used to argue with her own sons pisses you off'is really asking analyze Eminem's lyrics. for her ment about her 15-year-old son lis- about the ugly message of rap, about what you see that outrages "but,Lisa made me listen to the you-what do you see that threat- master's thesis on the "psycho dy- tening to Eminem: message that shows kids feel ens to steal your soul and chal- namic interplay between a cultural art "The contrast has been starkly in disempowered and downtrodden" lenges your sense of hope?" form, namely popular music in the my face—I read this great stuff,then Eminem's appeal to teenag- Eminem,argued Bottomley,has form of hip hop or rap,and its role in turn to my son listening to violent, ers,Bottomley noted,is his deep- been saying the evil that threatens teenagers'lives."The Pacifica Gradu- hate-filled music while he plays seated contradictions on his to steal souls isn't some foreign albums. "He effectively f***s thing."It's in us,"she said."It's the ate Institute student found that video games [that kill people]. It is with your head,and teens love shadow that's inside us,and we need minem raps profoundly about the very disturbing,but at 15,he is mak- Mr— ak this,"she explained."He is try- to come to terms with it.That's the felt by disenfranchised teenag- ing his own way,whether I like it or tog to rile up new segments of only way to deal with it." society so they will listen to the That's when her thesis adviser especially rural white males not—and let me tell you,I don't." injustices teens face," asked,"Are you advocating that and the rift between adolescents and "These messages[of rap artists]are In Enimem's CD"My Name being on the margin is a good the adult world. often too threatening to be heard and is 2000,"he rants about suicide, thing?" "I don't do black music/I don't See RAP,Page A 9 success and drugs. Startled, Bottomley took a "Since the age of 12 I feel like moment to reply."Yes,"she an- someone else because I hung my swered. original self from the top bunk But the scholar also noted: with a belt..../99 percent of my "Even Frank Sinatra was consid- life I was lied to/I just found out ered subversive.Still,when all is my mother did more drugs than I said and done,it could all mean • do..../My English teacher wanted something different." to flunk me in junior high/Thanks • a lot,next semester I'll be 35." Geiger counters Artist "Angry teens have become the Sofie Gelder expert Geiger counters for spotting false promises and abandoned ' hope,"wrote Bottomley."[They) "'� r . :( are disappointed children who ,,:: /. A;`: have grownup and are attempting ' r .: - to defend against a continuous r 1-" ' onslaught of assaults on their sense .;""'�~'' ' 4' '''':,4!)?:',.-''' of safety, and abilityfor V respect / . self-determination in the world." ff 1 ` �j Teens face threats to their -. • safety and respect even in good 'r(; •r schools. In"Brain Damage,"asi • song on The Slim Shady LP, •�/ Eminem recounts his bloodyen- ' • , - . • counter with a school bully. Come play with us! "I was harassed daily by this • fat kid named DeAngelo Bailey/ S A N [)CA S T L E An eighth-grader who acted/,'-- a ob- noxious,`cause his father boxes/ A Children's Store tyt ,--e y So every day he'd shove me into „y the lockers/And he had me in the .:i+ 84o Water St. position to beat me into submis- ,It ,ii Port Townsend sion/He banged myhead against a,-�F 8 8 �,a���t 360-385-4616 the urinal until he broke my nose/ •. Dogs taken from landowner 0 cause kennel shortage at shelter By Janet Huck actions,"Larry Fay,the county's one dog appeared to have been Leader Staff Writer outgoing Environmental Health abused, Dalzell said. They are director, told the Jefferson now being housed at the animal The pound dog, a cross be- County Board of Health on May services shelter. tween a Norwegian elkhound and 20, "there are consequences, Fay said they might have to a teddy bear,was next-the next challenges and repercussions. It hold the dogs until the court case dog to be euthanized. sounds easy to take the dogs was completed,which could ex- Jefferson County Animal away, but it's not quite that tend to seven months. Shelter volunteer Pamela Kolacy simple." However, Animal Control made a snap decision and de- Rook was arraigned May 24 Officer Bob Grewell said the cided to adopt the dog that re- for cruelty to animals in the s'ec- situation is a non-issue. Many minded her of the first dog she and degree. He pled not guilty. animal lovers have offered to adopted from the shelter. The pretrial hearing was set for providefoster homes for the "He was the guy who was June 21. overflow of dogs.Though foster there the longest," said Kolacy, For the past months,residents care might cause some compli- president of Pet Pals, who now of Rook's neighborhood,located cations for potential owners to owns three rescued dogs. "We one block from State Route 20 view the adoptable dogs,Grewell might have adopted him anyway, outside the city limits,have corn- said they could still arrange view- but the situation pushed my hus- plained that his dogs were being ing. band and me into a decision." neglected. Neighbors also said The Board of Health urged The"situation"resulted from the accumulation of junk and Fay's department to contact Pet1110 the confiscation of J.D. Rook's garbage on the property was con- Pals and other animal organiza- seven dogs.Ever since Jefferson tributing to a growing rat prob- tions to raise the money or find County Animal Services took 1em. the equipment to build interim custody of the dogs May 14,the One of the dogs apparently kennels. The health board in- agency has faced a shortage of ran away from the property on cludes two members-of the shelter dog kennels. The seven May 14 and was taken to a local Jefferson County Board of Com- dogs, doubling up in two cases, veterinarian, said Jefferson missioners,which oversees ani- occupy five of the 10 available County Prosecuting Attorney mal services. kennels for dogs. Juelanne Dalzell.The veterinar- "We would like to find a so- If animal services runs out of ian called her office to report con- lution by the Fourth of July,"said empty kennels,it would have to cerns about the dog's condition. Kolacy. "It's a big time because euthanize a dog,but no dog has As a result, Dalzell obtained a a lot of dogs run away from the been euthanized yet because of search warrant,and the other six firecrackers and their homes." a shortage of kennels. dogs were removed during the (Leader staff writer Barney "When you start compliance execution of the warrant. Only Burke contributed to this story.) • I Marrowstone water foes suingPUD • By Barney Burke May 19 in Jefferson County Su- ous local planning policies and "Db you know there's people Leader Staff Writer perior Court, are Conserve Wa- would create adverse environ- already out of water and this is ter First, a citizens' group mental impacts.Also challenged just May?"Hayes said Monday. Opponents of a Marrowstone incorporated in April 2003,along is whether the PUD has the nec- Even some of the people who Island water system approved by with island residents Rex and essary water rights to serve protested the project have now Jefferson County Public Utility Carrie Rice and Wayne and Marrowstone with well water requested hook-ups,she said. District 1 on April 22 are taking Nicole Chimenti. from Port Hadlock. "The signs are down and their battle to court. Representing the group is Se- Additionally, the suit asserts people are ready to move forward The plaintiffs in the suit,filed attle attorney Blair B.Burroughs, that the PUD violated the state and mend fences,"Hayes said of who has represented local pub- open meetings law and thus the the divisive issue."Islanders have lic utilities and given seminars on go-ahead decision is void. voiced their opinion." laws pertaining to the formation Asked to identify an environ- Delays will undoubtedly add of local utility districts. mental impact, Came Rice said cost to the project,said Hayes. Although the PUD has esti- "use of the resource,"adding,"I Kelly Hayes concurred with mated that 59 percent of never thought piping water from his wife's comments and noted Marrowstone property owners one place to the other makes any that opponents are also trying to support the project, the suit al- sense at all." stop plans to build a water tank leges that the PUD did not fol- Piping in more water might at Fort Flagler State Park that low state law in calculating the lead to people using more water would be large enough to meet percentage of protests. and that could cause septic sys- the park's needs as well as ben- The suit also suggests that the tems to fail, Rice said. She said efit the PUD. project is not authorized in van- it isn't clear whether the water By building a 60-foot-tall tank system could mitigate the saltwa- instead of a 35-foot tank, said ter intrusion problem,suggesting Kelly Hayes,there will be better instead that the community has water pressure and more storage not "decided what the problem capacity.Members of the public is." have until 4:30 p.m. today,May Rice said there are viable op- 26,to comment on a variance that tions to the $4.4 million PUD is needed from Jefferson County project,including catchment sys- to approve the.larger_tank. tems and and community wells. patients have said that the tank Marrowstone could try to be- would discourage conservation come a model for how a commu- and cause adverse environmen- nity can solve water problems, tal impacts. Rice noted. Regarding the allegation of • "I'm not interested in taking open meeting violations by the • • showers in catchment water," PUD,Rice said that following the said Gloria Hayes, a water May 19 PUD meeting when the project proponent.She expressed commissioners were served no- - concern with West Nile virus and tice,they immediately began dis- other potential problems with al- cussing the suit even though the temative water systems. meeting was adjourned. PUD Commission Chairman Dana Roberts said he couldn't comment specifically on the law- suit because the allegations con- tained in it are not detailed. He expected that the PUD would soon meet with its legal counsel and decide how to respond. (Contact Barney Burke at bburke@ptleader.com.) PENINSULA DAILY NEWS State 'skids • have lost healthcare Report says 17,000 immigrant children dropped coverage BY REBECCA COOK age were on Basic Health, THE ASSOCIATED PRESS according to the report. Now • SEATTLE — About 17,000 only about one-third are. Some immigrant kids have lost health may have found private health care coverage since the Legisla- •insurance, but most are likely ture kicked them off Medicaid uninsured. rolls two years ago,according to State officials confirmed the a report by the University of report's numbers. Washington's Health Policy It is not a surprise,but it is Analysis Program. a concern, Medicaid director "This report confirms our Doug Porter said. worst fears about what would Porter said many of the happen to immigrant children immigrants who were on Med- 1110 when this program was elimi- icaid have never participated in hated in 2002," said Paola a managed care health plan Maranan, executive director of before,so the concept of paying the Children's Alliance. "These premiums is strange and con- children haven't gone away,and fusing to them. Also, many of they're still getting sick." the families are very poor and The 2002 Legislature didn't couldn't afford the monthly want people to lose health Premiums, which start at $10 insurance altogether when law- Per person. makers ended Medicaid cover- The UW report said lan- age for immigrants, both legal guage barriers and paperwork and illegal,in response to a$1.5 hassles also forced many off the billion budget shortfall. Law- health care rolls. makers reserved enough spots Porter said he believes the on the state-subsidized Basic 2002 Legislature wanted to Health Plan for the 25,000 save money, but didn't intend immigrants losing coverage, for so many children to drop off hoping most would make the the health care rolls. switch. "This is something they're Most didn't.5In November going to have to factor in"dur- 2002, about half the immi- ing next year's budget negotia- grants who lost Medicaid cover- tions,Porter said. .1)D13 —Ll i • Health cuts. hitting home By Janet duck Leader Staff Writer Kristy Hansen was alone,pregnant and homeless. A year later,the happy,19-year-old mother bragged about her"wonderful son,"her three-bedroom trailer, her car,her job and a daycare.. "It's an amazing turnaround,"said Best Beginnings public health nurse Shena Kellewea, who visited Hansen several times a month for more than a year to guide,support and coach her. "I couldn't have done it without Shena,"said the teen mother in a low voice as she gently rocked her See HEALTH,Page A 11 • pd_Ay_S) •• S • O� 0 fibs 1820 Jefferson ff erson Street SK?"'S° P O. Box 1220 Port Townsend�� WA 98368 Oci to • G Dan Titterness,District 1 Glen Huntingford,District 2 Patrick M. Rodgers,District 3 9SltINGs9 July 12, 2004 Secretary Dennis Braddock Department of Social and Health Services P.O. Box 45010 Olympia, WA 98504 SUBJECT: Nurse Family Partnership Dear Secretary Braddock: This is to appeal for your financial support. As County Commissioners we face a budget crises of astronomical proportions; mandated and essential service expenses continue to soar, conversely- revenues continue to be threatened. Our most vulnerable population, mothers and their children, are at risk of losing critical preventative services. Jefferson County was recently notified that it would not receive Title V federal funding, funding which has sustained the Nurse Family Partnership (NFP) for the past 2 years. This is a prevention program that is changing generational norms and systems, not just perpetuating program services to a predictable set of families. It was chosen for our community based on local needs and problems with child abuse, substance abuse and poverty. NFP,based on the work by Dr. David Olds, was implemented in 1999 in Jefferson County. It is mentioned in the July 6,2004 Washington State Institute for Public Policy as a sound investment of public prevention money. NFP provides home visits by registered nurses to first-time mothers,beginning in early pregnancy and continuing until the child's second birthday. National research highlights the following outcomes related to the NFP model. Low-income, first time mothers and their children who received NFP had: 79% fewer verified reports of child abuse or neglect; • 31% fewer subsequent births; • 30 months less receipt of Aid to Families with Dependent Children; • 44% fewer maternal behavioral problems due to alcohol and drug abuse; • 69% fewer maternal arrests; • 60% fewer instances of running away on the part of the 15-year-old children; • 56% fewer arrests on the part of the 15-year-old children; and 56% fewer days of alcohol consumption on the part of the 15-year-old children. Phone (360)385-9100 Fax (360)385-9382 'effboc co.'efferson 1 J � 1 .wa.us Department of Social and Health Services July 12,2004 Page 2 The Nurse Family Partnership has a positive impact on children and their families. These afore- mentioned outcomes offer strength and hope to our local families, and mirror DSHS priorities. Local CPS referrals for young children have decreased by 50% in the last four years corresponding to the length of NFP service in our community. Additionally, none of the families served through NFP have been referred to CPS. We petition you to join in the funding of NFP to maintain services at a level that addresses the needs of our population. Jefferson County and Washington State can collaboratively fund NFP to serve families for$3,000 per family per year. This investment would in turn save thousands of dollars in welfare utilization, law and justice, child abuse and neglect,hospitalization/ER and alcohol/drug treatment costs. We project that with a$50,000 annual contribution from the Washington State, Jefferson County NFP can provide 233 visits per year to 25 families annually. First time mothers in the midst of pregnancy are in a pivotal period in their life stage development. NFP serves as catalyst for positive change. Without immediate financial support from the State, we will be forced to eliminate NFP, thereby reducing services to those who could benefit most. Thank you for your consideration of our request. Please contact me at your earliest convenience to further discuss this important issue. • Sincerely, i° 000 or.re/ /4,1r//, 6b.- ��`'.' Glen Huntin ��� ��� gr Dan Titterness, Member Patrick M. Rodgers, Member cc: Sherry McNamara, DSHS Director of Government& Community Relations Thomas Locke Jefferson County Board of Health City of Port Townsend City Council • W COU) cu >- O o c c co E 3 0 U O D V F- W W J 2 � � }- a w —J LL .v Q .c CI 0- 0 COU) w 0 w a a z e