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HomeMy WebLinkAbout2005-April Jefferson County Board of Health Retreat �► .agenda .Minutes April 21, Zoos x a ,. *IP k 4"''''4,.I..'{ , .. . } t h kt . ...... . :, k'ur ill 400:101 ,, , * 111 OS1) 6101.11111111.1. 411101:11, It4:11:) 4:4:44iiiliol ',',,,( , T,„:„. .,,,,,,,....,1,..„. „,,,,,,,,,,, . -�:iq; 0„i-.14,;,,,,,,kp,.,,,..„.,,,‘I,.., ',,'....).„,,'!..,,,"<.-',-,t'I.iff } s •a /; ' ' ' ,,,,,;II A+gin*: � 400.a. 4,ssliss'Iss-IsIi'IssIss:ssIsosil,ckstss.s.,,IIv4sIs:o..ss it, Ldp ^w��',.t. A ,,, s Fitt • JEFFERSON COUNTY BOARD OF HEALTH April 21, 2005 10:00-2:00 PM Point Hudson Resort Marina Room RETREAT AG ENDA I. Approval of Agenda 10:00 II. Approval of Minutes of Meetings of March 17, 2005 III. Public Comments IV. Review Jefferson County Heath and Human Services 10:30 1. Mission 2. Name 3. Goals & Performance Measures 2004 end of the year 4. JCHHS Programs and County General fund Contributions 11:00 S V. Vision & Prioritization Process: 1. Prevention Principles 12:00 Lunch 12:30 2. Standards from Public Health Improvement Plan 1:00 3. Local Assessment Capacity 4. Other priorities VI. Powers and Duties of Board of Health 1:45 VII. Agenda Planning VIII. Adjourn IX. Next Scheduled Meeting: May 19,2005 2:30 PM—4:30 PM Main Conference Room Jefferson Health and Human Services • • JEFFERSON COUNTY BOARD OF HEALTH • MINUTES Thursday,March 17,2005 Board Members: Staff Members: Phil Johnson-County Commissioner District#1 Jean Baldwin, Health &Human Services Director David Sullivan, Vice Chairman- County Commissioner District#2 Julia Danskin,Nursing Services Director Patrick M Rodgers-County Commissioner District#3 Thomas Locke,MD, Health Officer Geoffrey Masci, Chairman-Port Townsend City Council Jill Buhler-Hospital Commissioner District#2 Sheila Westerman-Citizen at Large(City) Roberta Frissell-Citizen at Large(County) Chairman Masci called the meeting to order at 2:35 p.m. in the Health Department Conference Room. All Board and Staff members were present with the exception of Julia Danskin. There was a quorum. APPROVAL OF AGENDA • Commissioner Rodgers moved to approve the Agenda as written. Commissioner Sullivan seconded the motion,which carried by a unanimous vote. APPROVAL OF MINUTES Member Frissell moved to approve the minutes of February 17,2005, as written. Commissioner Sullivan seconded the motion,which carried,with abstentions by Commissioner Rodgers and Member Buhler who were absent for the February meeting. PUBLIC COMMENT—None OLD BUSINESS AND INFORMATIONAL ITEMS Region 2 Public Health Newsletter and Communicable Disease Report: Jean Baldwin distributed to the Board copies of a new,bi-monthly newsletter concerning communicable disease issues,which had been produced through the three-county partnership. Seven Staff have now been trained on the communicable disease electronic tracking system,which permits sharing data with the State. Federal FFY 2006 Budget: Dr. Tom Locke reviewed a summary of"Discretionary"Health and lo Human Services funding produced by the Washington State Association of Local Public Health Officials (WSALPHO). He highlighted proposed cuts at a State and Federal level, including hundreds of millions cut from the CDC,which funds many local prevention programs. Most expect HEALTH BOARD MINUTES -March 17,2005 Page: 2 these major cutbacks to be approved by the majority in Congress. Some of these funds cut from counties are being redirected to Homeland Security tasks in several highly vulnerable cities, including Seattle. NEW BUSINESS Pre-Adoption Briefing—Jefferson County Food Code: Dr. Locke reviewed that this local code is being redrafted to be in alignment with the new State code,which takes effect in a little over a month. Staff proposed approving a local code that adopts the State code by reference. Dana Fickeisen then reviewed that the Board received a version with the strike outs,which are no longer covered in detail in the County code. The new State and proposed County codes vary only on the issue of hearing procedures. Dr. Locke noted that,procedurally,the Board would call for a public hearing and there would be a public notification with this draft code language. The Board then considered the timing of this series of events,understanding that the notification-hearing process takes about a month. Member Westerman moved that the Board call a public hearing on the adoption of the Jefferson County Food Code in May.Member Buhler seconded the motion. Member Buhler characterized as a weak link the lack of specificity in the timing of the Health . Officer's setting/continuing a hearing. Dr. Locke noted this same language exists in the current methamphetamine code but added that the intent was for it to be open-ended to accommodate the circumstances of a particular case. There was concern that it should state"timely"or"an extension available if appropriate"rather than having no timeframe. Commissioner Rogers expressed reservations about setting a timeframe without considering the advice of those experienced in such procedures. Staff agreed to investigate a conventional continuance timeline. The motion carried by a unanimous vote. Family Planning Services—1997-2004 Report: Kellie Ragan,Program Coordinator,presented highlights from their written program review of Family Planning Services. Referring to the 2004 Office of Financial Management population estimates,Kellie Ragan reported that the Department is serving almost one third of the 15-17 year olds and about three quarters of those 18 to 24. The total number of clients has doubled from 1997 to 2004. They have seen a 60%increase in services to new clients under the age of 20 and a 15%decrease in new clients age 20-24. There were increases of 13%in zip code 98368 versus an increase of 14%in other areas of the county. In 1997, 35%were sliding scale and now 51%are paid for through the Take Charge program. Staffing levels have increased,but include staff in the field and community education,which is a grant requirement. The average number of continuing clients per month has increased by 140%. The teen pregnancy rate has not changed significantly from 1985-1987 to 1998-2001. • HEALTH BOARD MINUTES -March 17,2005 Page: 3 Wendy White,Nurse Practitioner,then distributed a report with an overview of clinic services, a listing of the advantages of Health Department as the umbrella agency, scope of care,challenges for staff and positive aspects as well as barriers to access to care. She clarified that while Staff cannot restrict access to contraceptive services, STDs are reportable and Staff is bound to report sexual abuse. One of the advantages of the Health Department as an umbrella agency is to promote risk reduction and disease prevention, so they can offer STD services along with family planning services. Due to the increase in client volume in general,they adjusted their 2005 Staff schedule so that each practitioner is actually seeing twice as many patients in an eight-hour day than previously. They also address many secondary problems such as poverty,homelessness,domestic violence, mental health,medical/dental needs, and adolescent issues. She distributed copies of forms that are a requirement of Title X funding. In talking about possible improvements to access to care, she listed a new central triage/referral agent employed by Jefferson Healthcare and a one-stop application process that includes: a DSHS assessment,access to interpreters, forms written in Spanish(and other languages), and training for financial staff to be more sensitive to the disenfranchised. In answer to questions about striking contrasts between variances and curves in the State's numbers and those of the County, Staff explained that the relatively few incidents in our smaller population can cause more significant swings in the plotted data than they would in the larger statewide numbers. • 2004 Public Health Improvement Plan—Financing Public Health: Dr. Locke noted that the Board had received the public health improvement plan at last month's meeting.As a result of a process that began in 1994,Washington is now the only State with such a mandated plan.To make review of the plan manageable,he suggested Staff plan to address one of the seven main focus areas of this report at each successive meeting of the Board—what it knows about this problem area and what are we doing in terms of programs and interventions,beginning with funding of public health. Both Jean Baldwin and Dr. Locke have served on the various committees that prepared the plan. Dr. Locke noted that the agenda packet's white paper, "Public Health Financing for the 21st Century" attempts to make a more detailed case for a larger investment in public health and describe the consequences of not doing so. The continuing effort to address this legislatively are represented by two bills in Olympia. It was unsure whether the House study-bill got out of committee yesterday but if it did not, it would essentially be dead. SB5700 is still alive,the intent of which is to repeal the current 750 millage on property within the hospital's district and replace it with 200 millage on all property in the State. That substantially larger dollar amount would then be divided three ways to a)reimburse the same funds each hospital gained under the old millage,b)provide hospitals $21M +$17M for uninsured and uncompensated care,respectively, and c)the remainder—estimated to be as much as$93M per biennium—would go to public health departments. Dr. Locke cautioned that something so radical might take two or three attempts to be passed by the Legislature. Dr. Locke noted that to achieve the improvement plan's standard for public health would cost an additional$400 million per year statewide. The new scheme would create"more room"for other, • junior taxing districts by removing the hospital district's tax millage from the capped amount. HEALTH BOARD MINUTES - March 17,2005 Page: 4 • Expressing her dismay about continuing to look to property taxes for support,Member Westerman said she could not support this bill. She would like to see a longer-term, equitable taxing structure. Chairman Masci said failing the institution of a State income tax,there would still be a short-term funding crisis.In the short-term, this is the alternative proposed by the legislature. Jean Baldwin responded that despite its shortcomings, this bill does at least talk about public health as part of the healthcare system. Dr. Locke added that the bill acknowledges and spreads the responsibility over the entire State,not just among the residents of the hospital districts. Commissioner Rodgers liked the idea of a more equitable taxing system,but in the meantime better funding in public health prevention services could ease the hospital districts' inordinate burden. Vice Chairman Sullivan said he would support this bill, even though it is imperfect. Legislative Update—Live Bills,Dead Bills,Budget Forecasts: Dr. Locke reported that many things have changed since the legislative update was published.Although many bills certainly died with yesterday's cut-off, one bill that remains alive is HB2105,the on-site sewage for marine counties,which is being driven by South Hood Canal.It has passed the House and is now going on to the Senate. The Building Association appears to be opposed to the bill, especially to giving Boards of Health authority to regulate nitrogen loading in the environment. Although only about 10%of the nitrogen in the Canal is attributed to human activities,most of that is believed to come from on-site sewage disposal,one factor over which we have some control. Linda Atkins provided • an overview of the pending bills,on which she and Dave Christensen joined associates from Mason and Kitsap counties in presenting information before the select committee. Friends of Puget Sound and the Puget Sound Action Team have been instrumental in working on the language in this bill and carrying the bill forward. She reviewed summaries of very similar bills, SB5431 and HB 1458; although the Senate bill is effectively dead,HB 1458 has moved to the Policy and Ways and Means Committees. The bill has a grant and loan program for the repair of identified systems and provides State funding assistance for updating the on-site sewage plan. The County is significantly ahead of others in compliance with this plan and will focus on beefing up its electronic data systems. Commissioner Rodgers urged that funds be put where they can have the biggest impact,which he believes is in south Hood Canal where small sewer systems are needed Ms. Atkins agreed and said that this came up during the legislative committee,but there is still the issue of rural versus urban services that needs to be addressed. Josh Peters of the County's Long Range Planning Department provided a copy of HB2086,which he said would change some of the growth management policies to allow sewer systems in rural areas, a remedy that currently requires local health officials to declare an emergency. Member Westerman cautioned that legislated changes to the Growth Management Act to allow on- site sewage treatment opens the door to denser development and its needs for transportation and water. You can't simply change legislation because it would impact areas not totally built out. • HEALTH BOARD MINUTES -March 17,2005 Page: 5 Commissioner Rodgers noted that just as Health was instrumental for securing water for Quilcene Health can advance this issue as well. He felt that to address the problem any other way would never yield the desired results. Jean Baldwin noted not all County governments agreed to the solution of extending sewer services in order to contribute to reduction and removal of nitrogen.Noting that our portion of the Canal does not have the density to warrant small sewage systems, Linda Atkins recognized there is still the ability to address the issue through systems that deal with nitrogen. The opportunity for grants and deferred payment loans provides an incentive for communities like Beckett Point,which is trying to put in a community drain field as is Paradise Bay. ACTIVITY UPDATE/OTHER ANNOUNCEMENTS Chairman Masci, Member Frissell and Vice Chairman Sullivan volunteered to work with Jean Baldwin on planning the four-hour retreat. She also sent a note to the Board inviting Members and the Commissioners on an on-site tour led by Linda Atkins. Dr. Locke reminded that March 29-30 there would be a region-wide communicable disease outbreak simulation. • AGENDA PLANNING/ADJOURN The meeting was adjourned at 4:00 p.m. The next meeting will be on April 21,2005 at 2:30 p.m. in the Conference Room of the Jefferson County Health Department. JEFFERSON COUNTY BOARD OF HEALTH Geoffrey Masci, Chairman Jill Buhler,Member David Sullivan,Vice Chairman Sheila Westerman,Member Phil Johnson,Member Roberta Frissell,Member Patrick M. Rodgers,Member • Board of HeaCth Retreat Review Jefferson County 3{ealth and Human Services • .Agenda Item # 1'V., 1 .Mission April 21, 2005 • • Jefferson County Board of Health 2005 Retreat eNi ITT,7-r s, s kra`a kk ,., Int,H t tt `,,d o "k 44 It.t.htth 4 , ,U 4,„,, � ?111 ! {r t°'\)? t�Nsj ha":H ti y{. ,a .k,F.,y4L= ��''}y l.0 ,,Jth VN / 10 • ..... , —,,- , ''"'.°.„..,:::.,,,,,,,.4....6. ,1,014,.. ''' '... 14;41.1.4,7* ''''',::4•,..'N.4. • ic)'',./ .." �. /�� \tiJ .4 4 144 4 44 iN4 • - ."'" It N4.4 4. ttk -'. '4. ' 's ' ' 44{) ...24 ''' 010111W ,,... 'gypv"! t .t c 4 Melinda Bower, EH Specialist II & Sabine Discussing Green Building & Solid Waste at Jefferson County Health & Human Services Meeting • Board of Health Retreat Review ,Jefferson County Health and Human Services • .agenda Item # 2 Name April2l, 2005 • Jefferson County Public Health Page 1 of 2 ,,t� PUBLIC HEALTH • ALWAYS WORKING RIR A SAFER AND HEALThIER JEFFERSON HOME HEALTH ENVIRONMENT INFORMATION RESOURCES DATA Welcome! News Guide to Prevention Jefferson County Public Health provides essential programs and services to in Jefferson help protect and improve the health of our community. We are always County working to make Jefferson County, Washington, a safer and healthier place Wy Endoridelsed to live, work and play. (March 21, 2005) The Guide to New! Prevention in Jefferson County - A handbook for policy Prevention in makers, program planners and other frontline staff working to keep our Jefferson community safe and healthy. (2.7 MB) county, released today, has HEALTH ENVIRONMENT INFORMATION suppoort from Communicable Disease Programs Youth Yellow Pages dozens of organizations Prevention Food Safety Data & Publications in our Clinical Services community. Restaurants Birth/Death Records More.,. Family Support Services New Food • Developmental Drinking Water Events/Classes Rules Disabilities Living Environments Alerts & Notices Effective May 2, 2005 Prevention Programs Natural Resources Links (February 10, 2005) Coordinated Community Onsite Septic/Sewage Jefferson Programs County Solid Waste Environmental Tobacco Program Health works Solid Waste - Jefferson to make sure Co. food served to the public is Outdoor Burning safe to eat. More... FA JCPH INFO Contact Us I About Us I Email Contacts Restrictions Board of Health I Advisory Boards on Flu Vaccine (02/09/2005) Effective immediately there are no longer any restrictions on flu vaccine. . More... more news items » Events • No events currently scheduled. (August 10, ?ma.) http://www.jeffersoncountypublichealth.org/ 4/12/2005 • Board of Health Retreat Review ,Jefferson County 3-fealth and Human Services • .agenda Item # IV., 3 Goals & Performance .Measures 2004 end of the year 'Lpril2l, 2005 • Jefferson County Health and Human Services 2004 Report • Performance Measures Administration GOALS FOR FY 2004: ADMINISTRATION 1. Assure accurate and timely fiscal reports 2. Assure technical support in assessing the basic health needs of Jefferson County communities 3. Assure administrative, technical and financial support for all Health&Human Services contractual agreements. 4. Provide administrative, technical and financial support to Inter-local agencies that contract for fiscal services with JCHHS. 5. Assure accurate and timely technical and clerical support to each department within JCHHS in serving the residents of Jefferson County. Provide certified birth and death certificates to the Community with accurate and timely information of births and deaths OBJECTIVES FOR FY 2004 1. Provide quarterly fiscal reports to each division within Health&Human Services. 2. Present priorities identified through assessment of Healthy Jefferson to community. 3. Provide administrative and financial support to meet required reporting, invoicing, and tracking of contractual agreements with Federal & State agencies, inter- local/departmental agreements and MOU's held by Health&Human services. 4. As fiscal agent provide administrative and financial support to meet quarterly reports and contractual agreements as required by Federal & State agencies for all agreements held by agencies who contract with JCHHS. 5. Provide supervision, training, assistance and evaluation of the systems that provide the business service support to the various Public Health services provided to the residents of Jefferson County. 6. 100%of requests for birth and death certificates will be processed with 3 working days PERFORMANCE INDICATORS: 2003 2003 2004 Projected Actual Actual 100%compliance of all fiscal contractual 100% 100% 100% agreements Healthy of Jefferson County will identify indicators Book Book Priorities for Jefferson County priorities published published, identified and o meetings held taken to public 100%compliance on State/Federal Audits 100% 100% 100% Number of birth and death certificates issued by #Birth 463 #Birth 460 JCHHS #Death 1,632 #Death 1,593 SUMMARY OF KEY FUNDING/SERVICE ISSUES: Funding for public health services continues to be unstable and categorical so infrastructures such as administration are not always covered. JCHHS gives technical support to the community including internal support to the departments and is dependent on external funding. The department recognizes the inter- • relationships between the federal, state, county and city government and the importance of continued support from each. Categorical funding limits the ability of HHS administration to provide support for the whole department. 1 Jefferson County Health and Human Services Community Health Report 2004 • Performance Measures Family Support Programs BUDGET/PROGRAM: Community Health: Family Support Programs Maternal Child Health(MCH) including newborn follow-up, Child Birth education and Breast Feeding Support, Integrated Maternity Support Services (MSS)/Infant Case Management,Best Beginnings/Nurse-Family Partnership (NFP), Children with Special Health Care Needs (CSHCN), Women Infants and Children(WIC), and the Child Protective Services(CPS) Contract Programs: Alternative Response System(ARS), Early Intervention Program(EIP), and Passport. MISSION: The purpose of the Family Support Programs is to provide health and parenting education, skill building, support, and referrals to community resources to pregnant women and families with children. Services also include voluntary home visits to prenatal,post partum families, and families at risk of Child Protective Services involvement. These services are provided so county babies are born with the best opportunity to grow and thrive, the impact of health problems are minimized, and children receive the care and nurturing they need to become functional adults. GOALS FOR FY2004: 1. All newborns and their families will receive Newborn Health Screening to identify needs for Family Support Services including: intensive home-visiting, case management, lactation support, special health and child development support,nutrition education and parenting education. 2. Maintain the current number of clients served through the Family Nurse Partnership Program(Best Beginnings) for Jefferson County residents. 3. Monitor Nurse Family Partnership Program replication by tracking data on program fidelity. 4. To assess the percentage of pregnant and parenting women receiving JCHHS services, in which depression is an issue. 5. Continue to provide breastfeeding education and support so that all county mothers can provide their children with the physical and emotional benefits of breastfeeding. 6. Prevent nutritional related problems for pregnant women and children under five in Jefferson County. 7. Identify children with special health care needs in Jefferson County and assist families with health and development interventions and referrals as needed. 8. Provide services and information in Jefferson County aimed at preventing Child Abuse and Neglect. 9. Increase awareness and support of the Family Support Program mission and services among local health care and other service providers. OBJECTIVES FOR FY 2004: 1. PHN's will provide Universal Newborn Screening to all Jefferson County families of new babies through telephone calls and office or home visits in order to identify early intervention needs and offer services and referrals. 2. Support the Nurse-Family Partnership PHN's maintaining caseload intensity by providing opportunities for ongoing support and education both within JCHHS and through other offerings such as the Washington State Consortium for Nurse-Family Partnership. 3. Send client data monthly to Nurse-Family Partnership program head office for assessment and evaluation. As part of the Office of Juvenile Justice Department Grant-Preventing Delinquency Early we • are conducting an analysis of the MSS/MCM, Universal Newborn Screening, and Nurse-Family Partnership programs by collecting a variety of client specific data over the next year. Dr. Rebecca Kang, a professor at the U. of Washington, has been contracted to help design the assessment and analyze the data. 4. Depression screening and education will be offered to all pregnant and parenting women who are participating in JCHHS programs and appropriate referrals will be made for those who have a positive screen. 5. Provide WIC nutrition education and support to all eligible county women and children. 6. Through universal newborn screening,other JCHHS programs and community outreach to providers and the • schools children with special health and development needs will get referred for evaluation and intervention services 7. Awareness and assessment of risk for child abuse and neglect is an integral component of all Family Support Service Programs.Referrals to CPS/DCFS will be made as appropriate and services will be provided to families at risk or involved in CA/N through the ARS and EIP contracts. 8. Staff will meet with local health care and other service providers to share information about program goals, services,referral process,and to offer collaboration in care and services to Jefferson County families. PERFORMANCE INDICATORS: 2002 2003 2004 Actuals Actuals Actuals 1. Number of depression screenings completed 50 71 75 2. Number of newborn screened 136 165 145 4. Number of Home and Office visits provided for BB,MSS, 1356 1717 1217 MCM,MCH and Breastfeeding consultation 5. Yearly report from Family-Nurse Partnership ** ** ** 6. %of infants in Jefferson County Served by WIC 59% 54.5% 60.3% 7. Number of children with special health care needs 38 53 64 receiving Public Health Nurse intervention through JCHHS. 8. Number of families served through CPS/DSHS contract. 15 13 16 **report yearly SUMMARY OF KEY FUNDING/SERVICE ISSUES: • Family Support Programs faced several challenges in 2004. Changes in the Maternity Support Program funding and billing caused a slight reduction in funding. Maternity Case Management was changed to Infant Case Management and that funding was also limited slightly reducing revenue. The Federal Juvenile Justice grant wasn't continued for the 3rd year as expected and reduction in services was anticipated starting in July 2004. JCHHS Staff created a power point presentations on the value of Early intervention with Pregnant women and infants and presented it at a variety of community groups in the spring of 2004. These presentations increased the community awareness of the value of Early Intervention with pregnant women and infants. The City of Port Townsend and the Jefferson County committed local funding to continue level services through 2004. DSHS was approached to help with funding of Nurse Family Partnership and DSHS committed 6 months of funding for 2005. The Community Network applied for a Grant and also got funding for maintaining home visiting to high risk families. 2003 Jefferson County Health report published in May 2003 confirmed what the staff in the Family Support Programs have observed in their work in the community: `families with young children are very vulnerable'. Multiple factors contribute to this status: poverty, mental illness, substance abuse, and family abuse/violence. For many families these challenges have been transmitted across generations and now the newborns are vulnerable to these risk factors. Through the commitment of highly trained Public Health Nurses and Mental Health Specialist we are now able to effectively serve clients and families who previously were resistant, or too entrenched in complex psychosocial problems to accept services. Working effectively with these families requires a high degree of skill and support. These families,with multi-generational challenges,respond best to consistent, intensive services delivered over a long period of time. The program assessment project will increase our knowledge of this specific population and demonstrate that the positive outcomes shown in the national program are also being achieved in Jefferson County. March 25, 2005 Jefferson County Health and Human Services Community Health Report 2004 • Performance Measures Targeted Community Health Services BUDGET/PROGRAM: Targeted Community Health Services Family Planning, Breast and Cervical Health Program, and Foot Care MISSION: The purpose of the Targeted Community Health Services is to provide outreach, access,health education, support treatment to specific populations in Jefferson County in order to improve the health of the community. Specific program purposes are: • Family Planning: to provide reproductive health, clinics, outreach and education for Jefferson County residents in order to promote health and well-being and reduce unintended pregnancies. • Breast and Cervical Health Program: provide public education and health screening services to women age 40-64 with low incomes and no or limited health insurance in order to assure early detection and treatment of breast and cervical cancer. • Foot Care: provide foot care and health outreach to Jefferson County seniors to prevent health complications. GOALS FOR FY 2004: 1. Insure access to breast and cervical health exams to women age 40 to 65 years old. 2. Decrease unintended pregnancy rates in Jefferson County(measure)/Assure Family Planning Services are provided in every community •3. Support seniors' independence by maintaining their mobility OBJECTIVES FOR FY 2004: 1. Track Family Planning usage patterns and produce annual report 2. Maintain breast and cervical health program in Jefferson County 3. Emergency contraception to be provided under standing orders, 5 days per week, and expand community education and clinical services 4. Maintain the current level of community foot care and continue expanding into home care PERFORMANCE INDICATORS: 2002 2003 2004 Number of unduplicated clients served in FamilyPlannin Actuals Actuals Actuals g 1198 1292 1330 Number of adolescents under 19 served in Family Planning 320 328 332 Number of Breast&Cervical screening exams 93 122 148 Number of foot care contacts 2679 2537 2470 SUMMARY OF KEY FUNDING/SERVICE ISSUES: Preventing unintended pregnancies is a local, state, and national Public Health Goal. JCHHS provides the only Family Planning program in east Jefferson County. Family Planning is considered a Critical Health Service by the State Board of Health. See Family Planning Services 8 year review March 2004 BOH. JCHHS anticipates maintaining the increased numbers of clients with only minimal increases now. The Breast and Cervical Health program addresses the need for Cancer screening and early treatment to rease deaths from Breast and cervical Cancer in Jefferson County. JCHHS continues to increase BCHP ents with level funding from the state and federal government. In October 2004 JCHHS received$1,500 from Main Street funding raising project to support BCHP which help continues the services in 2004. Demographics in Jefferson County are showing an increase in the over 85-year-old population. JCHHS foot care program help this population maintain independence and mobility in a rural community. March 1, 2005 • Jefferson County Health and Human Services Community Health 2004 Report • Performance Measures Population and Prevention Programs BUDGET/PROGRAM: Population & Prevention Programs Raising Healthy Community Grant (HC), Tobacco (TP/C), School Health(S/H), Childcare health and Safety (CC),Peer-In(PI) and Oral Health(OH) MISSION: The purpose of the Population&Prevention Programs is to provide health education and public health interventions to county residents in order to prevent disease and unintentional injury, improve the quality of life and reduce disparities in health. GOALS FOR FY 2004: 1. Improve identified social and health indicators for school-age youth(S/H) 2. Improve indoor air quality for Jefferson County residents(TP/C) 3. Enhance the quality of child care provided in Jefferson County(CC) 4. Enhance the overall health&safety of Jefferson County children(PI) and(OH) 5. Improve Healthy Youth Coalition functioning(HC) OBJECTIVES FOR FY 2004: 1. Maintain delivery of school in-service/trainings, student health screenings, student health consults, student health care referrals (S/H) 2. Increase number of restaurants participating in smokefree campaign; number of mothers who do not smoke during pregnancy(TP/C) �3. Maintain child care provider consultation re: health, immunizations, safety and child development 4. Peer educators will provide school health classes to middle&high school students and health education classes will be provided to elementary,middle &high school students(PI) and increase awareness Oral Health prevention interventions. 5. Maintain number of Healthy Youth Coalition meetings annually PERFORMANCE INDICATORS: 2002 2003 2004 Number of student health screenings Actuals Actuals Actuals Number of restaurants offering 100%Indoor Smoke Free Dining(TP/C) 2612 1797 1566 Number of Peer-In educational presentations 67 50 62 60 54 5 Number of school health classes 260 222 200 Number of phone calls to WA State Tobacco Quit line from Jefferson Co. 84 76 ** Number of Healthy Youth Coalition Meetings 8 8 8 Number of businesses participating in `Smoking-free Doorway' initiative N/A N/A N/A ** data not available as of January 24, 2005 REPORT SUMMARY OF KEY FUNDING/SERVICE ISSUES: A specific Juvenile Justice grant funds Healthy Communities with in-kind services from the community agencies involved. Healthy Communities grant provides intervention and prevention programs to identified children in vulnerable families. Besides the Healthy Communities grant, the above programs provide universal prevention programs available to all in the community. State prevention health services monies come with ei, tensive evaluation components. Tobacco, Peer-In and Healthy Communities funding have community ific goals and measures that must be met to maintain funding. School funding is based on State School urse corp funds and contracts with school districts. School enrollment is decreasing slightly anticipating less health screening. January 24, 2005 Jefferson County Health and Human Services Community Health • Performance2004 Measures Communicable Disease BUDGET/PROGRAM: Communicable Disease TB, Communicable Diseases, Immunization, Travelers Immunization, Sexually Transmitted Disease, HIV, Syringe Exchange Program. MISSION: Communicable Disease The purpose of the Communicable Disease Health program is to protect Jefferson County residents from serious communicable diseases by providing disease surveillance, investigation and reporting, along with education, screening, treatment and immunization services. The program interacts with community members,medical providers, the Washington State Department of Health and other agencies while working toward this purpose. GOALS FOR 2004 1. Maintain the low rates of active TB in Jefferson County(TB) 2. Timely investigation of reportable conditions(CD) 3. Support universal access to State supplied vaccines for all children(Imm) 4. Continue to support immunization registry in Jefferson County,promoting use by all immunization providers (Imm) 5. The Family Planning and STD clinics will assist in controlling Chlamydia transmission in Jefferson County(STD) 6. HIV testing and counseling clinic resources are focused on persons at risk for HIV infection (HN) 7. Case management services will be easily accessed by new HIV clients who seek these services (HIV) 8. Prevent the spread of blood borne communicable diseases among injecting drug users and their partners(SEP) 9. Annual report to BOH for CD, TB, Immunization Programs, STD 10. Develop bioterrorism response capacity OBJECTIVES (INTERVENTIONS)FOR 2004 1. Encourage appropriate screening&treatment for latent TB infection(TB) 2. Develop &update protocols for investigation of reportable conditions(CD) 3. Maintain an efficient system for supplying State supplied vaccine and vaccine recommendation up-dates to private Health Care Providers in Jefferson County(Imm) 4. Continue to provide training on the Child Profile Immunization Registry to private Health Care Providers 5. Clients seen in Family Planning and STD clinics who are at higher risk for Chlamydia(age criteria)will be screened for Chlamydia(STD) 6. 75%of clients who receive HIV testing will be high risk(HIV) 7. 90%of new HIV clients who seek case management services will have an assessment within 1 week of the date requested(HIV) 8. Promote utilization of syringe exchange program services(SEP) 9. Develop bioterrorism plan, coordinating with plans of regional bioterrorism partners, local emergency response agencies, and Jefferson General Hospital PERFORMANCE INDICATORS: 2002 2003 2004 Actuals Actuals Actuals (TB)Number of clients started on preventive therapy for latent 2 2 4 TB infection • (CD)Number of communicable disease reports confirmed, 58 86 111 interventions applied and processed for reporting to the state (Imm)Number of doses of publicly funded vaccine, 3811 3873 4001 administered by private health care providers and Public Health clinics, supplied and monitored through Public Heath's immunization program (Imm)Number of local immunizations providers(clinics) 1 I-4 T- 5 provided information(I) and training (T) on the Child Profile T -2 immunization registry' (Imm)Number of providers participating in the Child Profile 1 3 5 immunization registry (Imm)Number of Jefferson County children<6 with one or 69% 70% 76% more immunization in Child Profile system (STD)Percent of at risk FP and STD clinic clients, at risk for 100% 100% 100% Chlamydia, screened(age criteria 14 - 24) (HIV)Number of persons counseled and tested for HW 79 101 1 88 infection (HIV)Percent of persons counseled and tested for HIV 71% 51% 77% infection that were in high-risk category (HN)Percent of new HIV clients seeking case management 100% 100% 100% services who have an assessment within 1 week of the date requested • (SEP)Number of SEP clinics 103 119 k 136 (SEP)Number of SEP clinics utilized 37 58 52 (SEP)Number of syringes exchanged 4,164 9,222 18,060 (SEP)Number of prevention/educational materials provided2 29 2,304 7,313 (SEP)Number of referrals to other services3 NA 18 11 (BT) Develop bioterrorism response plan 1 1 'All immunization providers participating in the Child Profile immunization registry were trained to use the new web-based version of Child Profile. 2 Prevention Materials include: tourniquets, cookers, cottons, water, sharps containers, alcohol preps, antibiotic ointment,band-aids, hygiene(toothbrushes/razors). Educational Materials include: Do Not Share, Overdose Prevention, Health alerts. Method of tracking materials changed in 2003 to better capture all materials supplied. 3 Referral Information includes: Drug Treatment,Health Care, Hepatitis Screening,HIV Counseling& Testing,Mental Health SUMMARY OF KEY FUNDING/SERVICE ISSUES: Communicable disease prevention is a locally funded program, since the county milage was returned from the state to counties for TB control. Immunization funds from the state are primarily in the form of vaccine. County funded Services are important in the Strategic Plan to promote healthy communities by having the infrastructure to maintain a professional staff preventing, identifying and responding to disease outbreaks. Substantial staff time is spent on responding to public requests for information about communicable diseases and screening for reportable illnesses in the process. IP HIV services are funded from the state and federal government to provide basic communicable disease prevention, HIV positive client case management, testing and counseling to high-risk community members, and focused high-risk interventions. Funds are highly programmatic and based on federal case numbers,which may not represent Jefferson County epidemic profile. Volatile program funding is based on formulas re-negotiated with Region VI AIDSNET every year. IIDeveloping the capacity for bioterrorism response is a new project. This response capacity is in coordination with our Bioterrorism Region 2 partners,Kitsap and Clallam Counties and our local emergency response agencies, Jefferson General Hospital, and other health care providers. The Jefferson County Health and Human Services Emergency Response Plan is a work in progress. Detailed operational plans (the appendices)will continue to be added over the next year as the Region 2 partners develop them. An annual report for CD, STD and TB numbers will be provided to the BOH at the March 2005 BOH meeting. The Region 2 Public Health Newsletter provides these numbers. 13 April 2005 • • Jefferson County Health and Human Services ENVIRONMENTAL HEALTH 2004 Report Performance Measures • ON SITE SEWAGE PROGRAMS (OSS) MISSION: The mission of the Onsite Sewage Program is to minimize the threat of surface and ground water contamination from failing or improperly designed,installed or maintained onsite sewage systems. GOALS FOR FY 2004: 1. Educate homeowners,builders,real estate personnel,banks, installers,designers and onsite system maintenance personnel in the proper operation and maintenance of onsite sewage systems. 2. Assure a high quality-monitoring program. 3. Implement and enforce state and local rules and regulations governing the installation and use of onsite sewage systems. 4. Investigate action requests and complaints in a timely manner to reduce the threat of human contact with untreated wastewater. 5. Assure high quality customer service. OBJECTIVES FOR FY 2004: 1. Develop written informational materials for public distribution and conduct workshops for community groups addressing onsite sewage system operation and maintenance. 2. Provide training to community groups to increase awareness of regulatory requirements for onsite sewage systems. 3. Review monitoring and inspection reports and provide timely follow up. 4. Utilize existing data systems to track action requests and complaints. 5. Develop and implement a system for routinely surveying customer service. 6. Assure that site inspections in response to permit applications are conducted within 14 days of receipt of application. • PERFORMANCE INDICATORS: 2002 2003 2004 2005 Planned Number of systems repaired/upgraded not associated 21 22 17 25 with a violation or building application. Percent of existing systems receiving regular 3rd party 14% 16% 21% 22% monitoring. Percent of system failures less than 5 years in use 1.4% 1.6% 0% 1.5% Number of complaints received 60 24 67 40 Percent of complaints requiring enforcement action. 21 18 30 20 Number of septic permit applications 318* 329* 317* 350* Number of permits<14 days to initial inspection 147 180 148 185 Number of permits>14 days to initial inspection 48 35 146 40 Percent of permits issued with clock stoppers that 52% 41% 50% 35% delay processing time Average days to process permits 14 15 25 15 Percent of permits applications pending 6.5% 6.0% 8.8% 6.0% Number of evaluations of existing system(EES) 210 230 275 280 Percent of EES resulting in required significant 30% 26% 37% 25% maintenance or repair. Percent of failures/major maintenance 2.9% 1.7% 6% 2% Number of educational workshops 18 5 5 9 III , Number of workshop participants 431 100 65 180 * Number of applications does not equal approved permits 1 SUMMARY OF KEY FUNDING/SERVICE ISSUES: Tracking will be done with existing data systems to evaluate effectiveness of monitoring programs. With the completion of the DOE non-point source pollution grant,ongoing O&M activities will need to be funded through permit and inspections fees. Implementation will focus on coordination with the PUD to set up systems for scheduling and tracking inspection activities and conducting community outreach to increase awareness of the new requirements. LINKS TO COUNTY STRATEGIC OBJECTIVES: • Protecting and Enhancing Natural Resources. • Addressing locally identified and defined public health problems. • Operating within a business plan based on sustainable resources,measured performance,and outstanding customer service. • • 2 Jefferson County Health and Human Services ENVIRONMENTAL HEALTH 2004 Report Performance Measures Drinking Water Programs MISSION: The mission of the Drinking Water Program is to assure that the residents and visitors to Jefferson County have access to the best quality drinking water that is reasonably available in order to minimize the threat of waterborne disease. GOALS FOR FY 2004: 1. Assure that all new wells are constructed in accordance with requirements established by the Washington Department of Ecology. 2. Provide technical assistance when requested so that individual water supplies are safe. 3. Limit public exposure to water systems with known deficiencies. 4. Integrate water adequacy review information with Natural Resource water quality database OBJECTIVES FOR FY 2004: 1. Inspect at least 50%of all new wells constructed and 100%of all wells being de-commissioned. 2. Increase compliance with state well drilling regulations. 3. Review all building permits and project applications to assure that potable water supplies meet basic public health standards as well comply with state statutory and regulatory requirements. 4. Provide technical guidance to any residents requesting assistance with their individual or small water systems to deliver safe drinking water. 5. Establish appropriate policies for alternative water supply systems. 6. Continue contracting with DOH for public water supply projects as long as adequate funding is provided. • PERFORMANCE INDICATORS: 200/- 2002 2003 2004" 21105:' Carretted- Actual I'lamed Number of well applications received&reviewed,includes 75 117 123 116 165 carry forward from previous years(USR's) Number of new wells start notification(drilled) 43 101 105 90 88 Number of wells abandoned 2 7 24 9 33 Number of applications with no well drilled(carry forward) 30 11 18 26 44 Number of new wells inspected(start notification received) 36 45 59 47 66 Percent of new wells(starts)inspected 84% 46% 56% 52% 75% Number of abandoned wells inspected 2 7 24 9 33 Percent abandoned well inspected 100% 100% 100% 100% 100% SUMMARY OF KEY FUNDING/SERVICE ISSUES: Increased tracking will be done within existing databases such as permit plan and the food service database. Databases, including the water quality database,will be updated as necessary to add new fields to track performance indicators. LINKS TO COUNTY STRATEGIC OBJECTIVES: • Protecting and enhancing natural resources • Addressing local public health problems • • Jefferson County Health and Human Services Environmental Health 2004 Report Performance Measures Food Program MISSION: The mission of the Food Program is to minimize the risk of the spread of disease from improperly prepared, stored or served foods handled in commercial settings. GOALS FOR FY 2005: 1. Provide classroom food safety instruction for all food service workers. 2. Assure minimum sanitary standards are observed in all food service establishments. 3. Provide basic food safety information to the general public. OBJECTIVES FOR FY 2005: 1. Offer food safety training at a frequency and in locations convenient to food service workers. 2. Review all new food service establishments for compliance with state and county requirements. 3. Inspect all food service establishments at a frequency adequate to assure compliance with state and local regulatory requirements. 4. Offer educational materials and technical assistance to non-regulated community groups and organizations where requested. • 5. Implement new State and County Food Rules and educate public and food workers about them. PERFORMANCE INDICATORS: 2001 2002 2003 2004 2005 Actual Planned #of food workers trained 1,008 1,090 1122 1,128 1,128 #of food worker classes at Health 51 60 79 52 52 Department #of food worker classes at other locations 13 18 14 18 18 #of food establishment permits N/A 251 255 240 240 #of required inspections completed 247 293 275 360 360 #of inspected establishments that required 22 21 8 32 32 repeat inspections due to critical violations. #of establishments receiving Outstanding 55 48 55 28 28 Achievement Awards #of temporary food service permits 72 65 75 73 73 #of complaints received and resolved 26 46 32 20 20 SUMMARY OF KEY FUNDING/SERVICE ISSUES: Food Program activities are largely funded through permit fees. 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'L3 �1 o 0 ,-X. 04 am 00 o O : Board of Health Retreat "Vision & Prioritization Process: .Agenda Item #"V. � Vision ApriC2z, 2005 1 i'50N �k �z c° JEFFERSON COUNTY PUBLIC HEALTH ) Always Working for a Safer and Healthier Je f ferson • „sknoss.:, January 13,2005 To: Jefferson County Board of Health From: Tom Locke,Health Officer Jean Baldwin,Health Director Re: 2005 Board of Health Workplan Overview: Local public health departments have long functioned in a political environment of rising demands and shrinking-resources. These trends show no sign abating. Federal cutbacks are projected to be substantial. The State of Washingtoi of s looking at a multi-billion dollar revenue shortfall for the third biennium in a row. In opinion polls, the public expresses strong support for public health programs but reluctance to translate this support into increased taxes. Carrying out the broad responsibilities of a local board of health is becoming ever more challenging. Program Review: Public programs should be accountable, efficient, and effective. To achieve these goals,performance measures must be developed and periodically reviewed by policy makers. For 2005, we propose that the Board focus on three major program areas for review—family planning services,maternal child health programs, and prevention services. The first of these reviews will be presented to the Board in February. Priority Setting: Local health departments throughout the state are in crisis and facing significant service cutbacks. The scale of those cutbacks will be determined by actions taken by the U.S. Congress and State legislature. Setting priorities is always necessary. This year, it will be critical. Both Washington state and Jefferson County have carried out Priorities of Government(POG) exercises. Public health and safety typically receive high ratings in these exercises since they are the fundamental reason governments exist. Extending this prioritization process to a review of local public health programs has yet to be done. Similar principles apply, i.e. consensus must be achieved about the fundamental duties of a local public health jurisdiction followed by a realistic matching of priority programs to available resources. We recommend that the Board of Health undertake a prioritization process for local public health services to guide us through the difficult days ahead. 615 Sheridan Street,Port Townsend Washington 98368 fax: (360)385-9401 web: www.jeffersoncountypublichealth.org • COMMUNITY ENVIRONMENTAL DEVELOPIUIENTAL HEALTH HEALTH DISABILITIES (360) 385-9400 DISABILITIES RESOURCES (360) 385-9444 (360) 385-9400 (360) 385-9444 Local Health Code Development: Two major public health rules will be implemented • in 2005—food safety and on-site sewage codes. The food codes were adopted in September of 2004 and become effective in May of 2005. Since they merge Washington's codes with a model national food code,they are highly comprehensive and require little in the way of supplemental local health codes. The on-site sewage codes are scheduled for public hearing in March of 2005 and adoption soon after. They will require revisions of Jefferson County's companion code. Both codes will require a reexamination of fee schedules to support new activities. Ex-govemor Locke's budget contains funding to support assessment and plan development for threatened marine shoreline areas. Failure of the legislature to appropriate these funds will have a major bearing on whether that aspect of the draft code is adopted. Emerging Issues: If recent history has taught us anything it is that emerging public health issues can be among the most time and resource consuming. SARS,bioterrorism preparedness, and vaccine shortages are among the most recent examples. Issues such as homelessness, sexually transmitted disease control, and health care access are often seen as"old news"but offer important opportunities to improve community health through application of public health approaches to the problem. As health policy issues emerge in Jefferson County,the Board of Health is an appropriate public forum for those issues to be explored and evidence-base intervention strategies developed. 410 • • HEALTH ¢f `I -, Phoenix, Arizona By William H. Foege, MD, MPH Dr. William Foege is a Senior Fellow at the Gates Foundation, where he advises the foundation on strategies that could be usefully pursued in global heat . He has served in a variety of executive positions at the Carter Center, is Presidential Distinguished Professor of International Health at the Rollins School of Public Health, and is a Fellow of the London School of • Tropical Medicine and Hygiene. Dr. Foege helped form the Task Force for Child Survival in 1984 to accelerate childhood immunization. In the 1970s he worked in the successful campaign to eradicate smallpox and served as director of the U.S. Centers for Disease Control and Prevention. INTRODUCTION-During most of my lifetime,public health has been the Rodney Dangerfield of health specialties. It got no respect. It got the leftovers. Little research, little interest, little attention. It will never be the place where young people throng to make money. But it is getting new respect. • fi At my age I am brimming with memories and now understand that saying that, "inside • every older person there is a younger person wondering what happened." Old age is not a rumor. Enough of looking back. Stephen Smith was 49 when he helped start APHA. On the 50th anniversary he gave the keynote address and at age 99 he went to the lectern and spoke on"The Future of Public Health." I have a five-year-old grandson, Max. Some weeks ago I was driving him home from school and he was making the rules of the game. He said, today you are a chicken, and I am T. rex. I heard a gulp and he said, "I just ate a chicken." I provided a muffled, "Help." He told me that no one could hear me but him. I repeated the help and he told me that now no one could hear me including him. It was time to change strategies. I then pretended to talk to myself. "It's too bad T. rex can't hear me because I wanted to give him some money."Not a sound from the backseat. So I continued, "Yes, I was going to give him two dollars."More silence and then a muffled voice from the backseat"Put it in my pocket." I began to think. My future is in that backseat both literally and figuratively. We see ourselves as walking into the future but the ancient Greeks were more correct when they saw themselves backing into the future. I can't really see what is back there. I hear muffled messages and then suddenly I am surprised by joy! The lesson?Awake every morning knowing that you are going to be surprised b o • Y Maybe not today or tomorrow. But it will come. If the thousands of state health eZ of the past could be resurrected to see what has happened to the health of the American people they would be surprised by joy. There are two questions I would like to share today. 1. What are some of the great challenges facing you? 2. What are some of the lessons of my decades? The things that might be worth passing on? I pass them on with the full knowledge that the passion to teach far surpasses the passion to learn. First, what are some of your very biggest challenges? Your grand challenges? ..._...... .... The first challenge is to do no harm. Public health is held to the same high standard of medicine. Do no harm. What is different?Public health has a perspective that medicine has lacked. The Institute Of Medicine did a great study on the harm caused by the medical profession. And they missed the point!! Absolutely missed the point. The book is concerned with the errors of commission. I would submit that far more harm is done by the errors of omission. The vaccines not given. The helmets not worn. The interventions not made for abused children. The science not used. As I was leaving to live in Africa 40 years ago, the parting words of my supervisor were chilling. In what appeared to be a throwaway line he said, "By the way, you will never forget the people you kill."That haunted me. And I finally, over the years, concluded he • 't • was wrong. You see the vast majority of the people I have killed were killed by errors of omission. The many things I did not get done. The children not reached, the water supplies not fixed, the ineffectual prevention of HIV transmission,the pregnant women not getting tetanus toxoid or other care. I don't know those people. They are easy to forget...unless public health people find ways to make them visible. Do no harm, for public health people,is a never-ending nightmare-influence not used, political actions untaken, errors of omission. It is your grand challenge. A second challenge?A rational health future. Inhealth,the greatest gift we can leave is to contribute to a rational health future. As I told a World Health Assembly some years ago, "You are building a cathedral."A thousand years ago the lines converged. Architects were able to solve the problems of large construction, builders were able to bring the materials and the skill to realize those plans and churches, dictators and capitalists assembled the capital. Artisans labored knowing the completed building would not be seen by their children or grandchildren and yet there is no indication that it lessened the quality of their work. We are all artisans in building a health cathedral for the world. We won't see it completed. Norman Cousins said the greatest gift the United States has given to the world is the belief that it is possible to plan a rational future. Your greatest gift is to provide a rational health future. .............:..::.: C.P Snow wrote that he would never see the gap between science and the humanities bridged. Well, the philosophy of public health bridges that gap. It was at an ASTHO meeting . many years ago. Someone asked during the question period what I saw as the specific philosophy of public health. I answered that the philosophy of science is to find truth. The philosophy of medicine is to use that truth for your patient. The philosophy of public health is to use that science for everyone or social justice in health. Joe Cannon, from Rhode Island, got up and said. "I have been in public health for 50 years. I have never heard that and yet I know intuitively that it is true."He said, don't ever miss a chance to say that so other people don't have to wait 50 years to understand it. You health jh bridge the gap between science and humanity every day making social justice that bridge. It is true that science is ahead of everything. Ahead of our understanding, our sociology, our theology, our ethics, our humanity. If the gap is to be truly bridged it will be because those of us in science insist on it. The ethicists will always be three steps behind unless we insist on ethical behavior. Even now. What is the biggest public health/ethical battle ground? It is not abortion,the right to die, or whether the government should intervene if a parent refuses treatment for a child. The biggest dilemma in public health and medical ethics is resource allocation and ethicists remain on the periphery. Why aren't we forcing the issue?How can we stand by watching$87 billion disappear down the Iraqi drain without presenting a clear picture of what$87 billion could do for public health in this country? • A I don't want a trillion dollars in tax cuts over the years if you can show me what a trillion • dollars could do to provide a next generation of Americans that has prenatal care,home nursing,post-natal parent support groups,head start programs, opportunities for the poorest parents to assure educational trust funds by enrolling preschool children in programs, active programs of scouting, second language training, music, sports and opportunities for every grade school student to contribute to their own educational trust fund. We now know the positive characteristics we want children to have...empathy,purpose, a feeling of some control or nonfatalism, social skills, cognitive skills...and we know how to enhance their development. On April 16, 1953,before the American Society of Newspaper Editors,President Eisenhower, a man trained in warfare, gave the best speech of his life- The Cross of Iron speech. "Every gun that is fired, every warship launched, every rocket fired signifies, in the final sense, a theft from those who hunger and are not fed, those who are cold and not clothed. This world in arms is not spending money alone. It is spending the sweat of its laborers,the genius of its scientists,the hopes of its children... " But we are living as if we have no children, as though there will be no next generation. A next generation better than us is possible and worth far more than tax cuts so why aren't we gathering the ethicists to say that?Do no harm means making the case for what public resources could do to make this country great in the future. That is patriotism. Public health leaders can't stay out of politics. I was influenced to think of medicine and Africa when, as a teenager, I read"At the Edge • of the Primeval Forest." I did not understand at the time that Schweitzer's philosophy of "reverence for life"was indeed a new look at the world. He felt that ethics was flawed because it dealt only with people. He incorporated animals and plants into his ethic in what we now understand as the beginning of a global ethic with concern for people, biodiversity, and the responsibility to the future. We could bridge that gap between science and the humanities. Social justice,health equity...that could be the ASTHO challenge. Roger Bacon told us seven centuries ago that science lacks a moral compass. Then 500 years ago the great French physician and humorist,Rabelais, used in one of his books, what Will Durant called ten words that challenge our time. He said, "Science without conscience is but the ruin of the soul."The unending challenge of ethics. The challenge of management. Vaccines unused are of no help. To match the science tools and the philosophy of using that science for everyone,we need management skills that deliver that science to everyone.Not just more efficient immunization programs,but figuring out how to measure health outputs so that we can harness the dollars of health care delivery. What would happen if we developed metrics so good that we could reward health plans for improving health rather than rewarding them for illness care? Suddenly it would mean profit to enroll sick people,there would be profit in preventing heart attacks and lung cancer, the market place would be harnessed in improving public health. Think of the legacy you would leave. • The challenge presented by people—The three leading causes of death in this country are tobacco, diet, and alcohol. Not nature against us but us against ourselves. The science of public health knows of no area outside our concern. We need the psychologists, the sociologists, the anthropologist to understand how to motivate people. What is the greatest biomedical breakthrough of the 20th century? It is not intensive care units, antibiotics or tertiary care. It is the fact that large parts of our population are able to use the science. Individuals can use the information on smoking, diet, alcohol, seat belt use, sun-screens,micronutrients, exercise, antihypertensives, antidepressants to control their own destiny. [If it is possible to make a majority of Americans believe that Iraq was actually involved in 9/11, it is possible to make them believe they can take more control of their health.] Now how do we extend that freedom to the poor, the fatalistic,the left- out?How do we extend it to developing countries? Our great success is always clouded by those persistent acts of omission, the people we have not yet reached. I once wrote about the 15 biggest challenges of public health. Five seems enough for after lunch. What are some of the most important lessons I have learned in 40 years? There are many of course, and because I am slow, most I have learned more than once. 1. The philosophy of public health- already mentioned. 2. For teaching me that there is no area of knowledge beyond the interest of public • health I thank Yemi Ademola, a classmate 40 years ago who was killed during the Nigerian civil war. 3. I believe I learned on my own, and now advise students, that the ideal career is to be both a generalist and a specialist simultaneously. Professor Pelican from Yale has said that good scholarship can usually be traced to the place of training, mentors, etc. But great scholarship can often be traced to how much a person knows outside of their field. What is the value of being a generalist?It is the absolute conviction that everything affects everything. There are no isolated events. It has been said that the real definition of genius is to see one's field whole. Understand the big picture and then you can see where your specialty fits in. 4. The understanding that every public heath decision rests on a political decision. I wish I had understood that earlier,when George Hardy was introducing me to the way Washington works. I have gone through various stages. The first stage was of being angry at political decisions. Second, realizing that when politicians make decisions that are not in the best interest of public health it is our fault. We didn't figure out how to get them the right information. Third, suggesting to public health workers that instead of retraining new politicians every year we should make a concerted effort to get public health people into politics. I still believe that. Not just medical people but public health people. Bill Frist ` wrote an editorial on cruise missiles as preventive medicine. That is not what I have in • mind as a solution. How do we get our political system to make the right decisions? Recently I had the opportunity to present the $1 million Gates Foundation prize to the Government of Brazil for their decision that they would treat all AIDS patients the same regardless of their ability to pay. I started as follows. Quote... "Last week I was seduced by an Oprah show devoted to `Extreme makeovers.' Some of you are aware of the premise. Individuals left home for six weeks. For some, 15 hours of surgery altered faces and bodies and this was followed by weeks of exercise,help with hairstyles and cosmetics and a new wardrobe. These people returned home movie-star-beautiful with new confidence and zest. Some are born with beauty but this offered hope to the rest of us. But then I thought. Wouldn't it be great to have a six-week extreme makeover for those not adequately endowed,who then find themselves in politics? They could emerge after six weeks with empathy, ethics,courage,humility,wisdom, knowledge and honesty...as servants of We The People. Because, in the final analysis, as the citizen of a country,there is only one organization that actually represents everyone. That is government. It is a national pastime to criticize and complain about government. It is the basis for comedy. But there is no other organization,no church group,no social group, no service organization that represents all of us...except government. When this is done poorly we know it and we suffer. There are countless examples. • When it is done well it brings tears to our eyes. Gary Wills describes the 272 words of the Gettysburg Address as the moment when the United States went from a plural noun to a singular noun. We all then belonged to one government. The Brazilian National AIDS Program demonstrated government at its best. A government that desires to protect every person individually and society collectively." ®isto make thepolitical system work I urge you to use your positions as state health, �, �,:, Y for social justice. Board of Health Retreat 1�ision & Prioritization Process: .Agenda Item #T., 1 • Prevention PrincipCes .2Lpril2i, 2005 • • Board of 3-fealth Retreat Vision & Prioritization Process: .agenda Item #T., 2 � Standards from Public .3-CealtFi Improvement Plan ApriC21, 2005 • 1 . - , ,.. .., ,,,,,,,,-: ,. ., , A. ,,,,,,„ipii,,,ipn,, ,,,,1„.„,,,,,:„.„, i __ IIIstorm Jzard or quantitative measures are used.Computer hardware and software is available to support Public health assessment skills and word processing,spreadsheets,complex analysis - - _ tools are in place in all public health capabilities,databases and Internet access. Sto-s dards for Public jurisdictions and their level is e Staff members who perform assessment activities continuously maintained and have documented training and experience in Health Assessment enhanced. epidemiology,research,and data analysis. Statewide training and peer exchange Local measures: opportunities are coordinated and documented. ® Current information on health issues affecting the community is readily accessible,including tar d 2 standardized quantitative and qualitative data. ® There is a written procedure describing how and Information about environmental where to obtain technical assistance on threats and community health status is assessment issues. collected,analyzed and disseminated at ® Goals and objectives are established for intervals appropriate for the X , assessment activities as a part of LHJ planning,and community staff or outside assistance is identified to perform the work. Local measures: ® Information on health issues affecting the (D Assessment data is provided to community community is updated regularly and includes groups and representatives of the broader information on communicable disease, community for review and identification of • environmental health and health status.Data being emerging issues that may require investigation. tracked have standard definitions,and ® The Board of Health receives information on local f< standardized qualitative or quantitative measures health indicators at least annually. = are used.Computer hardware and software is P ® Assessment procedures describe how population 0 ` available to support word processing, level investigations are carried out for ;� 44 spreadsheets with basic analysis capabilities, documented or emerging health issues and tx databases and Internet access. problems. a ® Staff who perform assessment activities have ® Assessment investigations of changing or emerging _ ... g, documented training and experience in health issues are part of the LHJ's annual goals epidemiology,research,and data analysis. and objectives. Attendance at trainings and peer exchange ® A core set of health status indicators,which may opportunities to expand available assessment include selected local indicators,is used as the expertise is documented. basis for continuous monitoring of the health State measures: status of the community. A surveillance system Understanding he,ilth issues 0 Consultation and technical assistance are using monitoring data is maintained to signal provided to LHJs and state programs on health changes in priority health issues. Protecting data collection and analysis,as documented by State me sures: people from logs or reports.Coordination is provided in the Reports are provided to LHJs and other groups. disease development and use of data standards,including The reports provide health information analysis definitions and descriptions. and include key health indicators tracked over Assuring safe, healthy ® Written procedures are maintained and time. environment for people disseminated for how to obtain consultation and technical assistance for LHJs or state programs A core set of health status indicators is used as Prevention regarding health data collection and analysis,and the basis for continuous monitoring of the health is best: promotingstatus of the state,and results are published at program evaluation. healthy hyingscheduled intervals. A surveillance system using Goals and objectives are established for monitoring data is maintained to signal changes in assessment activities as a part of DOH planning, ire.. r l priority health issues. =�•fi eta and resources are identified to perform the work services they need 0 Information on health issues affecting the state is ® Written procedures describe how population • updated regularly and includes information on level investigations are carried out in cooperation communicable disease,environmental health and with LHJs in response to known or emerging data about health status.Data being tracked have health issues.The procedures include expected standard definitions,and standardized qualitative time frames for response. 3 Standards for Public Health in Washington State O Investigations of changing or emerging health Standard 4 ® Employees are trained regarding confidentiality, issues are part of the annual goals and objectives including those who handle patient information established by DOH. Health policy decisions are guided by and clinical records,as well as those handling data. health assessment in formats n,with ® All employees and BOH members,as appropriate, involvement of representative have signed confidentiality statements. • Standard community members. State measures: Public health program results areLmeasures: evaluated to document effectiveness. ® Stakeholders that receive data have demonstrated ® There is documentation of community agreement to comply with confidentiality policies Local measures: involvement in the process of reviewing health and practices,as appropriate. ® The annual report to the BOH includes progress data and recommending action such as further There are written policies,including data sharing towards program goals. investigation,new program effort or policy agreements,regarding confidentiality that govern direction. the use,sharingand transfer of data within the ® There is a written procedure for using appropriate data to evaluate program ® The annual report to the BOH summarizes DOH and among the DOH,LHJs and partner assessment data,including environmental health, agencies.Written protocols are followed for effectiveness.Programs,whether provided directly or contracted,have written goals,objectives and and the recommended actions for health policy assuring protection of data(passwords,firewalls, performance measures,and are based on relevant decisions as evidenced through program,budget, backup systems)and data systems. research. and grant applications. ® All program data are submitted to local,state, ® There is a written protocol for developing regional and federal agencies in a confidential and Q3 Program performance measures are monitored, recommendations for action using health secure manner. the data is analyzed,and regular reports assessment information toide health poli document the progress towards goals. gu P cy 0 Employees are trained regarding confidentiality, decisions. including those who handle patient information ® LHJ program staff have training in methods to ® Key indicator data and related recommendations and clinical records,as well as those handling data. evaluate performance against goals and assess are used in evaluatinggoals and program objectives. ® All employees have signed confidentiality effectiveness. State measures: agreements. ® Changes in activities that are based on analysis of 0 key indicator data or performance measurement There is documentation of stakeholder data are summarized as a part of quality involvement in DOH health assessment and policy improvement activities. development. ® There is a written protocol for using health State measures: assessment information to guide health policy 0 Consultation and technical assistance are decisions. • provided to LHJs and state programs on program ® State health assessment data is linked to health evaluation,as documented by case write-ups or policy decisions,as evidenced through legislative logs. requests,budget decisions,programs or grants. ® Programs administered by the DOH have written goals,objectives and performance measures,and Standard 5 are based on relevant research.There is a written protocol for using appropriate data to evaluate Health data is handled so that program effectiveness. confidentiality is protected and health ® Program performance measures are monitored, information systems are secure. the data is analyzed,and regular reports Local measures: document the progress towards goals. State and LHJ staff members have been trained on ® Community members and stakeholders that program evaluation as evidenced by receive data have demonstrated agreement to documentation of staff training. comply with confidentiality policies and practices, as appropriate. El Changes in activities that are based on analysis of ® There are written policies regarding key indicator data or performance measurement confidentiality.Written policies,including data data are summarized as a part of quality sharing agreements,govern the use,sharing and improvement activities. transfer of data within the LHJ and with partner agencies.Written protocols are followed for assuring protection of data(passwords,firewalls, backup systems)and data systems. ® All program data are submitted to local,state, regional and federal agencies in a confidential and secure manner. 1111 Standards for Public Health in Washington State 4 • '. ,' - •-_,�. l el>-% Li f r-1 % 1 , } • Start , Key indicators and implications for investigation, intervention or education efforts are A surveillance and reporting system is documented. T— � - 'i t mainaned to identify emerging health � � � A statewide database for reportable conditions is threats. maintained;surveillance data are summarized and Standards for ®cal me tires` disseminated to LHJs at least annually.Uniform �_ �sc�� fe data standards and case definitions are updated Q Information is provided on how to contact the and published at least annually. Disease ®� Other LHJ to report a public health concern 24 hours per day.Law enforcement has current local and • Staff members receive training on communicable state 24-hour emergencycontact lists. disease reporting,as evidenced by protocols. Health Risks © Health care providers and labs know which Standard _:- .4,--:-,- 7,..'4-47.4...7457,.' diseases require reporting,have timeframes,and have 24-hour local contact information.There is a Response plans delineate roles and process for identifying new providers in the responsibilities in the event of community and engaging them in the reporting communicable disease outbreaks and YV process. other health risks that threaten the ©3 The local BOH receives an annual report,one health of people. '' element of which summarizes communicable 7rowdisease surveillance activity.,-- L®Cal measures: ® Written protocols are maintained for receiving ® Phone numbers for weekday and after-hours -, and managing information on notifiable conditions. emergency contacts are available to DOH and Y. The protocols include role-specific steps to take appropriate local agencies,such as schools and when receiving information as well as guidance on public safety. ' - providinginformation to the public. © APrimarY contact person or designated phone © Communicable disease key indicators and line for the LHJ is clearly identified in implications for investigation,intervention or communications to health providers and 0 education efforts are evaluated annually. appropriate public safety officials for reporting P` ..__: __ x---,%-,-, „4,_....:, purposes. _ �:, � © A communicable disease tracking system is used 3 Writtenpolicies orprocedures delineate specific which documents the initial report,investigation, P agency roles and responsibilities within enc findings and subsequent reporting to state andg y divisions z federal agencies. for local response and case investigations of ® Staff members receive training on communicable disease outbreaks and other health risks. disease reporting,as evidenced by local protocols. State measures: State measures: 0 Phone numbers for after-hours contacts for all 0 Information is provided to the public on how to local and state public health jurisdictions are Ui contact the DOH to report a ublic health updated and disseminated statewide at least Usti rsta . fg health issues Po P annually. concern 24 hours per day.Law enforcement has emergency current state 24-hour contact lists. Written policies or procedures delineate specific Protecting people froom �genc y Consultation and technical assistance are provided roles and responsibilities for state response to disease to LHJs on surveillance and reporting,as disease outbreaks or public health emergencies. There is a formal description of the roles and documented by case summaries or reports. Assuring safe, healthy Laboratories and health care providers,including relationship between communicable disease, environment for people new licensees,are provided with information on environmental health and program administration. disease reporting requirements,timeframes,and a Variations from overall process are identified in Prevention is best: promoting 24-hour DOH point of contact disease-specific protocols. Written procedures are maintained and Written procedures describe how expanded lab healthy livingdisseminated for how to obtain state or federal capacity is made readily available when needed for consultation and technical assistance for LHJs. outbreak response,and there is a current list of Helpingpeople get the Assistance includes surveillance,reporting,disease labs having the capacity to analyze specimens. services they need intervention management during outbreaks or 0DOH staff members receive training on the public health emergencies and accuracy and clarity policies and procedures regarding roles and IIIof public health messages. responsibilities for response to public health ® Annual goals and objectives for communicable threats,as evidenced by protocols. disease are a part of the DOH planning process. =' Standards for Public Health in Washington State St n �?r 3 communicable disease investigations and Standard 5 - consultations is done to monitor timeliness and Communicable dise se investigation compliance with disease-specific protocols. Communicable disease and other and control procedures are in place 0 DOH identifies key performance measures for health risk responses are routinely and actions documented° communicable disease investigations and evaluated for opportunities for • Local measures: consultation. improving public health system • - Q Lists of private and public sources for referral to ® Staff members conducting disease investigations response. treatment are accessible to LH staff have appropriate skills and training as evidenced in J job descriptions and resumes. Loca �� tires: Q Information is given to local providers through ® An evaluation for each significant outbreak public health alerts and newsletters about Standard 4 response documents what worked well and what managing reportable conditions. Urgent public health messages are process improvements are recommended for the Q Communicable disease protocols require that future.Feedback is solicited from appropriate . communicated quickly and clearly and investigations begin within I working day,unless a actions are decu►nented° entities,such as hospitals and providers.Meetings disease-specific protocol defines an alternate time are convened to assess how the outbreak was frame.Disease-specific protocols identify Local measures: handled,identify issues and recommend changes information about the disease,case investigation ® Information is provided through public health in response procedures. steps,reporting requirements,contact and clinical alerts to key stakeholders and press releases to ® Findings and policy recommendations for effective management(including referral to care),use of the media. response efforts are included in reports to the emergency biologics and the process forBOH. ® A current contact list of media and providers is exercising legal authority for disease control 3 (including non-voluntary isolation). maintained and updated at least annually.This list C) Local protocols are revised based on local review ( g ry is in the communicable disease manual and at findings and model materials disseminated by Documentation demonstrates staff member DOH. actions are in compliance with protocols and other appropriate departmental locations. state statutes. C) Roles are identified for working with the news ® Issues identified in outbreak evaluations are media.Policies identify the timeframes for addressed in future goals and objectives for ® An annual evaluation of a sample of communications and the expectations for all staff communicable disease programs. communicable disease investigations is done to regarding information sharing and response to ® Staff training in communicable disease and other monitor timeliness and compliance with disease- questions,as well as the steps for creating and health risk issues is documented. specific protocols. distributingclear and accuratepublic health alerts © A debriefing process for review of response to ® LHJs identify key performance measures for and media releases. public health threats or disease outbreaks is communicable disease investigation and ® enforcement actions. Staff who have lead roles in communicating urgent included in the quality improvement plan and messages have been trained in risk communication. includes consideration of surveillance,staff role © Staff members conducting disease investigations investigation procedures and communication. have appropriate skills and training as evidenced in State measures: job descriptions and resumes. 0 A communication system is maintained for rapid State measures: State measures: dissemination of urgent public health messages to 0 Timely information about best practices in disease the media and other state and national contacts. control is gathered and disseminated. . O Consultation and staff time are provided to LHJs Coordination is provided for a state and local for local support of disease intervention ® A communication system is maintained for rapid PP dissemination of urgent public health messages to debriefing to evaluate extraordinary disease management during outbreaks or public health LHJs,other agencies and health providers. events that required a multi-agency response;a emergencies,as documented by case write-ups. Consultation is provided to LHJs to assure the written summary of evaluation findings and Recent research findings relating to the most accuracy and clarity of public health information recommendations is disseminated statewide. effective population-based methods of disease prevention and control are provided to LHJs.Labs associated with an outbreak or public health 0 Model plans,protocols and evaluation templates are provided written protocols for the handling, emergency,as documented by case write-ups. for response to disease outbreaks or public health storage,and transportation of specimens. State-issued announcements are shared with LHJs emergencies are developed and disseminated to in a timely manner. LHJs. • DOH leads statewide development and use of a standardized set of written protocols for ® Roles are identified for working with the news 0 Model materials are revised based on evaluation media.Written policies identify the timeframes findings,including review of outbreaks. communicable disease investigation and control, including templates for documentation.Disease- for communications and the expectations for all 0 Response issues identified in outbreak evaluations specific protocols identify information about the staff regarding information sharing and response are addressed in future goals and objectives for to questions,as well as the steps for creating and communicable disease programs. disease,case investigation steps,reporting distributing clear and accurate public health alerts requirements,contact and clinical management ® Staff members are trained in surveillance, (including referral to care),use of emergency and media releases. outbreak response and communicable disease biologics and the process for exercising legal 0 Communication issues identified in outbreak control and are provided with standardized tools. authority for disease control(including non- response evaluations are addressed in writing ® A debriefing process for review of response to with future goals and objectives in the voluntary isolation).Documentation demonstrates public health threats or disease outbreaks is communicable disease quality improvement plan. staff member actions are in compliance with included in the quality improvement plan and protocols and state statutes. 0 Staff members with lead roles in communicating includes consideration of surveillance,staff role. 0 An annual evaluation of a sample of state urgent messages have been trained in risk investigation procedures and communication. communication. Standards for Public Health in Washington State 6 Assorkaw A Safe Healthy Environment for • Standard Environmental health education is a Services are available throughout the planned component of public health state to respond to environmental Standards for programs. events or natural disasters that Environmental Local measures: threaten the public's health. Health � O Information is available about environmental Local measures: health educational programs through brochures, @ Information is provided to the public on how to flyers,newsletters,websites or other report environmental health threats or public mechanisms. health emergencies,24 hours a day;this includes ® There are documented processes for involving a phone number. community members and stakeholders in ® Appropriate stakeholders are engaged in addressing environmental health issues,including developing emergency response plans.Following education and the provision of technical an emergency response to an environmental assistance. health problem or natural disaster,stakeholders ti �. 03 A plan for environmental health education are convened to review how the situation was exists and includes goals,objectives and learning handled,and this debriefing is documented with 4outcomes. a written summary of findings and ® The environmental health education plan recommendations. . identifies performance measures for education ® Procedures are in place to monitor access to • programs. There is an evaluation process for services and to evaluate the effectiveness of l health education offerings that is used to revise emergency responseplans.Findings g emer enc Findin and curricula. a. `'� - recommendations for emergency response t ® Staff members conducting environmental health policies are included in reports to the BOH. ' ` education have appropriate skills and training. ® There is a plan that describes LHJ roles and State measures: responsibilities for environmental events or natural disasters that threaten the health of the �,; ;3 ® Information is provided to the public about the people. There is a clear link between this plan «:•' availability of state level environmental health educational programs through contact and other local emergency response plans. _ A.a., information on brochures,flyers,newsletters, ® Key staff members are trained in risk d websites and other mechanisms. communication and in use of the LHJ ® There are documented processes for involving emergency response plan. stakeholders in addressing environmental health State measures: issues including education and the provision of 0 Information is provided to the public on how to technical assistance. report environmental health threats or public Understanding health issues ® A plan for environmental health education health emergencies,24 hours a day;this includes exists,with goals,objectives and learning a phone number. rotecting peJ outcomes. There is an evaluation process for ® Consultation and technical assistance are health education offerings that is used to revise provided to LHJs and other agencies on disease curricula. emergency preparedness,as documented by 0 Environmental health education services are case write-ups or logs.Following an emergency Assuring a safe, healthy provided in conformance with the statewide response to an environmental health problem environ;„ent for people plan. or natural disaster,LHJs and other agencies are 0 The environmental health education plan convened to review how the situation was Prevention is best: promoting identifies performance measures for education handled. This debriefing is documented with a programs that are monitored and analyzed on a written summary of findings and healthy liviroutine basis. recommendations. F x ® Staff members conducting environmental health Written procedures are maintained and e 8 6 a'he education have appropriate health education disseminated for how to obtain consultation services they need skills and training as evidenced by job and technical assistance regarding emergency • descriptions,resumes or training preparedness.Procedures are in place to documentation. monitor access to services and to evaluate the effectiveness of emergency response plans. Policies are revised based on event debriefing findings and recommendations. 7 Standards for Public Health in Washington State There is a plan that describes DOH internal Standard roles and responsibilities for environmental events or natural disasters that threaten the Compliance with public he.Ith health of the people. There is a clear link regulations is sought through between this plan and other state and local enforcement actions. • emergency response plans. All DOH program staff are trained in risk Local measures: communication and the DOH emergency 0 Written policies,local ordinances,laws and administrative codes are accessible to the response plan,as evidenced by training documentation. public. ® Compliance procedures are written for all areas Standard of environmental health activity. The procedures specify the documentation Both environmental health risks and requirements associated with enforcement environmental health illnesses are action.Documentation demonstrates that tracked,recorded and reported. environmental health work conforms with policies,local ordinances and state statutes. Local measures: ® There is a documented process for periodic ® Environmental health data is available for review of enforcement actions. community groups and other local agencies to ® An environmental health tracking system review. enables documentation of the initial report, ® A surveillance system is in place to record and investigation,findings,enforcement and report key indicators of environmental health subsequent reporting to other agencies as risks and related illnesses.Information is tracked required. over time to monitor trends. A system is in place to assure that data is shared routinely ® Environmental health staff members are trained on compliance procedures,as evidenced by with local,state and regional agencies. training documentation. Q A quality improvement plan includes consideration of environmental health State measures: information and trends,findings from public 0 Written policies,local ordinances,laws and input,evaluation of health education offerings administrative codes are accessible to the • and information from compliance activity. public. State measures: ® Information about best practices in 0 environmental health compliance activity is Coordination is provided in development of gathered and disseminated,includingform data standards for environmental health indicators.Information based on the surveillance templates,time frames,interagency coordination system is developed and provided to LHJs and steps,hearing procedures,citation issuance and other state stakeholders. documentation requirements. ® Compliance procedures are written for all areas ® A statewide surveillance system is in place to of environmental health activity carried out by receive,record and report key indicators for DOH.Documentation demonstrates that environmental health risks and related illnesses. environmental health work conforms with Results are tracked and trended over time and policies,local ordinances and state statutes. reported regularly. A system is in place to assure that data is transferred routinely to local, 0 There is a documented process for periodic review of enforcement actions. state and regional agencies. A quality improvement plan includes 0 An environmental health tracking system consideration of analysis of environmental enables documentation of the initial report, health information and trends,findings from investigation,findings,enforcement and debriefings,evaluation of health education subsequent reporting to other agencies as offerings and information from compliance required. activity. Environmental health staff members are trained on compliance procedures,as evidenced by training documentation. . - Standards for Public Health in Washington State 8 - rt wil do" is li,e-st: Promoting Healthy � ® g O Standard 6 ® A broad range of community partners takes part in planning and implementing prevention and Policies are adopted that support health promotion efforts to address selected prevention priorities and that reflect priorities for prevention and health promotion. a Standards for consideration of scientifically-based ® Staff members have training in community public health literature. mobilization methods as evidenced by training t r Peeve tion Local measures: documentation. Community Health C) Prevention and health promotion priorities are State measures: selected with involvement from the BOH, 0 The DOH provides leadership in involving Promotion community groups and other organizations stakeholders in considering assessment interested in the public's health. information to set prevention and health ® Prevention and health promotion priorities are promotion priorities. adopted by the BOH,based on assessment ® A broad range of partners takes part in planning information,local issues,funding availability, and implementing prevention and health program evaluation and experience in service promotion efforts to address selected priorities delivery,including information on best practices for prevention and health promotion. or scientific findings. ® Information about community mobilization efforts Tr ® Prevention and health promotion priorities are for prevention priorities is collected and shared reflected in the goals,objectives and performance with LHJs and other stakeholders. measures of the LH's annuallan.Data from p 0 The statewide plan for prevention and health program evaluation and key indicators is used to promotion identifies efforts to link public and develop strategies. private partnerships into a network of prevention Ir''' State measures: services. f,r ® Reports about new or emerging issues that ® DOH staff members have training in community contribute to health policy choices are routinely mobilization methods as evidenced by trainingdocumentation. developed and disseminated.Reports include .� information about best practices in prevention � .� � - � Standard and health promotion programs. ;, t� Access to high qualityprevention x� � � ® Consultation and technical assistance is available � T ----''':1--,---,-1--: <, fl to assist LHJs in proposing and developing services for individuals,families,and prevention and health promotion policies and communities is encouraged and linitiatives.Written procedures are maintained and enhanced by disseminating information shared,describing how to obtain consultation and about available services and by • assistance regarding development,delivery or • evaluation of prevention and health promotion engaging in and supporting initiatives. collaborative partnerships. Understanding health issues ® Priorities are set for prevention and health Prevention services may be focused on 1 promotion services,and a statewide reaching individuals,families and Protecting from implementation plan is developed with goals, communities. Examples of prevention disease objectives and performance measures. services include chronic disease prevention, 0 The statewide plan is evaluated and revised home visiting by public health nurses, Assuring . safe, healthy i regularly,incorporating information from health immunization programs,efforts to reduce assessment data and program evaluation. unintentional injuries and violence,including env)ronment osexual assault Prevention is best: promoting Local measures: healthy living Active involvement of community ® Summary information is available to the public 3 members is sought in addressing describing preventive services available in the Helping people get the i prevention priorities. community.This may be produced by a partner Local measures: organization or the LHJ,and it may be produced servicess in a paper or web-based format. • 4 ® The LHJ provides leadership in involving ® Local prevention services are evaluated and a gap community members in considering assessment analysis that compares existing community information to set prevention priorities. prevention services to projected need for 9 Standards for Public Health in Washington State services is performed periodically and integrated from outreach,screening,referrals,case ® Staff members have training in health promotion into the priority setting process. management and follow-up for program methods as evidenced by training documentation. ® Results of prevention program evaluation and improvement.Prevention programs,provided analysis of service gaps are reported to local directly or by contract,are evaluated against State easures` stakeholders and to peers in other communities. performance measures and incorporate 0 Health promotion activities are provided directly ® Staff have training in program evaluation methods assessment information.The type and number of by DOH or by contractors and are intende prevention services are included in programreach the entire population or at-risk popula as evidenced by training documentation. performance measures. in the community. ® A quality improvement plan incorporates program evaluation findings,evaluation of community ® Staff providing prevention,early intervention or ® Literature reviews of health promotion mobilization efforts,use of emerging literature outreach services have appropriate skills and effectiveness are conducted and disseminated. and best practices and delivery of prevention and training as evidenced by job descriptions,resumes Consultation and technical assistance on health health promotion services. or training documentation. promotion implementation and evaluation is provided for LHJs.There is a system to inform State measures: State measures: LHJs and other stakeholders about health _ 0 The DOH supports best use of available 0 Consultation and technical assistance on program promotion funding opportunities. resources for prevention services through implementation and evaluation of prevention ® Health promotion activities are reviewed for leadership,collaboration and communication with services is provided for LHJs.There is a system to compliance with science,professional standards, partners.Information about prevention and health inform LHJs and other stakeholders about and state and federal requirements.Health promotion evaluation results is collected and prevention funding opportunities. promotion materials that are appropriate for shared statewide. ® Outreach and other prevention interventions are statewide use and for key cultural or linguistic ® Prevention programs,provided directly or by reviewed for compliance with science,professional groups are made available to LHJs and other contract are evaluated against performance standards,and state and federal requirements. stakeholders through a system that organizes, measures and incorporate assessment Consideration of professional requirements and develops,distributes,evaluates and updates the information.In addition,a gap analysis that competencies for effective prevention staff is materials. compares existing prevention services to included. 0 Health promotion activities have goals,objectives projected need for services is performed ® Prevention services have performance measures and performance measures that are tracked and periodically and integrated into the priority that are tracked and analyzed,and analyzed,and recommendations are made for setting process. recommendations are made for program program improvements.The number and type of ® DOH staff members have training in program improvements. health promotion activities are tracked and evaluation methods as evidenced by training 0 Statewide templates for documentation and data reported,including information on content,target documentation. collection are provided for LHJs and other audience,number of attendees.There is an ® A quality improvement plan incorporates program contractors to support performance evaluation process for health promotion elf evaluation findings,evaluation of community measurement that is used to improve programs or revise mobilization efforts,use of emerging literature ® DOH staff members have training in prevention, curricula. and best practices and delivery of prevention and early intervention or outreach services as ® DOH staff members have training in health health promotion services. evidenced by training documentation. promotion methods as evidenced by training documentation. Standard tai a r Prevention,early intervention and Health promotion activities are outreach services are provided directly provided directly or through contracts. or through contracts. ®cab measures: Health promotion activities may be focused on the entire state or community or on @ Health promotion activities are provided directly groups within the community.Examples of by LHJs or by contractors and are intended to health promotion activities include reach the entire population or at-risk populations educational efforts aimed at increasing in the community. physical activity,reduction in tobacco use, ® Procedures describe an overall system to improved dietary choices. organize,develop,distribute,evaluate and update health promotion materials.Technical assistance is Local measures: provided to community organizations,including ® Prevention priorities adopted by the BOH are the `train the trainer'methods. basis for establishing and delivering prevention, ® Health promotion efforts have goals,objectives early intervention and outreach services. and performance measures.The number and type ® Early intervention,outreach and health education of health promotion activities are tracked and materials address the diverse local populations reported,including information on content,target and languages of the intended audience. audience,number of attendees.There is an Information about how to select appropriate evaluation process for health promotion efforts • materials is available to and used by staff. that is used to improve programs or revise ® Prevention programs collect and use information curricula. Standards for Public Health in Washington State 1® x�& hg ( the r k e Th 41 St; disseminated for how to obtain consultation and dtechnical assistance for LHJs and other agencies in gathering and analyzing information regarding Information is collected and made barriers to access. available at both the state and local Gaps in access to critical health services are Standards for Access level to describe the local health identified using periodic survey data and other to Critical Health system,including existing resources for assessment information. public health protection,health care 0 Periodic studies regarding workforce needs and Services providers,facilities and support the effect on critical health services are g-.......-...... services. conducted,incorporated into the gap analysis and disseminated to LHJs and other agencies. Local measures: Ql Up-to-date information on local critical health St. ndard3 services is available for use in building partnerships with community groups and Plans to reduce specific gaps in access stakeholders. to critical health services are developed .' ® LHJ staff and contractors have a resource list of and implemented through collaborative "` - local providers of critical health services for use efforts. i in making client referrals. Local measures: f'.-3s yQs The list of critical health services is used along Community groups and stakeholders,includingwith assessment information to determine where health care providers,are convened to address detailed documentation of local capacity is access to critical health services,set goals and :60; H8 needed. ',114take action,based on information about local State measures: resources and trends.This process may be led by ', the LHJ or it may be part of a separate =. 7= > 0 list of critical health services is established and { Q' . : a core set of statewide access measures community process sponsored by multiple frp --0.' -*_:.-- ,--.,' ..,,,,,,,_.-,.,;,_, established.Information is collected on the core partners,including the LHJ. set of access measures,analyzed and reported to ® Coordination of critical health service delivery the LHJs and other agencies. among health providers is reflected in the local 0 Information is provided to LHJs and other planning processes and in the implementation of agencies about availability of licensed health care access initiatives. providers,facilities and support services. ® Where specific initiatives are selected to improve access,there is analysis of local data and Standard 2 established goals,objectives and performance Available information is used to measures. analyze trends which,over time,affect State measures: Understanding health issues access to critical health services. Information about access barriers affecting groups within the state is shared with other state Protecting people from Local measures: agencies that pay for or support critical health disease ® Data tracking and reporting systems include key services. measures of access.Periodic surveys are 0 State-initiated contracts and program evaluations �t conducted regarding the availability of critical includeperformance measures that demonstrate Assuring a safe, healthy health services and barriers to access. p coordination of critical health services delivery environment for people ® Gaps in access to critical health services are among health providers. identified using periodic survey data and other 0 Protocols are developed for implementation by Prevention is best: promoting assessment information. state agencies,LHJs and other local providers to healthy living ® The BOH receives summary information maximize enrollment and participation in available regarding access to critical health services at least insurance coverage. Helping people get the annually. 0Where specific initiatives are selected to improve services they need State measures: access,there is analysis of local data and CP 0 Consultation is provided to communities to help established goals,objectives and performance gather and analyze information about barriers to measures. accessing critical health services. @ Written procedures are maintained and i i Standards for Public Health in Washington State Standard 4 State measures: Quality measures that address the 0 Information about best practices in delivery of critical health services is gathered and capacity, .,r deliveryand process disseminated.Summary information regarding • outcomes of critical health services are delivery system changes is provided to LHJs and established,monitored and reported other agencies. Local measures: ® Training on quality improvement methods is available and is incorporated into grant and Ql Clinical services provided directly by the LHJ or program requirements. by contract have a written quality improvement plan including specific quality-based performance ® Regulatory programs and clinical services or outcome measures.Performance measures are administered by DOH have a written quality tracked and reported. improvement plan including specific quality-based ® Staff members are trained in quality improvement performance or outcome measures. methods as evidenced by training documentation. Menu of Critical Health Services This menu identifies health services and health conditions or risks for which appropriate services—screening, education and counseling,or interventions m are needed. General access to health Cvmmunlcable and Cancer services services infectious diseases Cancer-specific screening(i.e.,breast, Ongoing primary care Immunizations for vaccine preventable cervical,colorectal)and surveillance Emergency medical services and care diseases Specific cancer treatment Consultative specialty care HIV/AIDS Chronic conditions and Home care services Tuberculosis disease management Long-term care Other communicable diseases Diabetes Health risk b.-h.vi,t rs Prtgn =acy and m,:ternal, Asthma Tobacco use inf me and child health Hypertension Dietary behaviors atnd development Cardiovascular disease Physical activity and fitness Family planning Respiratory diseases(other than asthma) Injury and violence prevention(bike safety, Prenatal care Arthritis,osteoporosis,chronic back motor vehicle safety,firearm safety,poison Women,Infants and Children(WIC) conditions prevention,abuse prevention) services Renal disease Responsible sexual behavior Well child care Oral he_ lth eh vioral he: lth °nd Dental care services m<--;gtal health services Water fluoridation Substance abuse prevention and treatment Depression Suicide/crisis intervention Other serious mental illness 1110 Standards for Public Health in Washington State 12 a, CI 0 oa' E a CO P 1 A Xel _0 N a) H to s U U ..Q o H Q• A a = W lii Ih ri)b °' s a� c)--1 GG ▪ ^ m O •- un 0 A 5 , 031c9 •02 5 3 .0 I. al ri 45 o a3 3 E ,_ o cg E rte. aa)i ami -S g u a' 6, .' 0 a' op e, , ci . 4•C o 0-' m ,.' ;m o>•. o o 'C y 0'CD4-4 V X a) 3ill 1-, a) y w ▪ «i o o a. a) 0 •f., a) aq a3 0 a] V Z w C a) I.. g ami D•G 8 fy >•. cd W o o d r:4 P. :5 ? 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' Jefferson Counol Health erHuman Services f !� CASTLE HILL CENTER • 615 SHERlOAN • PORT TOWNSENO,WA 98368 . milk April 25, 2003 Dear Community Leaders: We are pleased to provide you with the latest Health of Jefferson County Report. This report is the culmination of two years' worth of work by a community partnership made up of the City of Port Townsend,Jefferson General Hospital, Olympic Area Agency on Aging,Jefferson County WSU, Olympia, the Law&Justice Committee,Jefferson County Health & Human Services, and citizens of Jefferson County. Rural communities in Washington State face many familiar challenges —aging populations, economic recession, a fragile and fragmented health care delivery system, and limited opportunities for young workers and families. We also must confront a growing list of new, often frightening threats — 4110 bioterrorism, infectious disease outbreaks, and clandestine drug labs. As these challenges mount and the resources we have to deal with them become more and more limited, we, as a community, must make a crucial decision. Do we retreat into our private lives or do we unite to face our common threats together? Community leaders and policy makers need accurate, detailed information to prioritize community needs and allocate scarce resources. The attached Report contains a comprehensive review of existing data. The next step is to find patterns and trends within this data that will better inform our decision-making processes. Thank you for joining us today as we move from data to action in pursuit of our common goal of a healthier community. Sincerely, Th -erson County Board of Health / .i► ti i Geoff '►`asci, Chair Wendi W 4, rnkle Glen Huntin d Roberta Frissell III, 5(,,1:11,0, vJothro-.,---. ..-f---rirk-----10. /6_,,, . - K_______ Sheila Westerman Dan Titterness ell Buhler Working Toward a Healthier Jefferson County Introduction The 2003 Health of Jefferson County is a compilation of data from a growing health database about the people of Jefferson County. Its focus and structure are the result of the dedicated work of the Jefferson County Data Steering Committee, a broadly representative group of elected officials, community leaders, and health professionals. The project was funded by the City of Port Townsend and Jefferson County. The immediate goal of this assessment project is to provide policy makers with high quality data about the needs of Jefferson County residents to be used to better inform policy decisions and set priorities. The ultimate goal of this process is a healthier community. A healthy community is more than the sum of its vital statistics, health measures and economic indicators; it is also determined by the values, commitment, and leadership of community members. The next step in this process is to move from data to action, using the information gathered to better understand the complex patterns of preventable disease and disability within our community. Most, if not all, of the community health problems we will uncover are beyond the resources of any single institution or organization to resolve. Complex community problems require community-based partnerships committed to long-term efforts. To improve our community's health—to make Jefferson County a place where people are healthy, safe, and cared for–will take tremendous ongoing effort. We believe this community is ready to embrace this crucial challenge. Thank you for reviewing this material with us. We look forward to your thoughtful input and invite you to join your fellow community members in the important work that lies ahead. Sincerely, Jean'Baldwin, M.S.N., Director Dr. Thomas H. Locke Jefferson County Health and Human Services Health Officer, Jefferson County • 2003 Health of Jefferson County 6 Assessment Matrix BOH Retreat 04-13-05 411 Population surveyed or monitored Administration JCHHS JCHHS <18 18-25 25-44 45-65 65+ Survey Tool Schedule Analysis Capacity* Census Every 10 years 1990-yes + ft X X X X X 2000-yes BRFSS DOH (n=200); annual 2001-yes ✓ g) X X X X (03, 04, 05, 06) 2003-pending County(n=603)2001 2004-pending Healthy Youth Joint-sponsors 2002-yes + Q X Survey (DOH, OSPI, DASA, 2004-pending CTED); bi-annual 00, 02, 04, 06, 08 Grades 6, 8, 10, 12 Community Random Mailing TBD TBD X X X X Attitudes JCHHS Sponsor Survey Data Tool DSHS clients Annual e 0 X X X X X &services Intercensal WA-OFM e ® X X X X X Population Annual Estimates Vital Records Annual e o X X X X X Communicable Annual e 0 X X X X X 0 Disease Program Evaluation Family + W X X X X X Planning MCH ✓ O X X X X X Tobacco ✓ O X X X X X Prevention *KEY: JCHHS Analysis Capacity-Assessment of current infrastructure Infrastructure includes funding to pay for training of staff, dedicated staff time to conduct analysis and dedicated resources (web page, Information technology, printing)available to respond to community requests for information. + High capacity-agency has infrastructure to analyze data set on regular basis ✓ Developing capacity-agency is developing infrastructure to analyze data set on regular basis e Limited capacity-staff limited capacity to analyze data set on regular basis g) Available on JCPH website (http://www.jeffersoncountypublichealth.org) CD Information that could be posted on JCPH website in html,word, or pdf format • � '$4 DSHS Human Services in Your County, July 2002 - June 2003 !. < :t zs'xieyarw: ALL AGES Jefferson DOLLARS Number Served Use Rate Total Spent Per Client DSHS Agency Total 6,440 24.1% 21,980,518 3,413 • Population 26,700 A.ln. and Adult Services Total 240 ; 0.9% 3,174,479 13,227 A•u t Fami y Homes 3 0.0% 21,362 7,121 Adult Residential Care : 2 0.0% 9,219 4,609 Assisted Living 18 0.1% 141,868 7,882 In-Home Services 159 0.6% 1,673,284 10,524 Nursing Homes 79 0.3% 1,127,854 14,277 Additional Services(AAS Misc) 3 0.0% 200,893 66,964 Alcohol and Substance Abuse Total 247 0.9% 336,326 1,362 AD S' Assessments i 104 0.4% 21,148 203 Detoxification I 10 0.0% 7,677 768 Opiate Substitution Treatment: 1 - 2,379 2,379 Outpatient Assessment 80 0.3% 15,977 200 Outpatient Treatment i 144 0.5% 145,333 1,009 Residential Treatment I 72 0.3% 132,823 1,845 Additional Services(DASA Misc)? 43 0.2% 10,988 256 Children's Services Total 781 2.9°/a 1,285,319 1,646 Adoption Services i 121 0.50/0 280,342 2,317 Behavioral Rehabilitation Services-Emergent I 1 - 2,295 2,295 Behavioral Rehabilitation Services-Ongoing 6 0.0% 164,092 27,349 Child Care Services 28 0.1% 45,719 1,633 Child Protective Services Case Management i 475 1.8% 100,468 212 Child Welfare Services Case Management I 142 0.5% 210,372 1,481 Crisis Care i _ - - Family Reconciliation Service i 128 0.5% 33,707 263 Family-Focused Services 34 0.1% 39,663 1,167 Foster Care Placement`: 48 0.2% 266,639 5,555 Foster Care Support i 42 0.2% 125,534 2,989 Other Intensive Services 3 0.0% 3,827 1,276 Additional Services(CA Misc)i 8 0.0% 12,660 1,582 Developmental Disabilities Services Total 140 0.5% 1,593,556 11,383 Case Management i 135 0.50/0 104,818 776 Community Residential Services i 26 0.1% 676,299 26,012 County Services 46 0.2% 159,015 3,457 Family Support Service 24 0.1% 40,819 1,701 Personal Care i 44 0.2% 385,222 8,755 Professional Support Services 23 0.1% 4,400 191 RHCs and Nursing Facilities 1 - 5,364 5,364 • Voluntary Placement-Children I 4 0.0% 217,619 54,405 Additional Services(DDS Misc)I - - - - Economic Services Total 2,972 11.1% 3,821,667 1,286 Basic Foo. Program€ 2,601 9.7% 1,604,005 617 Consolidated Emergency Assistance I - - - - Diversion Cash Assistance 32 0.1% 13,959 436 General Assistance(GA-ABD,GA-I,GA-U, and GA-X)I 181 0.7% 335,667 1,855 Refugee Grants I - - - - Supplemental Security Income-State(SSI)3 50 0.2% 18,302 366 TANF and State Family Assistance i 824 3.1% 840,825 1,020 Work First; 378 1.4% 121,700 322 Working Connections Child Care i 610 2.3% 858,415 1,407 Additional Services(ESA Misc)% 182 0.7% 28,793 158 Juvenile Rehabilitation Total 16 0.1% 200,381 12,524 Community P acement i 2 0.0% 11,964 5,982 Institutions,Youth Camps, and Basic Training i 8 0.0% 154,700 19,337 Parole I 9 0.0% 26,867 2,985 Additional Services(JRA Misc)I 5 0.0% 6,850 1,370 Medical Assistance Total 5,315 19.90/a 9,628,733 1,812 Denta Services 1,313 4.9% 467,203 356 Hospital Inpatient I 419 1.6% 2,552,522 6,092 Hospital Outpatient 1,637 6.1% 1,248,261 763 Managed Health Care. 656 2.5% 690,834 1,053 Medically Eligible Clients(T19)I 5,059 19.o% - - Medically Eligible Clients(not T19)I 354 1.3% - - Other Medical Services 1,880 7.0% 1,082,030 576 Physician Services i 2,579 9.7% 1,048,737 407 Prescription Drugs; 2,513 9.4% 2,539,146 1,010 Mental Health Services Total 531 2.00/o 1,680,616 3,165 C i • Stu.y an. Treatment Center i. - - _ - Community Inpatient Evaluation and Treatment i 50 0.20/0 70,984 1,420 Community Services i 522 2.0% 1,225,447 2,348 State Hospitals(State Institutions) 9 0.0% 384,185 42,687 Vocational Rehabilitation Totat 186 0.7% 259,440 1,395 In.epen.ent Living Case Management1 - 472 472 i Medical and Psychological Services 17 0.1% 19,583 1,152 • Personal Support Services I 46 0.2% 12,357 269 Placement Support(Work Support)f 27 0.1% 23,138 857 Training, Education, and Supplies 28 0.1% 33,073 1,181 Vocational Assessments(Job Skills)I 90 0.3% 52,230 580 Vocational Rehabilitation Case Management; 184 0.70/0 118,587 644 Clients and dollars come from the DSHS,Research and Data Analysis,Client Services Database:analytical extract of 01/24/2005.Population is from the Office of Financial Management,2003 projection by county. January 2005. ��' S :?ExffQf ?;s DSHS Human Services in Your County, July 2002 -June 2003 YOUTH II Jefferson DOLLARS Number Served allEMEMII Total Spent MIEMEMINAIIII 41) DSHS A.enc Total 2,752 54.9% 5,799,799 2,107 Population 5,011 A.in and Adult Services Total 2 0.0% 1484 592 Adult Family Homes i - _ _ - Adult Residential Care i - - - _ Assisted Living': - - - - In-Home Services i 2 0.0% 1,184 592 Nursing Homes i _ - - _ Additional Services(AAS Misc)i _ - _ _ Alcohol and Substance Abuse Total 50 : 1..0% 79,626 1,593 6, aA Assessments 1 0.0% 189 189 Detoxification i _ _ - - Opiate Substitution Treatment i - - - - Outpatient Assessment i 32 0.6% 6,773 212 Outpatient Treatment 36 0.7% 39,654 1,102 Residential Treatment i 5 0.1% 24,479 4,896 Additional Services(DASA Misc) i 3 0.1% 8,531 2,844 Children's Services Total 351 7.0% 1,162,799 . 3,323 • Adoption Services 62 1.2% 278,382 4,490 Behavioral Rehabilitation Services-Emergent 1 0.0% 2,295 2,295 Behavioral Rehabilitation Services-Ongoing 6 0.1% 164,092 27,349 Child Care Services 28 0.6% 45,719 1,633 Child Protective Services Case Management 198 4.0% 43,908 222 Child Welfare Services Case Management 81 1.6% 177,470 2,191 Crisis Care - - - _ Family Reconciliation Service 49 1.0% 17,817 364 Family-Focused Services 23 0.5% 36,625 1,592 Foster Care Placement 46 0.9% 258,282 5,615 Foster Care Support 38 0.8% 123,162 3,241 Other Intensive Services 3 0.1% 3,827 1,276 Additional Services(CA Misc). 7 0.1% 11,222 1,603 Develo.mental Disabilities Services Total 51 i.00/0 201,022 3,942 Case Management E 49 1.0% 36,052 736 Community Residential Services _ - - _ County Services i 7 0.1% 12,856 1,837 Family Support Service 1 14 0.3% 25,357 1,811 Personal Carel 11 0.2% 74,499 6,773 III Professional Support Services! _ -- - - , RHCs and Nursing Facilities; - Voluntary Placement Children{ 2 0.o°/, - 52,257 26129 Additional Services(DDS Misc) - - - - Economic Services Total 1,124 r 22.4% 1,582,116 1,408 Basic Food Program i 931 18.6% 517,712 556 Consolidated Emergency Assistance i - - - _ Diversion Cash Assistance i 19 0.4°/n 7,787 410 General Assistance(GA-ABD, GA-I, GA-U, and GA-X)i - - - Refugee Grants i - - - - Supplemental Security Income-State(SSI)i 1 0.0% 16 16 TANF and State Family Assistance i 493 9.8% 549,897 1,115 Work First; 9 0.2% 3,720 413 Working Connections Child Care: 374 7.5% 502,953 1,345 Additional Services(ESA Misc)` 1 0.0% 31 31 Juvenile.Rehabilitation Total'' 9 0.2°/n 126,683 14,076 Community P acement; - _ - _ Institutions,Youth Camps, and Basic Training 1 6 0.1% 118,528 19,755 Parole1 3 0.1°!, 3,025 1,008 Additional Services(JRA Misc)l 4 0.1% 5,131 1,283 Medical Assistance Total 2,604 52.0°/a 2,255,979 866 Dental Services i 950 19.0% 288,890 304 Hospital Inpatient 45 0.9% 242,481 5,388 Hospital Outpatient E 714 14.3% 303,491 425 Managed Health Care; 541 10.8% 466,505 862 Medically Eligible Clients(T19)i 2,565 51.2% - - Medically Eligible Clients(not T19) 69 1.4°f° - - Other Medical Services 1 818 16.3% 432,183 528 Physician Services i 1,307 26.1% 293,544 225 Prescription Drugs i 1,148 22.9% 228,885 199 Mental Health Services Total 125 2.5% 390,064 3,121 Child Study and Treatment Center; - _ _ - Community Inpatient Evaluation and Treatment? 6 0.1% 7,478 1,246 Community Services i 125 2.5% 382,586 3,061 State Hospitals(State Institutions) - - - - Vocational Rehabilitation Total 1 ' 0.o°%n 326 326 Indepen•ent Living Case Management; - _ _ - III Medical and Psychological Services i - - - - Personal Support Services - - Placement Support(Work Support)` - - - Training, Education, and Supplies - - - _ Vocational Assessments(Job Skills) i - - - - Vocational Rehabilitation Case Management i 1 0.0% 326 326 Clients and dollars come from the DSHS,Research and Data Analysis,Client Services Database:analytical extract of 01/24/2005.Population is from the Office of Financial Management,2003 projection by county. January 2005. T:, `. ioct4,0 ,:`* DSHS Human Services in Your County, July 2002 -June 2003 ADULTS Jefferson iimmiligamiumommim DOU.ARs Number Served MEM= Total Spent MEMEarMEA DSHS'A.enc Total 3,213 19.8% 12,939,382 4,027 • Population 16,202 A.in."'and Adult Services Total 66 0.4°/a 866,233 13,125 Adult Family Homes; - - Adult Residential Care i 2 0.0% 9,219 4,609 Assisted Living I 3 0.0% 29,754 9,918 In-Home Services i 56 0.4% 549,026 9,804 Nursing Homes i 10 0.1% 77,583 7,758 Additional Services(MS Misc)i 2 0.0% 200,651 100,325 Alcohol and Substance Abuse Total 197 .i 1,2°/a 256,700 1,303 4 II, 4 Assessments i 103 0.6% 20,960 203 Detoxification i 10 0.1% 7,677 768 Opiate Substitution Treatment i 1 0.0% 2,379 2,379 Outpatient Assessment i 48 0.3% 9,205 192 Outpatient Treatment i 108 0.7% 105,678 979 Residential Treatment i 67 0.4% 108,344 1,617 Additional Services(DASA Misc)i 40 0.3% 2,457 61 Children's Services Total 310 1.9% 97,290 314 Adoption Services i 50 0.3% 1,542 31 Behavioral Rehabilitation Services-Emergent - - - - Behavioral Rehabilitation Services-Ongoing i - - - - Child Care Services E - - - - Child Protective Services Case Management' 192 1.20/0 38,750 202 Child Welfare Services Case Management 52 0.3% 30,239 582 Crisis Care - - - - Family Reconciliation Service 53 0.3% 11,577 218 Family-Focused Services i 10 0.1% 3,014 301 Foster Care Placement i 2 0.00/0 8,357 4,179 Foster Care Support i 4 0.0% 2,372 593 Other Intensive Services: - - - - Additional Services(CA Misc): 1 0.0% 1,438 1,438 Develo•mental Disabilities servicesTotal 85 0.5% 1,310,880 15,422 Case Management i 82 0.5% 66,048 805 Community Residential Services 24 0.2% 639,931 26,664 County Services 36 0.2% 130,822 3,634 Family Support Service: 10 0.1% 15,462 1,546 Personal Care 31 0.2% 283,950 9,160 Professional Support Services 21 0.1% 3,941 188 • RHCs and Nursing Facilities 1 0.0% 5,364 5,364 Voluntary Placement-Children 2 0.0% 165,362 82,681 Additional Services(DDS Misc) _ - - - Economic Services Total 1,759 10.90/o 2,180,817 1,240 Basic Foo. Program: 1,583 9.8% 1,035,971 654 Consolidated Emergency Assistance; _ - - - Diversion Cash Assistance i 13 0.1% 6,172 475 General Assistance(GA-ABD, GA-I,GA-U, and GA-X)l 178 1.10/0 329,964 1,854 Refugee Grants< _ - - - Supplemental Security Income-State(SSI)i 44 0.3% 16,045 365 TANF and State Family Assistance i 330 2.0% 290,461 880 Work First 369 2.3% 117,981 320 Working Connections Child Care i 236 1.5% 355,462 1,506 Additional Services(ESA Misc)s 181 1.1% 28,762 159 Juvenile Rehabilitation Total 7 0.0% 73,698 10;528 Community P acement 2 0.0% 11,964 5,982 Institutions,Youth Camps,and Basic Training 2 0.0% 36,172 18,086 Parole: 6 0.0% 23,843 3,974 Additional Services(3RA Misc): 1 0.0% 1,719 1,719 Medical Assistance Total 2,390 14.80/a 6,624,878 2,772 Dental Services i 331 2.0% 164,880 498 Hospital Inpatient i 341 2.1% 2,253,420 6,608 Hospital Outpatient i 810 5.0% 898,956 1,110 Managed Health Care 115 0.7% 224,329 1,951 Medically Eligible Clients(T19)i, 2,173 13.4% - - Medically Eligible Clients(not T19)i 285 1.8% - - Other Medical Services i 897 5.5% 550,355 614 Physician Services 1,158 7.2% 738,345 638 Prescription Drugs l 1,138 7.0% 1,794,594 1,577 Mental Health Services Total ''! 371 2.3°/a 1,273,781 3,433 C ild Study and Treatment Center i - _ - - Community Inpatient Evaluation and Treatment 39 0.2% 57,837 1,483 Community Services i 365 2.3% 831,759 2,279 State Hospitals(State Institutions)i 9 0.1% 384,185 42,687 Vocational Rehabilitation Total 184 1.10/0 255,105 1,386 In.ependent Living Case Management{ 1 0.0% 472 472 Medical and Psychological Services 16 0.1% 19,173 1,198 Personal Support Services 46 0.3% 12,357 269 • Placement Support(Work Support): 26 0.2% 22,658 871 Training, Education,and Supplies 27 0.2% 32,010 1,186 Vocational Assessments(Job Skills) 89 0.6% 51,151 575 Vocational Rehabilitation Case Management 182 1.1% 117,284 644 Clients and dollars come from the DSHS,Research and Data Analysis,Client Services Database:analytical extract of 01/24/2005.Population is from the Office of Financial Management,2003 projection by county. January 2005. - , asf4QFYi� DSHS Human Services in Your County, July 2002 - June 2003 3. A: i:3_rsiccs Jefferson Iiiiminimamminsts EIDERS DOLLARS Number Served Mir= Total Spent „..... ill DSHS A.enc Total 356 6.5°/a 3,216,779 Population 5,487 9,036 A.in• and Adult Services Total 172 s 3.1°/a 2,307,062 3,413 Adult Family Homes i 3 0.1% 21,362 17,121 Adult Residential Care; - - 7,121 Assisted Living 15 0.30k 112,114 7,474 In-Home Services 101 1.8% 1,123,073 11,120 Nursing Homes 69 1.3% 1,050,271 Additional Services(AAS Misc) 15,221 1 0.0% 242 Alcohol and Substance Abuse Total - 242 IA` A •ssessments i - - Detoxification _ - Opiate Substitution Treatment - - - - Outpatient Assessment' - - - - Outpatient Treatment - - - - Residential Treatment - - - - Additional Services(DASA Misc) - - - - Children's Services Total 1 0.0% 672 672 A.option Services Behavioral Rehabilitation Services-Emergent: - - - Behavioral Rehabilitation Services-Ongoing - - - Child Care Services - - - - - Child Protective Services Case Management: 1 0.0% Child Welfare Services Case Management' - 248 248 Crisis Care - - - - Family Reconciliation Service 1 0.0°h 424 Family-Focused Services 424 - - Foster Care Placement - - - Foster Care Support - - - - Other Intensive Services - - - Additional Services(CA Misc) - - - - - Develo.mental Disabilities Services Total 4 0.1% Case Management! 4 0.1% 6.36 8 2,718 20,4148 1849 Community Residential Services' 2 0.0% 36,368 18,184 County Services 3 0.1% 15,337 5,112 Family Support Service? - - Personal Care. 2 0.0% 26,772 13,386 0 Professional Support Services f 2 0 0% 459 RHCs and Nursing Facilities E 230 Voluntary Placement-Children - - - - - Additional Services(DOS Misc) - Economic Services Total 89 1.6% 58,734 Basic Food Program f 87 660 Consolidated Emergency Assistance; 1.6%-° 50,322 578 Diversion Cash Assistance' .. - - General Assistance(GA-ABD, GA-I, GA-U, and GA-X)i 3 ° 0.1/- 5,703 1,901 Refugee Grants - Supplemental Security Income-State(SSI)f 5 0.1% TANF and State Family Assistance: 2,241 448 1 0.0% 467 467 Work First _ _ Working Connections Child Care f - - - - Additional Services(ESA Misc) - - - Juvenile Rehabilitation Total - - - - - Community Placement: : - Institutions,Youth Camps, and Basic Training i - - - Parole l - - - - Additional Services(JRA Misc) - - - - - Medical Assistance Total 321 5.9°/a 747,876 2,330 Dental Services: 32 0.6% 13,433 420 Hospital Inpatient) 33 0.6% 56,622 1,716 Hospital Outpatient I 113 2.1% 45,814 Managed Health Care i - 405 - - Medically Eligible Clients(T19)) 321 5.9% Medically Eligible Clients(not T19)f - - Other Medical Services) 165 3.0% 99,492 Physician Services i 114 2.1% 148 Prescri tion Dru s% 15,668 148 P. 9 t 227 4.1% 515,667 6771 2479 MentakHealth Services Total _ 35 o.6°i° Chi!. Study and Treatment Center 16,771 479 - - Community Inpatient Evaluation and Treatment l 5 0.1% Community Services f 5,669 1,134 State Hospitals(State Institutions 32 0.6% 11,102 347 Vocational Rehabilitation Total 1 0.0°ia - - In•epen.ent Living Case Management: 4,009 4,009 Medical and Psychological Services l1 0.0% III Personal Support Services f 410 410 Placement Support(Work Support)) 1 0.0% Training, Education,and Supplies f0.0% 480 480 Vocational Assessments(Job Skills) 1 0.1 0.0%0 1,063 1,063 1,079 1,079 Vocational Rehabilitation Case Management f 1 0.0°/a 977 977 Clients and dollars come from the DSHS,Research and Data Analysis,Client Services Database:analytical extract of 01/24/2005.Population is from the Office of Financial Management,2003 projection by county. January 2005. • N 00 N O CN vl .-. 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N N N N N -. 1D V O) N O C CO .0 a) U Q .. m v rn N N v cm W et Q) et Of t- 0) aT + Q o / rnou oio oioou, o I? <omtinooin F � mZ • Q o u) o h o IIS o un o In o N o h o In o o O u! . a- a- N N M I'7 'at of II) U) CO CO n n CO F.. N --. O Z M SPECIAL COMMUNICATION • Actual Causes of Death in the United States, 2000 Ali H.Mokdad,PhD Context Modifiable behavioral risk factors are leading causes of mortality in the United James S.Marks,MD,MPH States.Quantifying these will provide insight into the effects of recent trends and the implications of missed prevention opportunities. Donna F.Stroup,PhD,MSc Objectives To identify and quantify the leading causes of mortality in the United Julie L.Gerberding,MD,MPH States. N A SEMINAL 1993 ARTICLE,I Design Comprehensive MEDLINE search of Englishlanguage articles that identified McGinnis and Foege'described the epidemiological, clinical, and laboratory studies linking risk behaviors and mortality. major external(nongenetic)nuodi_ The search was initially restricted to articles published during or after 1990, but we fiable factors that contributed to later included relevant articles published in 1980 to December 31,2002. Prevalence death in the United States and labeled and relative risk were identified during the literature search.We used 2000 mortality data reported to the Centers for Disease Control and Prevention to identify the causes them the"actual causes of death."Dur- and number of deaths.The estimates of cause of death were computed by multiply- ing the 1990s,substantial lifestyle pat- ing estimates of the cause-attributable fraction of preventable deaths with the total tern changes may have led to variations mortality data. in actual causes of death.Mortality rates Main Outcome Measures Actual causes of death. from heart disease, stroke, and cancer Results Ts dah 200 ee t000 deaths;18.1 have declined. At the same time,behav- f total US he deaths)leading, poor dietcauseof and ephysicaltin0 inactivitywr (400obacco0(435 00 deaths; 16.6%), and . ioral changes have led to an increased aolcohol consumption (85000 deaths;3.5%). Other actual causes of death were mi- prevalence of obesity and diabetes.' crobial agents (75000), toxic agents (55000), motor vehicle crashes (43000), inci- Most diseases and injuries have mul- dents involving firearms (29000), sexual behaviors (20000), and illicit use of drugs tiple potential causes and several fac- (17000). tors and conditions may contribute to Conclusions These analyses show that smoking remains the leading cause of mor- a single death. Therefore,it is a chal- tality. However, poor diet and physical inactivity may soon overtake tobacco as the lenge to estimate the contribution of leading cause of death. These findings, along with escalating health care costs and each factor to mortality. In this ar- aging population,argue persuasively that the need to establish a more preventive ori- tide,we used published causes of death entation in the US health care and public health systems has become more urgent. reported to the Centers for Disease Con- JAMA.2004;291:1238-1245 www.jama.com trol and Prevention (CDC) for 2000, relative risks(RRs),and prevalence es- titles including the following key deaths, we used mortality data re- timates from published literature and words:mortality,smoking,physical ac- ported in 2000 to the CDC.4 We used tivity, diet, obesity, alcohol, microbial no unpublished information or data. governmental reports to update actual causes of death in the United States—a agents,toxic agents,motor vehicle,fire- We used the following formula to cal- method similar to that used by arms, sexual behavior, illicit drug use. culate attributable fractions for each dis- McGinnis and Foege. Our search allowed for words with simi- ease: I(P0+IP; (RR;))-1]/[P.+IP; lar meaning to be included (ie, exer- (RR,)],in which Po is the percentage of METHODS cise as well as physical activity). The individuals in the United States not en- Our literature review used a MEDLINE search was initially restricted to ar- gaging in the risk behavior,P,is the per- database search of English-language ar- tides published during or after 1990, but we later included relevant articles Author Affiliations: Division of Adult and commu- ticles that identified epidemiological, Wily Health(Dr Mokdad),Office of the Director(Drs clinical, and laboratory studies link- published in 1980 to December 31, Marks and Stroup),National Center for Chronic Dic- 2002 (search strategies are available tease Pre venr tio and Hd nlg),Cen otionr Disea�ice of ing risk behaviors and mortality. Our search criteria were to include all ar- from the authors on request).For each trol and Prevention,Atlanta,Ga. risk factor,we used the prevalence and Corresponding Author: Ali H.Mokdad,PhD,Divi- RR identified by the literature search. cion of Adult and Community Health,4770 Buford For editorial comment see p 1263. Hwy, NE, Mailstop K66, Atlanta, GA 30341 To identify the causes and number of (amokdad@cdc.gov). • 1238 JAMA,March 10,2004—Vol 291,No.10(Reprinted) 02004 American Medical Association.All rights reserved. w CAUSES OF DEATH centage engaging in separate catego- • ries of the risk behavior, and RR; is Table 1.Leading Causes of Death in the United States in 2000* the RR of death for each separate cat- Death Rate per Cause of Death No.of Deaths 100000 Population egory relative to none.For instance,in Heart disease 710760 258.2 the case of smoking,Po is the percent- Malignant neoplasm 553091 200.9 age of persons who never smoked, P; Cerebrovascular disease 167 661 60.9 is the percentage of former smokers, Chronic lower respiratory tract disease 122 009 44.3 P2 is the percentage of current smok- Unintentional injuries 97900 35.6 ers, RR, is the RR of a certain type of Diabetes mellitus 69301 25.2 death for former smokers compared Influenza and pneumonia 65313 23.7 with those who never smoked, and Alzheimer disease 49558 18 RR, is the RR of death for current Nephritis,nephrotic syndrome,and nephrosis 37251 13.5 smokers compared with those who Septicemia 31224 11.3 never smoked. We then multiplied Other 499283 181.4 estimates of the cause-attributable Total 2 403 351 873.1 fraction of preventable deaths by *Data are from Mininoetal' total mortality data. Whenever pos- sible,we used RRs of death and mor- Prevention Study Wand included deaths weight.9 Recent articles have reported tality data by other variables such as due to secondhand smoking. that overweight increased in all seg- age,sex,and race. We used data from the Behavioral Risk ments of the US population.'"To de- We estimated ranges for our esti- Factor Surveillance System(BRFSS),a rive the attributable number of deaths mated number of deaths by using the cross-sectional telephone survey con- due to overweight,we used estimates smallest and highest RRs and their ducted by state health departments with from the CDC's 1999 and 2000 Na- boundaries when available.When data the CDC's assistance, to determine tional Health and Nutrition Examina- were available,we used specific under- changes in US smoking prevalence from tion Surveys.'Z We used the same pro- lying causes of death in deriving some 1995-1999 to 2000.A detailed descrip- cedure reported by Allison et al13 to of our estimates(ie,firearms,motor ve- tion of survey methods is available else- estimate annual overweight-attribut- hides,and illicit drug use).Further de- where.°A slight decline in smoking was able deaths.We used the body mass in- tails of these methods may vary due to observed from 1995-1999 to 2000.The dex(BMI)range of 23 to 25 as our ref • - availability of data and are presented in prevalence of smoking in 1995-1999 was erence category to match the method each section below.We used SAS(ver- 22.8% for current smokers (males: used by Allison et al.Body mass index sion 8.2,SAS Institute Inc, Cary,NC) 25.1%;females:20.6%),24.1%for former is calculated as weight in kilograms di- and SUDAAN (version 8.0, Research smokers(males:283%;females:20.3%), vided by the square of the height in me- Triangle Institute, Research Triangle and 53.1% for never-smokers (males: ters.Using data from the 1999 and 2000 Park,NC)statistical software. 46.5%;females:59.2%).In 2000,these National Health and Nutrition Exami- estimates were 22.2%for current smok- nation Surveys,the percentages for BMI RESULTS ers (males: 24.1%; females: 20.5%), cut points were less than 23(22.3%),23 The number of deaths in the United 24.4%for formersmokers(males:283%; to less than 25(15.09%),25 to less than States in 2000 was 2.4 million,which females: 20.7%),and 53.4%for never- 26(7.49%),26 to less than 27(7.36%), is an increase of more than 250000 smokers(males:47.6%;females:58.8%). 27 to less than 28 (6.23%), 28 to less deaths in comparison with the 1990 We estimate that approximately than 29 (6.30%), 29 to less than 30 total,due largely to population growth 435 000 deaths were attributable to (5.94%),30 to 35(16.95%),and more and increasing age.2'4 Leading causes smoking in 2000,which is an increase than 35(12.62%). of death were diseases of the heart of 35000 deaths from 1990(TABLE 2). We used hazard ratios reported pre- (710 760), malignant neoplasms This increase is due to the inclusion of viouslyi3 to recompute annual deaths (553091), and cerebrovascular dis- 35000 deaths due to secondhand smok- for 6 major population-based studies. eases(167661) (TABLE 1). ing and 1000 infant deaths due to ma- The mean estimate of the total num- ternal smoking,which were not in- ber of overweight-attributable deaths in Tobacco eluded in the article by McGinnis and 2000 was 494921. For the Alameda We used methods and software used in Foege.' County Health Study, the estimated previous CDC reports to compute the number of overweight-attributable annual smoking-attributable mortality Poor Diet and Physical Inactivity deaths in 2000 was 567683;Framing- for 2000.56 As in previous reports,we To assess the impact of poor diet and ham Heart Study, 543981;Tecumseh used RRs for each cause of death from physicalinactivity on mortality,we corn- Community Health Study, 462,005; the American Cancer Society's Cancer puled annual deaths due to over- American Cancer Society Cancer Pre- ©2004 American Medical Association.All rights reserved. (Reprinted)JAMA,March 10,2004-Vol 291,No. 10 1239 CAUSES OF DEATH • Table 2.Actual Causes of Death in the United States in 1990 and 2000 consumption.The National Health In- Actual Cause No.(%)in 1990* No.(%)in 2000 terview Survey,a household survey that measured alcohol intake in 1999 and Tobacco 400 000(19) 435 000(18.1) 2000,and the BRFSS,a telephone sur- Poor diet and physical inactivity 300 000(14) 400000(16.6) vey that measured alcohol intake in Alcohol consumption 100 000(5) 85 000(3.5) 1999.8,26 Microbial agents 90 000(a) 75 000(3.1) We used RRs from the Australian Na- Toxic agents 60 000(3) 55 000(2.3) Motor vehicle 25 000(1) 43000(1.8) tional Drug and Safety Report that were Firearms 35 000(2) 29 000(1.2) based on mortality rates derived from Sexual behavior 30 000(1) 20 000(0.8) pooled data of several studies.27 28 The Illicit drug use 20000(<1) 17 000(0.7) RR values were 1.33 for hazardous Total 1 060 000(So) 1 159 000(48.2) drinking(4.01-6.00 drinks/d for males *Data are from McGinnis and Foege.'The percentages are for all deaths. and 2.01-4.00 for females)and 1.47 for harmful drinking(?6.01 drinks/d for vention Study I,451708;Nurses Health ber of deaths from the 1999-2000 data males and >_4.01 for females) in con- Study,504602;and the National Health may well be the expected number of trast to low levels of drinking (0.26- and Nutrition Examination Survey I deaths in the next few years.Thus,we 4.00 drinks/d for males and 0.26-2.00 Epidemiologic Follow-up Study, believe a more accurate and conserva- for females) and abstinence (0-0.25 439 548.14-'9 tive estimate for overweight mortality in drinks/d for both males and females). As in the study by Allison et al, the 2000 such as 385 000, which is the We used BRFSS data to compute the estimate for the attributable number of rounded average of 2000 and 1991 es- number of alcohol-attributable deaths deaths for nonsmokers or never- timates(494921 and 280184). for the US population aged 18 years or smokers was higher than the estimate Overweight would account for the older. The BRFSS also asked ques- for the total because smoking is asso- major impact of poor diet and physi- tions about binge drinking (ie, ?5 ciated with both lower body weight and cal inactivity on mortality.20 Diet may drinks per occasion).To account for the higher mortality. Also in 2000, the have a minor additional effect on mor- effect that respondents appeared not to mean estimate of the total number of tality mainly from lack of certain es- include binge drinking in their re- • overweight-attributable deaths among sential nutrients.21'22 Consumption of ported regular drinking,we reran our nonsmokers or never-smokers was fruits and vegetables increased in the analyses,adding 5 drinks per binge oc- 543 797. For the Alameda County 1990s,23 and fat intake as a percentage casion to average drinks per day.The Health Study, the estimate of over- of calories declined.24 Physical activ- total number of deaths attributable to weight-attributable deaths among non- ity has increased slightly.25 We esti- alcohol was 103 350. smokers or never-smokers was 639026; mate that poor diet and physical inac- We also used 3 other recent studies Framingham Heart Study,583913;Te- tivity will cause an additional 15000 to estimate alcohol-attributable mor- cumseh Community Health Study, deaths a year,although this too may be tality. Two studies were based on the 457460;American Cancer Society Can- conservative. Nutritional deficiencies National Health Interview Survey295° cer Prevention Study I,466 729;Nurses alone(International Classification of Dis- and the National Alcohol Survey."Us- Health Study, 570 855; and the Na- eases,10th Revision(ICD-10jcodes E40- ing all-cause mortality and RRs from tional Health and Nutrition Examina- E64) were reported as the causes of these studies, we estimated approxi- tion Survey I Epidemiologic Fol- 4242 deaths in 2000. mately 60000 deaths per year.This dif- low-up Study,544798. Our estimates We estimate that 400000 deaths were ference in number of deaths is mainly indicate an increase of 76.6%over the attributable to poor diet and physical due to the fact that BRFSS respon- 1991 estimate of overweight-attribut- inactivity,an increase of one third from dents report a higher percentage of able deaths,with more than 80%of ex- 300000 deaths estimated by McGinnis heavy drinking than do respondents in cess deaths occurring among individu- and Foege,' and the largest increase a household survey such as the Na- als with class 2 and 3 obesity. among all actual causes of death.How- tional Health Interview Survey. The prevalence of overweight used in ever,poor diet and physical inactivity In another approach,we aggregated this study is based on data from 1999- could account for even more deaths alcohol-related deaths from specified 2000.Because the effects of overweight (>500000)when the 1999-2000 previa- ICD codes that were summed to pro- on mortality may not appear until some lence estimates of overweight have their vide an overall estimate of deaths. In years after a person becomes over- full effect. 2000,18 539 deaths were reported as al- weight, it is likely that the increase in cohol-induced (ICD-10 codes F10, prevalence of overweight in the 1990s Alcohol Consumption G31.2,G62.1,142.6,K29.2,K70,R78.0, overestimates the current actual num- We used 2 large nationally representa- X45,X65).In addition,16653 persons ber of deaths.However,the total num- five surveys to determine US alcohol were killed in alcohol-related crashes.72 • 1240 JAMA,March 10,2004-Vol 291,No.10(Reprinted) ©2004 American Medical Association.All rights reserved. CAUSES OF DEATH We estimate another 34797 deaths in 776.41n general,mortality from infec- daily average of PM1°concentration in 2000 using BRFSS alcohol consump- tious and parasitic diseases has de- 2000,''$which results in an estimate of tion data and disease-specific RRs from dined since 1990."Because pneumo- 24000 deaths per year(range, 22 000- the Australian study for oropharyn- nia and septicemia occur at higher rates 52000 deaths)from air pollution alone. geal,esophageal,liver,laryngeal,and fe- among patients with cancer,heart dis- The National Institute for Occupa- male breast cancers;stroke; hyperten- ease,lung disease,or liver disease,some tional Safety and Health(NIOSH)esti- sive heart disease;and other chronic liver of these deaths really are attributable mates that about 113 000 deaths are due disease and cirrhosis (ICD-10 code to smoking,poor diet,and alcohol con- to occupational exposure from 1968 to K73-74).This totals to 69989 deaths in sumption.39'43 We estimate that ap- 1996.5}The number of deaths caused by 2000 from these factors alone. In the proximately 75 000 deaths were attrib- occupational exposure has declined dur- Australian study,all-cause mortality was utable to microbial agents in 2000 from ing that period. In 1996, NIOSH esti- also higher than the summation of cause- all ICD-10 codes for infectious and para- mated 3119 deaths from pneumoconio- specific mortality. sitic mortality.The major cause of the sis and 1176 from asbestosis.Although, Total alcohol-attributable deaths decline was a decrease in deaths from particulate air pollution accounts for the would reach about 140000 if mortal- influenza and pneumonia probably re- majority(about 60%) of mortality re- ity among previous alcohol drinkers flecting at least in part an increase in lated to toxic agents,54 indoor air pollu- were included.It is unclear whether ex- immunization in older adults against tion,environmental tobacco smoke,ra- cess mortality among former alcohol vaccine-preventable diseases.This con- don,lead in drinking water,and food drinkers is due to damage or illness trasts with 90000 deaths attributed to contamination are associated with in- from past alcohol consumption. microbial agents in 1990 estimates. creased mortality.55•56 We estimate that Taking these various numbers into ac- toxic agents(excluding environmental count,our best estimate for total alcohol- Toxic Agents tobacco exposure)were associated with attributable deaths in 2000 is approxi- Estimating the number of deaths due to 2%to 3.5%of total mortality in 2000.We mately 85000,based on the conservative toxic agents is more challenging than any estimate approximately 55 000 deaths at- estimate from cause-specific deaths and of the other risk factors due to limited tributable to toxic agents in 2000.This the high estimate using all-cause mor- published research and the challenges estimate is our least certain of the vari- tality. This is a reduction of 15 000 of measuring exposure and outcome.In ous causes. deaths from the 1990 estimates. the 1990s, many improvements were made in controlling and monitoring pol- Motor Vehicles Microbial Agents lutants."There is more systematic moni- Motor-vehicle crashes involving pas- We excluded human immunodefi- toring of pollutants at state and county sengers and pedestrians resulted in ciency virus(HIV)from this category levels, and exposure to asbestos, ben- 43354 deaths in 2000.4 This decline and included it with sexual behaviors zene,and lead have declined.44 In fact, from 47000 deaths in 1990 represents to be consistent with the analysis by the US Environmental Protection successful public health efforts in motor- McGinnis and Foege.' In the past,in- Agency reported a decline of 25%from vehicle safety.5758 Deaths from alcohol- fectious agents were the leading cause 1970 to 2001 in 6 principal air pollut- related crashes declined from 22084 in of mortality.33 These agents still pre- ants:carbon monoxide,lead,ozone,ni- 1990 to 16653 in 2000.32 Major con- sent a major threat to the nation's health trogen dioxide,sulfur dioxide,and par- tributing factors include the use of child and are associated with high mor- ticulate matter.45 safety seats and safety belts,59•6°de- bidity.34 Several improvements in the Toxic agents are associated with in- creases in alcohol-impaired driving,61 health system have led to a decline in creased mortality from cancer,respira- changes in vehicle and highway de- mortality from infectious diseases.The tory,and cardiovascular diseases.46"9 We sign,62,63 and national goals to reduce mo- increase in US immunization rates led used the National Morbidity, Mortal- tor-vehicle—related mortality and in- to a decline in mortality from many vac- ity,and Air Pollution Study to estimate jury."We estimate that approximately cine-preventable diseases.35-37 Several mortality due to air pollution.50 The 26500 deaths in 2000 were attribut- laws ensure this high immunization rate study assessed the association between able to motor-vehicle crashes in which for children by requiring vaccination for air pollution and mortality and morbid- alcohol was not a factor.This is an in- school and day-care enrollment38 There ity in 90 cities in the United States.Only crease of 1500 from the 1990 report be- also have been substantial improve- particulate matter(PM)was associated cause both estimates were not adjusted ments in sanitation and hygiene,anti- with a significant increase in mortal- for the number of registered vehicles, biotics and other antimicrobial medi- ity—an approximate 0.5%increase in number of crashes,nor miles of travel. cines,and hospital-infection control.35 total mortality for each 10-11/m3 in- We included alcohol-related deaths to In 2000, influenza and pneumonia crease in PM10. Previous studies re- stress that efforts to educate the public accounted for 65 313 deaths,septice- ported a range of 0.4%to 1%for that as- and enforce laws against driving while mia for 31224, and tuberculosis for sociation.st52 We used 23.8 p/m3 as the intoxicated have accounted for most of ©2004 American Medical Association.All rights reserved. (Reprinted)JAMA,March 10,2004—Vol 291,No. 10 1241 • CAUSES OF DEATH . the decline in deaths related to motor- HIV infection, pneumonia, violence, relatively minor changes from 1990 to vehicle crashes. mental illness,and hepatitis.27.28•72'77 An 2000 in the estimated number of deaths estimated 3 million individuals in the due to actual causes. Our findings in- Firearms United States have serious drug prob- dicate that interventions to prevent and Firearm-related incidents resulted in lems.78•79 Several studies have re- increase cessation of smoking, im- 28663 deaths among individuals in the ported an undercount of the number of prove diet,and increase physical activ- United States in 2000.4 This is a de- deaths attributed to drugs by vital sta- ity must become much higher priori- cline from approximately 36000 deaths tistics8°; however, improved medical ties in the public health and health care in 1990. The largest declines were in treatments have reduced mortality from systems. deaths from homicides and uninten- many diseases associated with illicit The most striking finding was the tional discharge of firearms. In 2000, drug use.In keeping with the report by substantial increase in the number of 16586 deaths were due to intentional McGinnis and Foege,' we included estimated deaths attributable to poor self-harm(suicide)by discharge of fire- deaths caused indirectly by illicit drug diet and physical inactivity. We esti- arms(ICD-10 codes X72-X74).Assault use in this category.We used attribut- mate that roughly 400000 deaths now (homicide) by discharge of firearms able fractions to compute the number occur annually due to poor diet and (ICD-I 0 codes X93-X95) resulted in of deaths due to illicit drug use.27•28.81 physical inactivity. The gap between 10 801 deaths. Un intentional dis- Overall,we estimate that illicit drug use deaths due to poor diet and physical in- charge of firearms(ICD-10 codes W32- resulted in approximately 17000 deaths activity and those due to smoking has W34)resulted in 776 deaths,while dis- in 2000, a reduction of 3000 deaths narrowed substantially.Because rates charge of firearms,undetermined intent from the 1990 report. of overweight increased rapidly dur- (ICD-1 0 codes Y22-Y24),resulted in 230 ing the 1990s,we used a conservative deaths.The remaining 270 deaths were Other Factors approach to make our estimates, ac- due to legal intervention(1CD-10 code Several other factors contribute to an counting for the delayed effects of over- Y35).These numbers were ascertained increased rate of death.There are fac- weight on mortality.In addition,over- from death certificate reports. tors that we do not know of such as un- weight lessens life expectancy.87,88 known pollutants or perhaps expo- However,it is clear that if the increas- Sexual Behavior sures that may cause a considerable ing trend of overweight is not re- • Sexual behavior is associated with an in- number of deaths.Poverty and low edu- versed over the next few years,poor diet creased risk of preventable disease and cation levels are associated with in- and physical inactivity will likely over- disability.65 An estimated 20 million per- creased mortality from many causes,A2•83 take tobacco as the leading prevent- sons are newly infected with sexually partly due to differential exposure to the able cause of mortality. transmitted diseases each year in the risks described above. However, con- The most disappointing finding may United States.66•67 Mortality from sexu- trolling for differential exposure to risk be the slow progress in reducing to- ally transmitted diseases is declining due factors is unlikely to explain the en- bacco-related mortality. A few states, to the availability of earlier and better tire impact on mortality. Lack of ac- notably California,have had major suc- treatment, especially for HIV.67.68 In cess to proper medical care or preven- cess in programs that led to reducing 2000,H1V disease(ICD-I 0 codes B20- five services is associated with increased deaths from heart disease and can- B24)resulted in 14578 deaths.In 1990, mortality.e4 Biological characteristics cer.89 However, efforts in most other HIV was the cause of 27695 deaths for and genetic factors also greatly affect states are too recent or short-term to persons older than 13 years,indicating risk of death.85 In most studies we re- have a similar effect.In response to the about a 48%decline in HIV mortality viewed, low education levels and in- increase in tobacco use among youth during the decade.Based on the sexual come were associated with increased in the early 1990s,state and national behavior–attributable fraction from the risk of cardiovascular disease,cancer, tobacco-control efforts increased their literature,69'n we estimate that 20000 diabetes, and injury. The Healthy focus on prevention of initiation and deaths(range,18000-25000 deaths)in People 2010 initiative has made the recognized the importance of cessa- 2000 were due to sexual behavior— elimination of health disparities,espe- tion on reducing smoking-related mainly HIV; other contributors were dally racial and ethnic disparities,a pri- deaths.Thus, most national and state hepatitis B and C viruses and cervical mary goal." efforts now address comprehensive pro- cancer. The decline of 10000 deaths gram strategies.9° Current tobacco- from the 1990 estimates'was due to the COMMENT control efforts will also need strong ces- decline in H1V mortality. • We found that about half of all deaths sation components to show a decline that occurred in the United States in in tobacco deaths in a future assess- Illicit Use of Drugs 2000 could be attributed to a limited ment. Recent reports on the effects of Illicit drug use is associated with sui- number of largely preventable behav- telephone quit lines for smokers are en- cide, homicide, motor-vehicle injury, iors and exposures.Overall,we found couraging.91 On the other hand,large • 1242 JAMA,March 10,2004—Vol 291,No.10(Reprinted) ©2004 American Medical Association.All rights reserved. CAUSES OF DEATH state budget shortfalls are leading to fers great potential for treating and ame- findings in this study argue persua- • large cuts in public health,with a cor- liorating risk.Identifying individuals at sively for the need to establish a more responding diversion of resources from higher risk for a disease through ge- preventive orientation in health care tobacco taxes and settlement dollars to netic testing may promote lifestyle and public health systems in the United cover deficits instead of tobacco- changes that can help prevent the on- States. control programs. set of that disease.93 Despite the call to action on these risk In this study we also did not exam- Author Contributions: Dr Mokdad had fullaccess to the data in this study ad takes full responsibility for factors a decade ago,there has been little inc the effects of high blood pressure the scientific integrity of the data and the accuracy of progress in reducing the total number and cholesterol or lipid profile on mor- the analysis and content of the manuscript. of deaths from these causes. The tali althou h some of the effects of Study coinceptand design:Mokdad,Marks,Stroup, ty' g Gerberdng. progress that has occurred primarily in- these factors are meditated through Acquisition of data:Mokdad,Stroup,Gerberding. volves actual causes of death that are poor diet and physical inactivity.These str lup,Gerb rdt;n retation of data:Mokdad,Marks, less prominent.With the shift in the age risk factors are common among adults Drafting of the manuscript:Mokdad,Marks,Stroup, distribution of the population, more in the United States.More than 30%of Gerberding. ision of thmanuscrpt for important adults now are in the age group at high- US adults have high blood pressure or intellectual content:eMokdad/Marks, Stroup, est risk because of the cumulative ef- high cholesterol.94.95 Monitoring and Stats tical expertise:Mokdad,Stroup. fects of their behavior. The net effect controlling blood pressure and choles- obtained funding:Marks,Gerberding. is that both total deaths and total terol is crucial to preventing prema- Administrative, technical, or material support: burden due to the actual causes have ture mortali and morbidity. Mokdad,Marks,Stroup,Gerberding. �r Y Study supervision:Marks,Gerberding. increased. One of the most difficult aspects of Funding/Support: There was no external funding for Our analyses have several limits- this analysis is that the attribution of this work. Acknowledgment:We acknowledge the valuable con- tions.Our study reported actual causes the actual cause that led to death var- tributions of Barbara A.Bowman,PhD,Robert D. of mortality in the United States.How- ies depending on perspective.We used Brewer,MD,MSPHe,Earl S.Ford,MD,MPH,Wayne H.Giles,MD,lames D and Eduardo.). PhD,Cheryl Pel- ever, these causes are also associated similar methods to those used by lerin,Susan Y.Chu,PhD,and Eduardo J.Simoes,MD, with a large morbidity burden. In ad- McGinnis and Foege' to allow com- MPH. Con- dition to premature death,years of lost Role of the Sponsor. The Centers for Disease parisons.We tried when possible to use trot and Prevention reviewed and approved this re- life,diminished productivity,and high RRs that are fully adjusted for other risk port before submission. rates of disability,decreased quality of factors in our analyses,but possibly not life is also strongly associated with these eliminating duplicate attribution of REFERENCES0 actual causes. A recent World Health causes. We also explicitly included 1. 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Fontaine KR,Redden DT,Wang C,Westfall AO, United States,1988-2000.JAMA.2003;290:199- use and life style among college undergraduates:a 30- Allison DB.Years of life lost due to obesity.JAMA. 206. year longitudinal study.Am J Psychiatry.2001;158: 2003;289:187-193. 96. Strum R.The effects of obesity,smoking,and prob- 1519-1521. 88. Peeters A,Barendregt JJ,Willekens F,et al,for lem drinking on chronic medical problems and health 79.Johnston LD,O'Malley PM,Bachman 1G.Na- the Netherlands Epidemiology and Demography care costs.Health Aff(Millwood). 2002;21:245- tional Survey Results on Drug Use From the Moni- Compression of Morbidity Research Group.Obesity 253. toring the Future study,1975-1999.Volume I:Sec- in adulthood and its consequences for life expec- 97. Visscher TL,Seidell IC.The public health impact ondary School Students. Ann Arbor:University of tancy:a life-table analysis.Ann Intern Med.2003; of obesity.Annu Rev Public Health. 2001;22: Michigan;2000. 138:24-32. 355-375. • ©2004 American Medical Association.All rights reserved. (Reprinted)JAMA,March 10,2004-Vol 291,No.10 1245 Chronic Disease - Overview Page 1 of 6 CDC Home Search 'Health Topics AZ - plNational Center for Chronic Disease Prevention and Health Promotion Chronic Disease Prevention FEp'x CS LTNJ PAR•P'EO?R.'.E'�` Home I Contact Us CHRONIC DISEASE Chronic Disease Overview PREVENTION • Chronic Disease The profile of diseases contributing most heavily to death, illness, Overview • CDC s Chronic and disability among Americans changed dramatically during the Disease Programs last century. Today, chronic diseases—such as cardiovascular • Tracking Conditions disease (primarily heart disease and stroke), cancer, and &Risk Behaviors diabetes—are among the most prevalent, costly, and preventable • Major of all health problems. Seven of every 10 Americans who die each Accomplishments year, or more than 1.7 million people, die of a chronic disease. The • Scientific prolonged course of illness and disability from such chronic Observations diseases as diabetes and arthritis results in extended pain and • Exemplary State suffering and decreased quality of life for millions of Americans. Programs Chronic, disabling conditions cause major limitations in activity for • State Profiles more than one of every 10 Americans, or 25 million people. • Publications • About CDC's Chronic Causes of Death in the United States Disease Center • Press Room Most Common, 1999* • Grants and Funding Diseases of the heart • Postgraduate All camera Opportunities Strolu Related Links DbrOntocbstruidive pulmonary disease unintentional injuries Diabetes mellitus Influenza and pneumonia Alz ir€ is disease Nephritis and neporasts 0 10 20 30 40 Percentage of an deaths Actual, 1990 t Total=use Poor died lack of exercise Alhol use Infectious agents Pe utan$Jtoxirs Firm Risky sexual behavior Motor vehicle crashes RIM drug use • 0 S t1 1 Percentage ofMI the *All data are age adjusted to 2000 total U.S. population. http://www.cdc.gov/nccdphp/overview.htm 4/7/2005 Chronic Disease - Overview Page 2 of 6 t McGinnis JM, Foege WH. Actual causes of death in the United States.JAMA 1993; 270:2207-12. (Text._descriptions of these charts are also available.) • Leading Causes of Disability Among Persons Aged 15 Years or Older, United States, 1991-1992 Arthritis or rheumatism Back or spine omblem Heart trouble Lung ix reSPiraerY ifoubla Highil Stiffness of Wonky of limb MOM Diabetes sings or Other visual i+ airmerit Deafn i 9 Stroke r 6 I f t 2I Percentage of all deabiNtiaa Source: CDC. Prevalence of disability and associated health conditions—United States, 1991-1992. MMWR 1994;43(40): 730-1, 737-9 • (A text description of this chart is also available.) Costs of Chronic Disease The United States cannot effectively address escalating health care costs without addressing the problem of chronic diseases: • More than 90 million Americans live with chronic illnesses. • Chronic diseases account for 70% of all deaths in the United States. • The medical care costs of people with chronic diseases account for more than 75% of the nation's $1.4 trillion medical care costs. • Chronic diseases account for one-third of the years of potential life lost before age 65. • Hospitalizations for pregnancy-related complications occurring before delivery account for more than $1 billion annually. • The direct and indirect costs of diabetes are nearly $132 billion a year. • Each year, arthritis results in estimated medical care costs of more than $22 billion, and estimated total costs (medical care and lost productivity) of almost $82 billion. • • The estimated direct and indirect costs associated with smoking exceed $75 billion annually. • In 2001, approximately $300 billion was spent on all cardiovascular diseases. Over $129 in lost productivity was http://www.cdc.gov/nccdphp/overview.htm 4/7/2005 Chronic Disease - Overview Page 3 of 6 due to cardiovascular disease. • The direct medical costs associated with physical inactivity was nearly $76.6 billion in 2000. • Nearly $68 billion is spent on dental services each year. • Estimated Per Capita Health Expenditures, by Age and Sex, 1995 18,000 16,e .Men 14,0001 Uen 12,E La 1-0,000 0 8,000 0 40 6,000 4,000 2,000 Age in Years Source: From Baby Boom to Elder Boom: Providing Health Care for an Aging Population. Copyright 1996, Watson Wyatt Worldwide. Cost-Effectiveness of Prevention • • For every $1 spent on water fluoridation, $38 is saved in dental restorative treatment costs. • For a cost ranging from $1,108 to $4,542 for smoking cessation programs, 1 quality-adjusted year of life is saved. Smoking cessation interventions have been called the gold standard of cost-effective interventions. • The direct medical costs associated with physical inactivity was $29 billion in 1987 and nearly $76.6 billion in 2000. Engaging in regular physical activity is associated with taking less medication and having fewer hospitalizations and physician visits. • For each $1 spent on the Safer Choice Program (a school- based HIV, other STD, and pregnancy prevention program), about $2.65 is saved on medical and social costs. • For every $1 spent on preconception care programs for women with diabetes, $1.86 can be saved by preventing birth defects among their offspring. • According to one Northern California study, for every $1 spent on the Arthritis Self-Help Program, $3.42 was saved in physician visits and hospital costs. • A mammogram every 2 years for women aged 50-69 costs only about $9,000 per year of life saved. This cost compares favorably with other widely used clinical preventive services. • For the cost of 100 Papanicolaou tests for low-income elderly women, about $5,907 and 3.7 years of life are saved. • After controlling for physical limitation and major socioeconomic factors, more than 12% of annual medical costs of the inactive persons with arthritis is associated with physical inactivity. Physical activity interventions may be a http://www.cdc.gov/nccdphp/overview.htm 4/7/2005 Chronic Disease - Overview Page 4 of 6 cost-effective strategy for reducing the burden of arthritis. Burden of Chronic Disease on Minority Racial Populations and Women • Breast and Cervical Cancer • African American women are more likely to die of breast cancer than are women of any other racial or ethnic group. The incidence of cervical cancer—a 100% preventable cancer—is more than five times greater among Vietnamese women in the United States than among white women. Cardiovascular Disease • More than half of persons who die each year of heart disease are women. • Heart disease is the leading cause of death for all racial and ethnic groups in the United States. In 1998, rates of death from cardiovascular disease were about 30% higher among African American adults than among white adults. Age-Adjusted Death Rates for Diseases of the Heart* Among Women, by Race/Ethnicity,1996-1998 c 200 - • 10 - 8 0100 - 50 - Whale African Hispanic Amer Indian,AeianPac. American Alaska Nates islander Race/Ethnicity *Average annual deaths per 100,000 women, age adjusted to 1940 U.S. standard population, International Classification of Diseases, 9th Rev.,codes 390-398, 402, and 404-429. Source:Journal of Women's Health and Gender-Based Medicine,Vol. 10, No. 8, 2001. pp. 717-24. (A text description of this chart is also available.) Diabetes • Diabetes affects more women than men. • The prevalence of diabetes is 70% higher among African • Americans and nearly 100% higher among Hispanics than among whites. The prevalence of diabetes among American Indians and Alaska Natives is more than twice that of the total population, and the Pimas of Arizona have the highest http://www.cdc.gov/nccdphp/overview.htm 4/7/2005 'Chronic Disease - Overview Page 5 of 6 known prevalence of diabetes in the world. Infant and Maternal Mortality • • African American, American Indian, and Puerto Rican infants have higher death rates than white infants. In 1998, the death rate among African American infants was 2.3 times greater than that among white infants. • African American women are four times more likely to die of pregnancy-related complications than are white women, and American Indian and Alaska Native women are nearly twice as likely to die. U.S. Infant Mortality Rates, by Race/Ethnicity of Mother, 1998 - t: 472 15- > 0 8 lo- ci0 5- 0 11 0 White African Hispanic Amer.Indian/Aa ra1Pac. • Am'emailr ai iva Wander Race/EthnicAlasityka Source: CDC, National Center for Health Statistics. (A text description of this chart is also available.) Disability • Life expectancy is higher for women than for men, but women older than 70 years are more likely to be disabled. Related Information • Birth.._Defects.__and Developmental Disabilities • Genomics and Disease Prevention • The Burden of Chronic Disease and the Future of Public Health. • Privacy Policy I Accessibility Home I Contact Us CDC Home I Search I Health Topics A-Z http://www.cdc.gov/nccdphp/overview.htm 4/7/2005 Chronic Disease - Overview Page 6 of This page last reviewed October 15, 2004 United States DeRartment of Health and Human Services Centers for Disease Control and Prevention National Center for Chronic Disease Prevention and Health Promotion • • httn://wTvvvudc 4/7/2005 i Board of Healtfi, Retreat Towers and Duties of the Board of Health • .agenda Item # 17.1. ApriC21, 2005 • '&§sra ,� 3 ^+w 'r '@ Safi., ;1:,,;*:.';',,',1';:;--?,:l.,-,:-",,,,,,-!:.7:.!' i ,.sNt `r s3 < ,..---',.. ,.;,,,.- .7, • 0 .. ... , , . 4 ' ''Iliiiiii ' ,,. 4 ei Vfli .,„ , �'' r' t xs ff d'g'.-1 $ s " ✓ 4. i f a '. ¢. y4,f 3 i 17,---' -:''''''':''''''''',:14..:*-- '''''''''''''''',,Ifig:'=Zr8 4 q ,7 t .. 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Fa*. wx Iii *« x cd= %"4 $,"f; a, :I't/A7''''.t''.:.,f:''-'fi7'f.;.t'"i7T.;;-.):.:Ao—,:'tt,.,':'*f:"':,•:'.,z4.::',4:''7!.ik.,,,,.:'';':,,,.4;:',;r::..'...,,,:'',4,-'.'.;:'!,;.':':;;:I':','i::...;t:..r..;t-iti,.,.,..,::1:4,'' ;..+� +wa BMs fi' -4&, 4 E ',s14s t �+ t za�rfx# ..ww + xw r " a�` .� rx l" .'. ),...,i.'„,..-.1r" % i 'sy e t,,,,,,,,„,...0„,,,,� '''..,01;.,.:44,-.7.,0.-4' x "a.vS_ ' {, Ex" tcs . � . y w4e 1±. . { s r.°. . Chapter 70.05 Title 70 RCW: Public Health and Safety 70.05.100 Determination of character of disease. (1) "Local health departments" means the county or 11 in 05.110 Locals officials and physicians to report contagious district which provides public health services to persons 120 Violations—Remedies—Penalties. within the area• iu.05.130 Expenses of state,health district,or county in enforcing (2) "Local health officer" means the legally qualified health laws and rules—Payment by county or city. physician who has been appointed as the health officer for 70.05.132 Expenses of state or county in enforcing health laws and the county or district public health department. reguulationssa ayment by city or cows—Procedure on (3) "Local board of health" means the county or district failre to p . 70.05.135 Treasurer—District funds—Contributions by counties and board of health. cities. (4) "Health district"means all the territory consisting of 70.05.140 County to bear expense of providing public health services. one or more counties organized pursuant to the provisions of 70.05.145 Payments by city or town to support health department— chapters 70.05 and 70.46 RCW. Agreement with jurisdiction operating department— Procedure if agreement not reached—Board of arbitra- (5) "Department" means the department of health. tors. [1993 c 492 § 234; 1967 ex.s. c 51 § 1.] 70.05.150 Contracts for sale or purchase of health services authorized. 1993 c 492: See notes following RCW 43.72.005. 70.05.160 Moratorium on water,sewer hookups,or septic systems— Public hearing—Limitation on length. systems— Short ti mot la 70.05.170 Child mortality review. of legislative power—Effective dates-1993 c 492: See RCW 43.72.910 Health districts: Chapter 70.46 RCthrough 43.72.915. W. Severability-1967 ex.s.c 51: "If any provision of this act,or its State board of health: Chapter 43.20 RCW. application to any person or circumstance is held invalid,the remainder of the act,or the application of the provision to other persons or circumstances is not��." [1967 ex.s.c 51 §24.] For codification of 1967 ex.s.c 70.05.005 Transfer of duties to the department of health. (Effective until July 1, 1995.) The powers and 51.see Codification Tables,Volume 0. duties of the department of social and health services and the secretary of social and health services under this chapter 70.05.020 Cities and towns—Organization of local shall be performed by the department of health and the health boards. (Effective until July 1, 1995.) The secretary of health. [1989 1st ex.s.c 9 § 243.] governing body of every city or town in this state, except Effective date—Severability-1989 1st ex.s.c 9: See RCW where such city or town is a part of a county health depart- 43.70.910 and 43.70.920. ment,a health district,or is purchasing health services-under a contract as authorized by chapter 70.05 RCW and RCW 41E0.05.010 Definitions. (Effective until July 1, 1995.) 70.46.020 through 70.46.090, shall hereafter organize as a We purposes of chapter 70.05 RCW and RCW 70.46.020 local board of health or shall appoint a local board of health tnrough 70.46.090 and unless the context thereof clearly from its members of at least three persons who shall indicates to the contrary: organize as a local board of health for such city or town. (1) "Local health departments" means the city, town, [1967 ex.s. c 51 § 2.] county or district which provides public health services to persons within the area; 70.05.030 Counties—Board of county commission- (2) "Local health officer" means the legally qualified ers to constitute local health board—Jurisdiction. physician who has been appointed as the health officer for (Effective until July 1, 1995.) The board of county the city, town, county or district public health department:- commissioners of each and every county in this state,except (3) "Local board of health" means the city,town,county where such county is a part of a health district or is purchas- or district board of health. ing services under a contract as authorized by chapter 70.05 (4) "Health district" means all territory encompassed RCW and RCW 70.46.020 through 70.46.090, shall consti- within a single county and all cities and towns therein except tute the local board of health for such county,and said local cities with a population of over one hundred thousand,or all board of health's jurisdiction shall be coextensive with the the territory consisting of one or more counties and all the boundaries of said county, except that nothing herein cities and towns in all of the combined counties except cities contained shall give said board jurisdiction in cities of over of over one hundred thousand population which have been one hundred thousand population or in such other cities and combined and organized pursuant to the provisions of towns as are providing health-services which meet health chapter 70.05 RCW and RCW 70.46.020 through 70.46.090: standards pursuant to RCW 70.46.090. [1967 ex.s. c 51 § PROVIDED, That cities with a population of over one 3.] hundred thousand may be included ina health district as provided in RCW 70.46.040. [1967 ex.s. c 51 $ 1.] 70.05.030 Counties—Local health board— Severability-1967 ex.s.c 51: "If any provision of this act,or its Jurisdiction. ective July 1,1995.) In counties without application to any person or circumstance is held invalid,the remainder of a home rule charter,the board of county commissioners shall the act,or the application of the provision to other Persons or circumstances constitute the local board of health, unless the county is part is not affected." [1967 ex.s.c 51 §24.) For codification of I967 exs.c of a health district p 51.see Codification Tables,Volume O. pursuant to chapter 70.46 RCW. The jurisdiction of the local board of health shall be coextensive 0 0.05.010 uu • (Effective July 1, 1995.) with the boundaries of said county. [1993 c 492 § 235: -the purposes of chapters 70.05 and 70.46 RCW and unless 1967 ex.s.c 51 § 3.] the context thereof clearly indicates to the contrary: 1993 c 492 notes following RCW 43.72.005. IA [Title 90 nCWe 01 ' 09;4 E.) Local Health Departufielts, Boards, Officers—Regulations 70.05.030 Short title-zSeverability—Sa " not fiat of one year. [1993 c 492 § 236; 1984 c 25 § 1; 1983 1st 'legislative power—Effective dates-1993 c 492: See RCW 43.72.910 ex.s. c 39 § 1; 1967 ex.s. c 51 § 4.] rough 43.72.915. tent-1993 c 492: See notes following RCW 43.72.005. 70.05.035 Home rule charter—Local board of short not Intion ealth. (Effective July 1, 1995.) In counties with a home of legislative power—Effective dates-1993 c 492: See RCW 43.72.910 through 43.72.915. Ile charter, the county legislative authority shall establish a cal board of health and may prescribe the membership and 70.05.045 Administrative officer—Responsibilities. lection process for the board. The jurisdiction of the local The administrative officer shall act as executive secretary )aid of health shall be coextensive with the boundaries of and administrative officer for the local board of health, and e county. The local health officer, as described in RCW shall be responsible for administering the operations of the ).05.050, shall be appointed by the official designated board including such other administrative duties required by tier the provisions of the county charter. The same the local health board, except for duties assigned to the ficial designated under the provisions of the county charter health officer as enumerated in RCW 70.05.070 and other ay appoint an administrative officer, as described in RCW applicable state law. [1984 c 25 § 2.) L05.045. [1993 c 492 § 237.] Findings—Latent-1993 c 492: See notes following RCW 43.72.005. 70.05.050 Local health officer—Appointment— Shen title—Sevezabi ity—saving¢—CaptiGes tat is Term—Employment of legislative power—Effective dates-1993 c 492: See RCW 43.72.910 personnel—Salary and expenses. Nigh 43.72.915. (Effective until July 1, 1995.) Each local board of health, other than boards which are established under RCW 70.05.037 Combined city-county health depart- 70.05.030 and which are located in counties having home ,nts—Establishment. (Effective July 1, 1995.) Any city rule charters, shall appoint a local health officer. In home th one hundred thousand or more population and the rule charter counties which have a local board of health unty in which it is located, are authorized, as shall be established under RCW 70.05.030, the local health officer red upon between the respective governing bodies of such shall be appointed by the official designated under the pro- y and said county, to establish and operate a combined visions of the countys charter. y and county health department, and to appoint a local The local health officer shall be an experienced physi- elan licensed to practice medicine and surgery or osteopathy filth officer for the county served. Class AA counties may • point a director of public health as specified in this and surgery in this state and who is qualified or provisional- apter. [1993 c 492 § 244; 1985 c 124 § 1; 1949 c 46 § 1; ly qualified in accordance with the standards prescribed in m. Supp. 1949 § 6099-30. Formerly RCW 70.08.010.] RCW 70.05.051 through 70.05.055 to hold the office of local Findings--Intent-1993 c 492: seen following RCW 43.72.005. health officer. No term of office shall be established for the local health officer but he shall not be removed until after Short power verab;li -sav -Capaoas not m�—Reservation given him,and an opportunity notice is mislative power—Effective dates-1993 c 492: See RCW 43.72.910 for a hearing before ugh 43.72.915. - the board or official responsible for his appointment under this section as to the reason for his removal. He shall act as 70.05.040 Local board of health—Chairman— executive secretary to, and administrative officer for the ministrative officer—Vacancies. (Effective until July local board of health and shall also be empowered to employ [995.) The local board of health shall elect a chairman such technical and other personnel as approved by the local may appoint an administrative officer. A local health board of health except where the local board of health has icer shall be appointed pursuant to RCW 70.05.050. appointed an administrative officer under RCW 70.05.040. :ancies on the local board of health shall be filled by The local health officer shall be paid such salary and ointment within thirty days and made in the same manner allowed such expenses as shall be determined by the local vas the original appointment. At the first meeting of the board of health. [1984 c 25 § 5; 1983 1st ex.s. c 39 § 2; tl board of health,the members shall elect a chairman to 1969 ex s. c 114 § 1; 1967 ex.s. c 51 § 9.) •e for a period of one year. In home rule charter counties have a local board of health established under RCW 70.05.050 Local health officer—Qualifications- 15.050, the administrative officer may be appointed by Employment of personnel—Salary and expenses. (Effec- official designated under the county's charter. [1984 c tive July 1, 1995.) The local health officer shall be an 1; 1983 1st ex.s. c 39 § I; 1967 ex.s. c 51 § 4.] experienced physician licensed to practice medicine and surgery or osteopathy and surgery in this state and who is 70.05.040 Local board of health—Chair— qualified or provisionally qualified in accordance with the uinistrative officer—Vacancies. (Effective July 1, standards prescribed in RCW 70.05.051 through 70.05.055 • 9.) The local board of health shall elect a chair and may to hold the office of local health officer. No term of office Tint an achpinistrative officer. A local health officer shall shall be established for the local health officer but the local ppointed pursuant to RCW 70.05.050. Vacancies on the health officer shall not be removed until after notice is I board of health shall be filled by appointment within given, and an opportunity for a hearing before the board or days and made in the same manner as was the original official responsible for his or her appointment u this )intment. At the first meeting of the local board of section as to the reason for his or her removal. The local h,the members shall elect a chair to serve for a period -health officer shall act as executive s to,and admin- istrative officer for the local board of health and shall also F ) r am 9aa tom_ an 70.05.050 Title 90 RCW: Public H_G-x and S ety be empowered to employ such technical and other personnel (2) An on-the-job, self-training program pursuant to a as approved by the local board of health except where the standardized syllabus setting forth the major duties of a local local board of health has appointed an administrative officer health officer including the techniques and practices of 40 under RCW 70.05.040. The local health officer shall be public health principles expected of qualified local health paid such salary and allowed such expenses as shall be officers: PROVIDED, That eachrovisionallY qualified determined by the local board of health. [1993 c 492 §238; local health officer may choose which inghe or 1984 c 25 § 5; 1983 1st ex.s. c 39 § 2; 1969 ex.s. c 114 § she shall pursue. [1991 c 3 § 306; 1979 c 41§77 1969 1; 1967 ex.s. c 51 § 9.] ex.s. c 114 § 4.] Findings—Intent-1993 c 492: See notes following RCW 43.72.005. Short ti ev"'bR'ty—S""ngsC' ons not law tion 70.05.055 Provisionally qualified of legislative power—Effective dates-1993 c 492: See RCW 43.72.910 officers—Interview—Evaluation as to qualificationhealth through 43.72.915. local public health officer. Each year, on a date which shall be as near as possible to the anniversary date of 70.05.051 Local health officer—Qualcations, The appointment as provisional local health officer, the secretary following persons holding licenses as required by RCW 70.05.050 shall be deemed qualified to hold the position of of health or his or her designeeshall personally visit such local health officer. provisional officer's office for a personal review and discus- sion of the activity,plans,and study being carried on relative (1) Persons holding the degree of master of public to the provisional officer's jurisdictional area: PROVIDED, health or its equivalent; (2)Persons not meeting the requirements of subsection That the third such interview shall occur three months prior tO (1)of this section, who upon August 11, 1969 are currently theend of the three year provisional term. A standardized employed in this state as a local health officer and whom the checklist shall be used for all such interviews, but such secretary of social and health services recommends in writ- checklist shall not constitute a grading sheet or evaluation form for use in the ultimate decision of qualification of the ing to the local board of health as qualified; and (3)Persons qualified by virtue of completing three years provisional appointee as a public health officer. Copies of the results of each interview shall be supplied of service as a provisionally qualified officer pursuant to RCW 70.05.053 through 70.05.055. [1979 c 141 § 75; 1969 to the terviswnal officer within two weeks following each such intery ex.s. c 114 § 2.] iew. Following the third such interview, the secretary shall evaluate the provisional local health officer's in-service 70.05.053 Provisionally qualified local health performance and shall notify such officer by certified mail officers--Appointment—Term--Requirements. A person of his or her decision whether or not to qualify such officer RIF holding a license required by RCW 70.05.050 but not as a local public health officer. Such notice shall be mailed meeting any of the requirements for qualification prescribed at least sixty days prior to the third anniversary date of pro- by RCW 70.05.051 may be appointed by the board or visional appointment. Failure to so mail such notice shall official responsible for appointing the local health officer constitute a decision that such provisional officer is qualified. under RCW 70.05.050 as a provisionally qualified local [1991 c 3 § 307; 1979 c 141 § 78; 1969 ex.s. c 114 § 5.] health officer for a maximum period of three years upon the following conditions and in accordance with the following procedures: 70.05.060 Powers and duties of local board of (1) He or she shall participate in an in-service orienta- health. Each local board of health shall have supervision over all matters pertaining to the preservation of the life and tion to the field of public health as provided in RCW 70.05.054,-and health of the people within its jurisdiction and shall: (2) He or she shall satisfy the secretary of health (1) Enforce through the local health officer or the pursuant(2) re periodic interviews prescribed y RCW administrative officer appointed under RCW 70.05.040, if 70.05.055 that he or she has successfully completed such in- any,the public health statutes of the state and rules promul- service orientation and is conducting such program of good gated by the state board of health and the secretary of health; health practices as may be required by the jurisdictional area (2)Supervise the maintenance of all health and sanitary concerned. [1991 c 3 § 305; 1983 1st ex.s. c 39 § 3; 1979 measuces for the protection of the public health within its c 141 § 76; 1969 X.S.ec 114 § 3.1 jurisdiction; (3) Enact such local rules and regulations as are 70.05.054 Provisionallynecessary in order to preserve, promote and improve the officers---.In-service iic htqualified local health public health and provide for the enforcement thereof; program. cntrol and prevention of any The secretary of health shall provide an in-service pldangerous, c ntagio Corinfectio s disease within the health orientation program for the benefit of provisionally jurisdiction of the local health qualified local health officers. department; Such program shall consist of (5)Provide for the prevention,control and abatement of (1) A three months course in public health training nuisances detrimental to the public health; III by the secreta (6) Make such reports to the state board of health conducted ry either inthe state hoo a county andtr city health department of through the local health officer or the administrative officer department, in a local as the state board of health may require; and health district, or in an institution of higher education; or (7) Establish fee schedules for issuing or renewing licenses or permits or for such other services as are autho- [Title 70:';CW.pege 101 (1994 Ed.) Local Health DepL-°, eats, Boards, is egulations 70.05.064 rized by the law and the rules of the state board of health: (2)Take such action as is necessary to maintain healtl PROVIDED,That such fees for services shall not exceed the and sanitation supervision over the territory within his or he actual cost of providing any such services. [1991 c 3 § 308; jurisdiction; 1984 c 25 § 6; 1979 c 141 § 79; 1967 ex.s. c 51 § 10.] (3) Control and prevent the spread of any d mus contagious or infectious diseases that may occur ;, 70.05.070 Local health officer—Powers and duties. or her jurisdiction; (Effective until July 1, 1995.) The local health officer, (4) Inform the public as to the causes, nature, anc acting under the direction of the local board of health or prevention of disease and disability and the preservation. under direction of the administrative officer appointed under promotion and improvement of health within his or het RCW 70.05.040, if any, shall: jurisdiction; (1)Enforce the public health statutes of the state,rules (5) Prevent, control or abate nuisances which are of the state board of health and the secretary of health, and detrimental to the public health; all local health rules, regulations and ordinances within his (6) Attend all conferences called by the secretary of or her jurisdiction including imposition of penalties autho- health or his or her authorized representative; rized under RCW 70.119A.030 and filing of actions autho- (7) Collect such fees as are established by the state rized by RCW 43.70.190; board of health or the local board of health for the issuance (2)Take such action as is necessary to maintain health or renewal of licenses or permits or such other fees as may and sanitation supervision over the territory within his or her be authorized by law or by the rules of the state board of jurisdiction; health; (3) Control and prevent the spread of any dangerous, (8)Inspect, as necessary, expansion or modification of contagious or infectious diseases that may occur within his existing public water systems, and the construction of new or her jurisdiction; . public water systems,to assure that the expansion, modifica- (4) Inform the public as to the causes, nature, and tion,or construction conforms to system design and plans; prevention of disease and disability and the preservation, (9) Take such measures as he or she deems necessary promotion and improvement of health within his or her in order to promote the public health, to participate in the jurisdiction; establishment of health educational or training activities,and (5) Prevent, control or abate nuisances which are to authorize the attendance of employees of the local health detrimental to the public health; department or individuals engaged in community health (6) Attend all conferences called by the secretary of programs related to or part of the programs of the local health or his or her authorized representative; health department. [1993 c 492 § 239; 1991 c 3 § 309; 1990 (7) Collect such fees as are established by the state c 133 § 10; 1984 c 25 § 7; 1979 c 141 § 80; 1967 ex..1 board of health or the local board of health for the issuance § 12.] or renewal of licenses or permits or such other fees as may —1993 c 492: See notes following RCW-.�.,_ J. be authorized by law or by the rules of the state board of Short tions not law—Reservation health; of legislative power—E ective dates-1993 c 492: See RCW 4332.9W (8) Inspect, as necessary, expansion or modification of through 43.72.915. Findings--Severability-1990 c 133: See notes following RCW existing public_water systems, and the construction of new 3694140 public water systems, to assure that the expansion,modifica- tion, odification, or construction conforms to system design and plans; 70.05.080 Local health officer—Failure to appoint— (9) ppoint (9) Take such measures as he or she deems necessary Procedure. (Effective until July 1, 1995.) If the local in order to promote the public health, to participate in the board of health or other official reible for appointing a I establishment health educational or training activities,and local �officer under RCW 70spons0 refuses or neglects I to authorize thea spons attendance of employees of the local health to int a local health officer after a vacancy exists, the department or individuals engaged in community health secretary of health may appoint a local health officer and fix programs related to or part of the programs of the local the compensation. The local health officer so appointed health department.1979 c [1§ 80;1 c 3 § 309; 19901 133 § 10; 1984 shall have the same duties, powers and authority as though c 25 § 7; 1979 c 141 § 1967 ex.s. c 51 § 12.] appointed under RCW 70.05.050. Such local health officer Findings—Severability-1990 c 133: See notes following RCW shallserve until a qualified individual is appointed according 36.94.140. to the procedures set forth in RCW 70.05.050. The board or 70.05.070 Local health officer—Powers and duties. official responsible for appointing the local health officer (EffeetivewJuly 1, 1995.) The local health officer, acting under RCW 70.05.050 shall also be authorized to appoint an acting health officer to serve whenever the health officer is under the direction of the local board of health or under absent or incapacitated and unable to fulfill his or her re- direction of the .050administrative officer appointed under RCW sponsibilities under the provisions of chapter 70.05 RCW 70.05.040 or 70.05.035, if any, shall: and RCW 70.46.020 through 70.46.090. [1991 c 3 § 310; (1)Enforce the public health statutes of the state,rules 1983 1st ex.s. c 39 § 4; 1979 c 141 § 81; 1967 ex.s.c 51 § of the state board of health and the secretary of health, and 13.] all local health rules, regulations and ordinances within his • or her jurisdiction including imposition of penalties autho- �.�.� � �officer—Failure to al?. rized under RCW 70.119A.030 and filing of actions autho- Procedure. (Effective July 1, 1995.) If the local board of rued by RCW 43.70.190; health or other official responsible for appointing a local (1994 Ed.) - ['Title 70 11CW ge 111 •V.0/d.V¢DV s®°e /aa Kt..yr: moue mann and Safety health officer under RCW 70.05.050 refuses or neglects to appoint a local health officer after a vacancy exists, the by removed� local health officer or administrative officer of health may appoint a local health officer and fix e exceptthe state board of health and shall not again beh reappoint- secretaryy the compensation. The local health officer so appointed ���consent of the state board of health. Any shall have the same duties, powers and authority as though the person may complain to the state board of health concerning io appointed under RCW 050. Such local health officer carryfail�of the local health officer administrative officer shall serve until a qualified individual is appointed out the laws or the rules and regulations concerning to the procedures set forth in RCW 70.05. . according public health, and the state board of health shall, if a board or preliminary investigation so warrants, call a hearing to official responsible for appointing the local health officer determine whether the local health officer or administrative under RCW 70.05.050 shall also be authorized to appoint an officer is acting health officer to serve whenever the health officer isguilty of the alleged acts. Such hearings shall bed absent or incapacitated and unable to fulfill his or her re- held pursuant to the provisions of chapter 34.05 RCW, and the rules sponsibilities under the provisions of chapters 70.05 and regulations of the state board of health adopted thereunder.70.46 RCW. [1993 c 492 § 240; 1991 c 3 § 310; 1983 1st ex.s. c 39 § 4; 1979 c 141 § 81; 1967 ex.s. c 51 13. Any member of a local board of health who shall • tent 1993 c 492: See notes following RCW 43.72.005. RCW 70.46.020 throughate any of the provisions 46090 or refuse RCW and ect 10 Start obey or enforce any of the rules,regulations or orders lof the of legislative power—Effective motes-1993 c 492: See RCW 43.72.910 through 43.72.915. state board of health made for the prevention,suppression or control of any dangerous contagious or infectious disease or 70.05.090 Physicians torefor the protection of the health of the any physician n shall attends . Wheneverpeopconvictionle of this stateshall, y person sick with anydanger- shall ed notl lessy a misdemeanor,nor more than two d 8 be fined not than ten dollars hundred ous contagious or infectious disease, or with any diseases dollars. required by the state board of health to be reported, he or to they physician who shall refuse or neglect to report she shall, within twenty-four hours,give notice thereof to the P )�'health officer or administrative officer within local health officer within whose jurisdiction such sick twelve hours after first attending any case of contagious or person may then be or to the state departmentinfectious disease or any diseases required by Olympia c 3 § 311; 1979 c 141 82; of healths.in of health to be reported state go e of such org any case msuspiciousdmof being one 51 § 14.] diseases,shall be guilty of a misdemeanor, and upon conviction shall be fined not less than ten dollars nor more 70.05.100 bete than two hundred dollars for each case that is not reported. case of the question ant s gas®o whether aractoro not any person of disease. Any person violating any of the provisions of chapter r is affected or is sick with a dangerous, contagious or violating or r5 RCW efusing nd o 70.46.020throughobey any 70.46.090 or infectious disease, the opinion of the local health officer regulations or orders made for the prevention, suppression shall prevail until the state department of health can be and control of dangerous contagious y of the rules, notified,and then the opinion of the executive officer of the by the local board of health or local heinfath officer or state department of health, or any physician he or she may administrative officer or state board of health, or who shall appoint to examine such case, shall be final. [1991 c 3 § leave any isolation hospital or quarantined house or place 312; 1979 c 141 § 83; 1967 ex.s. c 51 § 15.] without the consent of the proper health officer or who 70.05.110 evades or breaks quarantine or conceals a case of contagious Local health officials and physicians to or infectious disease or assists in evading or breaking any report contagious diseases. It shall be the duty of the local quarantine or concealing any case of contagious or infectious board of health, health authorities or officials, and of disease,shall be guilty of a misdemeanor, and upon convic- physicians in localities where there are no local health don thereof shall be subject to a fine of not less than twenty- authorities or officials, to report to the state board of health, five dollars nor more than one hundred dollars or to impris- promptly upon discovery thereof, the existence of any one of onment in the count the following diseases which may come under their observa- both fine and imprisonment Y jail not to exceed 8; 196 days or 1 tion, to wit: Asiatic cholera,yellow fever,smallpox,scarlet § 17.1 t [1984 c 25 § 8; 1967 ex.s. c 51 fever, diphtheria, typhus, typhoid fever, bubonic plague or leprosy, and of such other contagious or infectious diseases 70.05.120 Violations—Remedies—Penalties. as the state board may from time to time specify. [1967 (Effective July 1, 1995.) Any local health officer or ex.s. c 51 § 16.] administrative officer appointed under RCW 70.05.040, if 70.05.120 Violations—Remedies®Penalties, , who shall refuse or neglect to obey or enforce the visions of chapters 70.05 and 70.46 RCW or the rules, (Effective until July 1, 1995.) Any 10,1 health officer or . regulations or orders of the state board of health or who administrative officer appointed under RCW 70.05.040, if shall refuse or neglect to make any, who shall.refuse or neglect to obey or enforce the to the state board of health,may be removaccurate heeaalth provisions of chapter 70.05 RCW and RCW 70.46.020 officer or administrative officer by the state board of health through 70.46.090 or the rules, regulations or orders of the and shall not again be state board of health or who shall refuse or neglect to make state reappointed except with the tore of the state board of health Any perrsonn may complainmto prompt and accurate reports to the state board of health,may the state board of health concerning the failure of the local [Title 70 RCW—page 121 • (1994 Ed.) . cx_b � . :c - , _mss Local Health Dept j., ,en k, Boards, ece Re lations 70.05.120 70.05.130 Expenses of state, health district, or health officer or administrative officer to carry out the laws or the rules and regulations concerning public health, and the county in enforcing health laws rul Payment by state board of health shall, if a preliminary investigation so county. (Effective July 1, 1995.) All expenses incurred by warrants,call a hearing to determine whether the local-health the state,health district,or county in carrying out the i. officer or administrative officer is guilty of the alleged acts. sions of chapters 70.05 and 70.46 RCW or any or] Such hearings-shall be held pursuant to the provisions of health law, or the rules of the department of health ena...ed • chapter 34.05 RCW, and the rules and regulations of the under such laws, shall be paid by the county and such state board of health adopted thereunder. expenses shall constitute a claim against the general fund as Any member of a local board of health who shall provided in this section. [1993 c 492 § 242; 1991 c 3 § 313; violate any of the provisions of chapters 70.05 and 70.46 . 1979 c 141 § 84; 1967 ex.s.c 51 § 18.] RCW or refuse or neglect to obey or enforce any of the ogs—Iot st-1993 cm: See noses following RCW 43.72.005. rules, regulations or orders of the state board of health made short not for the prevention, suppression or control of any dangerous of legislative power—Effective dates-1993 c 492: See RCW 43.72.910 contagious or infectious disease or for the protection of the through 43.72.915. health of the people of this state,shall be guilty of a misde- meanor,and upon conviction shall be fined not less than ten 70.05.132 Expenses of state or county in enforcing dollars nor more than two hundred dollars. Any physician health laws and regulations—Payment by city or town— who shall refuse or neglect to report to the proper health Procedure on failure to pay. (Effective until July 1, officer or administrative officer within twelve hours after 1995.) All expenses incurred by the state or county in first attending any case of contagious or infectious disease or carrying out the provisions of chapters 70.05 and 70.08 any diseases required by the state board of health to be RCW, any other public health law, or the rules enacted reported or any case suspicious of being one of such under such laws by the state board of health shall be paid by diseases, shall be guilty of a misdemeanor, and upon the city or town by which or on whose behalf such expenses conviction shall be fined not less than ten dollars nor more - were incurred. The local health officer or the administrative than two hundred dollars for each case that is not reported. officer appointed under RCW 70.05.040,if any, shall certify Any person violating any of the provisions of chapters the amount agreed upon or determined by arbitration under 70.05 and 70.46 RCW or violating or refusing or neglecting RCW 70.05.145 which remains unpaid by each city or town to obey any of the rules, regulations or orders made for the to the fiscal or warrant issuing officer of such city or town. prevention, suppression and control of dangerous contagious If the certified expense is not paid by the city or town and infectious diseases by the local board of health or local within thirty days after the end of the fiscal year, the local health officer or administrative officer or state board of health officer shall certify the amount due to the audits health, or who shall leave any isolation hospital or quaran- the county in which the city or town is situated, v tined house or place without the consent of the proper health promptly issue a warrant on the county treasurer officer or who evades or breaks quarantine or conceals a of the current expense fund of the county, or in accordance case of contagious or infectious disease or assists in evading with the procedures of the fiscal agent of the combined city- or breaking any quarantine or concealing any case of county health department. Any sums paid in this manner contagious or infectious disease, shall be guilty of a misde- shall be reimbursed by the county auditor out of the money meanor, and upon conviction thereof shall be subject to a due the city or town at the next monthly settlement or fine of not less than twenty-five dollars nor more than one settlements of the collection of taxes and until the certified hundred dollars or to imprisonment in the county jail not to amount is satisfied and shall be transferred to the county's exceed ninety days or to both fine and imprisonment. [1993 current expense fund or to the fiscal agent of the combined c 492 § 241; 1984 c 25 § 8; 1967 ex.s. c 51 § 17.] city-county health department. [1984 c 25 § 9; 1983 1st flndiogs —Intent-1993 c 492: See notes following RCW 43.72.005. ex.s. c 39 § 6.] Shat not of legislative power—Effective dates-1993 c 492: See RCW 43.72.910 70.05.135 Treasurer—District funds—Contributions through 43.72.915. by counties and cities. See RCW 70.46.080. 70.05.130 Expenses of state, health district, or 70.05.140 County to bear expense of providing county in enforcing health laws and rules—Payment by public health services. See RCW 70.46.085. cou ity or city. (Effective until July 1, 1995.) All expens- es incurred by the state,health district,or county in carrying 70.05.145 Payments by city or town to support out the provisions of chapter 70.05 RCW and RCW health department—Agreement with jurisdiction operat- ing through 70.46.090 or any other public health law, department—Procedure if agreement not reached— or the rules of the state department of health enacted under Bird (Effective until J�, 1, 1985.) Each such laws, shall be paid by the county or city by which or city or town which is part of a county health department in behalf of which such expenses shall have been incurred established under chapter 70.05 RCW or a combined city- and such expenses shall constitute a claim against the county health department established under chapter 70.08 141 § 84; 1967 ex.s. c 51 § 18.1 fund provided herein. [1991 c 3 § 313; 1979 c RCW, or is purchasing health services from a her'''f 141 § partment under a contract authorized by RCW 70.0.. 70.08.090, shall pay such sums to support the operations.,. such department as are agreed upon by the city or town and (1994 Ed.) [Title 713 ='CW—pege 131 70.05.145 Title 70 RCW: Public Heal:r a.,-d Safety • the jurisdiction operating the department, in accordance with public hearing is held and findings of fact are made prior to guidelines established by the state board of health which each renewal. [1992 c 207 § 7.] specify those services or types of services that cities,towns, • and counties must provide, and those services which are op- 70.05.170 Child mortality review. (I)(a) The le tional. If no agreement can be reached between the jurisdic- gislature finds that the mortality rate in Washington state tion operating the health department and such city or town among infants and children less than eighteen years of age following a reasonable period of good faith negotiations, is unacceptably high, and that such mortality may be including mediation where appropriate, the matter shall be preventable. The legislature further finds that, through the resolved by a board of arbitrators which shall be convened performance of child mortality reviews, preventable causes at the request of either party. The board of arbitrators shall of child mortality can be identified and addressed, thereby consist of a representative of the jurisdiction operating the reducing the infant and child mortality in Washington state. health department, a representative from the city or town (b) It is the intent of the legislature to encourage the involved, and a third representative appointed by the other performance of child death reviews by local health depart- two representatives. If no agreement can be reached ments by providing necessary legal protections to the regarding the third representative, the third representative families of children whose deaths are studied, local health shall be appointed by a judge of the superior court of the department officials and employees, and health care profes- county of the jurisdiction operating the department. The sionals participating in child mortality review committee determination by the board of arbitrators of the amount to be activities paid by the city or town shall be binding on all parties. The (2) As used in this section, "child mortality review" cost, if any, of the representative appointed by each party means a process authorized by a local health department as shall be borne by that party. The cost, if any, of the third such department is defined in RCW 70.05.010 for examining representative shall be shared equally by both parties. [1983 factors that contribute to deaths of children less than eigh- 1st ex.s. c 39 § 5.] teen years of age. The process may include a systematic review of medical, clinical, and hospital records; home 70.05.150 Contracts for sale or purchase of health interviews of parents and caretakers of children who have services authorized. (Effective until July 1, 1995.) In died; analysis of individual case information; and review of addition to powers already granted them, any city, town, this information by a team of professionals in order to county, district or local health department may contract for identify modifiable medical, socioeconomic,public health, either the sale or purchase of any or all health services from behavioral, administrative, educational, and environmental any local health department: PROVIDED, That such factors associated with each death. contract shall require the approval of the state board of (3) Local health departments are authorized to conduct • health. [1967 ex.s. c 51 § 22.1 child mortality reviews. In conducting such reviews, the following provisions shall apply: 70.05.150 Contracts for sale or purchase of health (a)All medical records, reports, and statements procured services authorized. (Effective July 1,1995.) In addition by, furnished to,or maintained by a local health department to powers already granted them, any county,district,or local pursuant to chapter 70.02 RCW for purposes of a child health department may contract for either the sale or pur- mortality review are confidential insofar as the identity of an chase of any or all health services from any local health individual child and his or her adoptive or natural parents is department. Such contract shall require the approval of the concerned. Such records may be used solely by local health state board of health. [1993 c 492 § 243; 1967 ex.s.c 51 § departments for the purposes of the review. This section 22.] does not prevent a local health department from publishing Findings—Intent-1993 c 492: See notes following RCW 43.72.005. statistical compilations and reports related to the child short ntk_Sevet e7_sa not m mortality review, if such compilations and reports do not of legislative power—Effective dates-1993 c 492: See RCW 43.72.910 identify individual cases and sources of information. through 43.72.915. (b) Any records or documents supplied or maintained for the purposes of a child mortality review are not subject 70.05.160 Moratorium on water,sewer hookups,or to discovery or subpoena in any administrative, civil, or septic systems—Public Limitation on length. A criminal proceeding related to the death of a child reviewed local board of health that adopts a moratorium affecting This provision shall not restrict or limit the discovery or water hookups, sewer hookups, or septic systems without subpoena from a health care provider of records or docu- holding a public hearing on the proposed moratorium, shall ments maintained by such health care provider in the hold a public hearing on the adopted moratorium within at ordinary course of business, whether or not such records or least sixty days of its adoption. If the board does not adopt documents may have been supplied to a local health depart- findings of fact justifying its action before this hearing,then ment pursuant to this section. the board shall do so immediately after this public hearing. (c) Any summaries or analyses of records, documents, A moratorium adopted under this section may be effective or records of interviews prepared exclusively for purposes of for not longer than six months, but may be effective for up a child mortality review are not subject to discovery. III to one year if a work plan is developed for related studies subpoena, or introduction into evidence in any adininistra- providing for such a longer period. A moratorium may be five, civil, or criminal proceeding related to the death of a renewed for one or more six-month periods if a subsequent child reviewed. nue 70 RCW—pace 14) 0994 Et) Local Health Departments, Boards., Officera—Regulations 90.05.170 (d)No local health department official or employee, and meet as a minimum one of the following standards of no members of technical committees established to perform educational achievement and vocational experience to be case reviews of selected child deaths may be examined in qualified for appointment to the office: any administrative, civil, or criminal proceeding as to the (1)Bachelor's degree in business administration, existence or contents of documents assembled, prepared, or administration,hospital administration,management, maintained for purposes of a child mortality review. environmental health, epidemiology, ublic health,, • (e) This section shall not be construed to prohibit or equivalent and five years of experience in administration in restrict any person from reporting suspected child abuse or a community-related field; or neglect under chapter 2644 RCW nor to limit access to or (2) A graduate degree in any of the fields listed in use of any records, documents,information,or testimony in subsection (1)of this section,or in medicine or osteopathy, any civil or criminal action arising out of any report made plus three years of administrative experience in a communi- pursuant to chapter 26.44 RCW. [1993 c 41 § 1; 1992 c 179 ty-related field. § 1-1 The director shall not engage in the private practice of the director's profession during such tenure of office and Chapter 70.08 shall not be included in the classified civil service of the said city or the said county. COMBINED CITY-COUNTY HEALTH If the director of public health does not meet the DEPARTMENTS qualifications of a health officer or a physician under RCW 70.05.050, the director shall employ a person so qualified to Sections advise the director on medical or public health matters. 70.08.005 Transfer of duties to the department of health. [1985 c 124 § 3; 1984 c 25 § 3; 1949 c 46 § 3;Rem. Supp. 70.08.010 Combined city-county health departments—Establishment. 70.08.020 Director of public health—Powers and duties. 1949 § 6099-32.] 70.08.030 Qualifications. 70.08.040 Director of public health—Appointment,term of office. - 70.08.040 Director of public health—A 70.08.050 May act as health officer for other cities or towns. pions t o ntthe 70.08.060 Director of public health shall be registrar of vital statistics, term of office. Notwithstanding any provisions to the 70.08.070 Employees may be included in civil service or retirement contrary contained in-any city or county charter, where a plans of city,county,or combined department. combined department is established under this chapter, the 70.08.080 Pooling of funds. director of public health under this chapter shall be appoint- 70.08.090 Other cities or agencies may contract for services. ed by the county executive of the county and the mayor of 70.08.100 Termination of agreement to operate combined city-county health department the city for a term of four years and until a successor is 70.08.110 Prior expenditures in operating combined health department appointed and confirmed. The director of public health ID ratified- be reappointed by the county executive of the county 70.08.900 Severability-1980 c 57. mayor of the city for additional four year terms. Th.. ar Control of cities and towns over water pollution: Chapter 35.88 RCW. pointment shall be effective only upon a majority vote confirmation of the legislative authority of the county and 70.08.005 Transfer of duties to the department of the legislative authority of the city. The director may be health. The powers and duties of the secretary of social and removed by the county executive of the county, after health services under this chapter shall be performed by the consultation with the mayor of the city, upon filing a secretary of health. [1989 1st ex.s. c 9 § 244.] statement of reasons therefor with the legislative authorities Effective date—Severability-1989 1st ex.s.c 9: See RCW of the county and the city. [1985 c 124 § 4; 1980 c 57 § 1; 43.70.910 and 43.70.920. 1949 c 46 § 4; Rem. Supp. 1949 § 6099-33.] 70.08.010 Combined city-county health depart- 70.08.050 May act as health officer for other cities ments—Establishment: (Effective until July 1, 1995.) or towns. Nothing in this chapter shall prohibit the director Any city with one hundred thousand or more population and of public health as provided herein from acting as health the county in which it is located, are authorized, as shall be officer for any other city or town within the county, nor agreed upon between the respective governing bodies of such from acting as health officer in any adjoining county or any city and said county, to establish and operate a combined city or town within such county having a contract or city and county health department, and to appoint the agreement as provided in RCW 70.08.090: PROVIDED, director of public health. [1985 c 124 § 1; 1949 c 46 § 1; HOWEVER, That before.being appointed health officer for Rem. Supp. 1949 § 6099-30.] such adjoining county,the secretary of health shall first give his or her approval thereto. [1991 c 3.§ 314; 1979 c 141 § 70.08.020 Director of public health—Powers and 85; 1949 c 46 §8;Rem. Supp. 1949 § 6099-37.] duties. The director of public health is authorized to and shall exercise all powers and perform all duties by law 70.08.060 Director of public health shall be Ives- vested in the local health officer. [1985 c 124 § 2; 1949 c tray of vital statistics. The director of public health under 46 § 2;Rem. Supp. 1949 § 6099-31.] 'this chapter shall be registrar of vital statistics for all cities and counties under his jurisdiction and shall conduct c^� 70.08.030 Qualifications. Notwithstanding any vital statistics work in accordance with the same laws provisions to the contrary contained in any city or county rules and regulations pertaining to vital statistics for a city o. charter,the director of public health, under this chapter shall (1994 EL) [Title 70 RCW—$age 151 70.08.IN hr Title 70 RCW: Public Health and Safety the first class. [1961 ex.s. c S § 4; 1949 c 46 § 9; Rem. lently and which were within the legal limits of indebted- Supp. 1949 § 6099-38.] ness, towards the expense of maintenance and operation of Vital statistics: Chapter 70.58 RCW a combined health department, are hereby legalized and ratified. [1949 c 46 § 11; Rem. Supp. 1949 § 6099-40.] Aft 70.08.070 Employees may be included in civil service or retirement plans of city,county,or combined 70.08.900 Severability-1980 c 57. If any provision department. Notwithstanding any provisions to the contrary of this act or its application to any person or circumstance is contained in any city or.county charter, and to the extent held invalid, the remainder of the act or the application of provided by the city and the county pursuant to appropriate the provision to other persons or circumstances is not legislative enactment, employees of the combined city and affected. [1980 c 57 § 4.] county health department may be included in the personnel system or civil service and retirement plans of the city or the county or a personnel system for the combined city and Chapter 70.10 county health department that is separate from the personnel COMPREHENSIVE COMMUNITY HEALTH system or civil service of either county or city: PROVID- CENTERS ED,That residential requirements for such positions shall be coextensive with the county boundaries: PROVIDED Sections FURTHER,That the city or county is authorized to pay such 70.10.010 Declaration of policy—Combining health services—State parts of the expense of operating and maintaining such authorized to cooperate with other entities in construct- parts system or civil service and retirement system and mg' Y 70.10.020 'Comprehensive community health center"defined. to contribute to the retirement fund in behalf of employees 70.10.030 Authorization to apply for and administer federal or state such sums as may be agreed upon between the legislative funds. authorities of such city and county. [1982 a 203 § 1; 1980 70.10.040 Application for federal or state funds for construction of c 57 § 2; 1949 c 46 § 5; Rem. Supp. 1949 § 6099-34.] facility as part of or separate from health center— Processing and approval by administering agencies— Decision on use as part of comprehensive health center. 70.08. Pooling of funds. The city by ordinance, 70.10.050 Application for federal or state funds for construction of and the county by appropriate legislative enactment, under facility as part of or separate from health applica- thiscenter— chapter may pool all or any part of their respective Cooperation between agencies in standardizing procecedures and forms. funds available for public health purposes, in the office of 70.10.060 Adoption of rules and regulations—Liberal construction of the city treasurer or the office of the county treasurer in a chapter. 4111 special pooling fund to be established in accordance with Community mental health services act: Chapter 71.24 RCW. • agreements between the legislative authorities of said city Mental health and retardation services, interstate contracts: RCW and county and which shall be expended for the combined 71-28010. health department. [1980 c 57 § 3; 1949 c 46 § 6; Rem. Supp. 1949 § 6099-351 70.10.010 Declaration of policy—Combining health Expenses of county in enforcing health laws,payment by city or town: services—State authorized to cooperate with other RCW 70.05.132. entities in constructing. It is declared to be the policy of Payments by city or town for health services: RCW 70.05145. the legislature of the state of Washington that, wherever feasible, community health, mental health and mental retardation services shall be combined within single facilities 70.08.090 Other cities or agencies may contract for• services. Any other city in-said county,other governmental - in order to provide maximum utilization of available funds agency or any charitable or health agency may by contract and personnel, and to assure the greatest possible coordina- or by agreement with the governing bodies of the combined tion of such services for the benefit of those requiring them health department receive public health services. [1949 c 46 It is further declared to be the policy of the legislature to § 7; Rem. Supp. 1949 § 6099-36.] authorize the state to cooperate with counties, cities, and . other municipal corporations in order to encourage them to 70.08.100 Termination of agreement to operate take such steps as may be necessary to construct comprehen- combined ph'- ty health t. Agreement to sive community health centers in communities throughout operate a combined city and county health department made the state. [1967 ex.s. c 4 § 1.1 under this chapter may after two years from the date of such agreement, be terminated by either party at the end of any 70.10.020 "Comprehensive community health calendar year upon notice in writing given at least six center" defined. The term "comprehensive community health center" as used in this chapter shall mean a health months prior thereto. The termination of such agreement shall not relieve either party of any obligations to which it facility housing community health, mental health, and has been previously committed. [1949 c 46 § 10; Rem. developmental disabilities services. [1977 ex.s. c 80 § 37; Supp. 1949 § 6099-39.] 1967 ex.s.c 4 § 2.] Purpose—Intent—Severability-1977 ex.s.c SO: See notes 70.08.110 Prior expenditures in operating combined following RCW 4.16.190. health department ratified. Any expenditures heretofore 70.1Q030 Authorization to for and administer made by a city of one hundred thousand population or more, apply and by the county in which it is located, not made fraudu- feral or state funds. The several agencies of the state (`Title 70 RCW 16] (1994 Ed.) Compreheuive Community Health Centers 70.10.030 authorized to administer within the state the various federal health,or developmental disability facilities shall cooperate acts providing federal moneys to assist in the cost of to develop general procedures to be used in implementing establishing community health, mental health, and mental the statute and to attempt to develop application forms and retardation facilities,are authorized to apply for and disburse procedures which are as nearly standard as possit•' •r federal grants, matching funds,or other funds,including gifts taking cognizance of the different information requii �`; or donations from any source,available for use by counties, various programs,to assist applicants in applying to vanous cities,other municipal corporations or nonprofit corporations. state agencies. [1977 ex.s. c 80§ 39; 1967 ex.s. c 4 § 5.] Upon application,these agencies shall also be authorized to Purpose—Intent—Severability-1977 ex.s.c 80: See notes distribute such state funds as may be appropriated by the following RCW 4.16.190. legislature for such local construction projects: PROVIDED, That where state funds have been appropriated to assist in 70.10.060 Adoption of rules and regulations— covering the cost of constructing a comprehensive commu- Liberal construction of chapter. In furtherance of the nity health center, or a community health, mental health,or legislative policy to authorize the state to cooperate with the mental retardation facility, and where any county,city,other federal government in facilitating the construction of municipal corporation or nonprofit corporation has submitted comprehensive community health centers,the state agencies an approved application for such state funds, then,after any involved shall adopt such rules and regulations as may applicable federal grant has been deducted from the total become necessary to entitle the state and local units of cost of construction, the state agency or agencies in charge government to share in federal grants, matching funds, or of each program may allocate to such applicant an amount other funds,unless the same be expressly prohibited by this not to exceed fifty percent of that particular program's chapter. Any section or provision of this chapter susceptible contribution toward the balance of remaining construction to more than one construction shall be interpreted in favor of costs. [1967 ex.s. c 4 § 3.1 the construction most likely to satisfy federal laws entitling the state and local units of government to receive federal 70.10.040 Application for federal or state funds for grants,matching funds or other funds for the construction of construction of facility as part of or separate from health comprehensive community health centers. [1967 ex.s. c 4 § center—Processing and approval by administering 6.] agencies—Decision on use as part of comprehensive health center. Any application for federal or state funds to Chapter 70.12 be used for construction of the community health, mental PUBLIC HEALTH FUNDShealth, or developmental disabilities facility, which will be part of the comprehensive community health center asp • defined in RCW 70.10.020, shall be separately processed and 70.12.005SectiTransfer of duties to the department of health. approved by the state agency which has been designated toCOUNTY FUNDS administer the particular federal or state program involved. Any application for federal or state funds for a construction 70.12.015 Secretary may expend funds in counties. project to establish a community health, mental health, or 70.12.025 County funds for public health. developmental disabilities facility not part Of a cornprehen- - PUBLIC HEALTH POOLING FUND sive health center shall be processed by the state agency 70.12.030 Public health pooling fund authorized—"Health district" which is designated to administer the particular federal or defined. state program involved. This agency shall also forward a 70.12.040 Fund,bow maintained and disbursed. copy of the application to the other agency or agencies 70.12.050 Expenditures from fund. designated to administer the program or programs providing 70.11060 Expenditures to budget. 0.12.070 Fund subject to audit and check by state. funds for construction of the facilities which make up a comprehensive health center. The agency or agencies 70.12.005 Transfer of duties to the department of receiving this copy of the application shall have a period of health. (Effective until July 1, 1995.) The powers and time not to exceed sixty days in which to file a statement duties of the department of social and health services and the with the agency to which the application has been submitted secretary of social and health services under this chapter and to any statutory advisory council or committee which shall be performed by the department of health and the • has been designated to advise the administering agency with secretary [1989 1st ex.s. c 9 § 245.] regard to the program, stating that the proposed facilityof health.da [1 989 1 t ex.s. c9 1st ex.s.c 9: Sec RCW should or should not be part of a comprehensive health Effective43.70.910 and 43.70.920. center. [1977 ex.s.c 80 § 38; 1967 ex.s. c 4 § 4.1 Purpose—Intent—Severability-1977 ex.s.c 80: See notes COUNTY FUNDS following RCW 4.16.190. 70.10.050 Application for federal or state'funds for 70.12.015 Secretary may expend funds in counties. construction of facility as part of or separate from health The secretary of health is hereby authorized to apportion and center—Cooperation between agencies in standardizing expend such sums as he or she shall deem necessa^110 application procedures and forms. The several state public health work in the counties of the state, fi agencies processing applications for the construction of appropriations made to the state department of healtn _ comprehensive health centers for community health, mental county public halth work. [1991 c 3-§ 315; 1979 c 141 § [I'Itie 70RCW—page 171 (1994 Ed.) 70.12.015 Title 70 RCW: Public Health and Safety 86; 1939 c 191 § 2; RRS § 6001-1. Formerly RCW (6)Any contributions from any charitable or voluntary 70.12.080.] agency or contributions from any individual or estate. Any school district may contract in writing for health 70.12.025 County funds for public health. Each services with the health department of the county, first class • county legislative authority shall annually budget and city or health district, and place such funds in the public appropriate a sum for public health work. [1975 1st ex.s,c health pooling fund in accordance with the contract. [1983 291 § 2.] c 3 § 170; 1945 c 46§ 2; 1943 c 190§ 2;Rem. Supp. 1945 Effective dates—Severability-197S 1st ez.s.c 291: See notes § 6°99-2.] following RCW 82.04.050. 70.12.050 Expenditures from fund. (Effective until PUBLIC HEALTH POOLING FUND July 1, 1995.) All expenditures in connection with salaries, wages and operations incurred in carrying on the health 70.11030 Public health pooling fund authorized— department of the county, first class city or health district "Health district" defined. (Effective until July 1, 1995.) shall be paid out of such fund. [1945 c 46§ 3; 1943 c 190 Any county, first class city or health district is hereby § 3; Rem. Supp. 1945 § 6099-3.] authorized and empowered to create a"public health pooling fund", hereafter called the "fund", for the efficient manage- 70.12.050 Expenditures from fund. (Effective July ment and control of all moneys coming to such county,first 1, 1995.) All expenditures in connection with salaries, class city or district for public health purposes. wages and operations incurred in carrying on the health "Health district" as used herein may mean all territory department of the county, combined city-county health consisting of one or more counties and all cities with a department,or health district shall be paid out of such fund. population of one hundred thousand or less, and towns [1993 c 492 § 246; 1945 c 46 § 3; 1943 c 190 § 3; Rem. therein. [1945 c 46 § 1; 1943 c 190§ 1; Rem. Supp. 1945 Supp. 1945 §6099-3.] § 6099-1.] Findings—figent-11993 c 492: See notes following RCW 43.72.005. Short 't).— gs—Capes not law--Reservation 70.12.030 Public health pooling fund. (Effective of legislative pow—Effective dates-1993 c 492: Sec RCW 43.72.910 July 1, 1995.) Any county, combined city-county health through 43.72.915. department, or health district is hereby authorized and • empowered to create a"public health pooling fund",hereof- 7012.060 Expenditures geared to budget. Any fund ter called the "fund", for the efficient management and established as herein provided shall be expended so as to • control of all moneys coming to such county, combined make the expenditures thereof agree with any respective department, or district for public health purposes. [1993 c appropriation period. Any accumulation in any such fund so 492 § 245; 1945 c 46 § 1; 1943 c 190§ 1;Rem. Supp. 1945 established shall be taken into consideration when preparing - - § 6099-1.] any budget for the operations for the ensuing year. [1943 c F tent-1993 c 492: See notes following RCW 43.72.005. 190 § 4; Rem. Supp. 1943§ 6099-4.] Shorttitledir9—Sa ' not -of legislative power—Effective dates-1993 c 492: See RCW 43.72.910 70.12.070 Fund subject to audit and check by state. through 43.72.915. The public health pool fund shall be subject to audit by the divi70.12.040 Fund, how maintained and disbursed. by thesion state f departmental audits and shall be subject to check department of health. [1991 c 3 § 316; 1979 c Any such fund may be established in the county treasurer's 141 § 87; 1943 c 190 § 5; Rem. Supp. 1943 § 6099-5.] office or the city treasurer's office of a first class city according to the type of local health department organization. Chapter 70.14 In a district composed of more than one county, the HEALTH CARE SERVICES PURCHASED BY county treasurer of the county having the largest population STATE AGENCIES shall be the custodian of the fund,and the county auditor of said county shall keep the record of receipts and disburse- Sections ments; and shall draw and the county treasurer shall honor 70.14.020 State agencies to identify alternative health care providers. 70.14.030 Health care utilization review procedures. and pay all Such warrants. be paid: 70.14.040 Review of prospective rate setting methods. Into any such fund so established may 70 (1) All grants from any state fund for county public 14050 Drug rn purchasing costcontrols—Euabhshrnen t of drug for- health work; State health care cost containment policies: RCW 43.41.160. (2)Any county current expense funds appropriated for the health department; 70.14.020 State agencies to identify alternative health(3) Any other money appropriated by the county for health care providers. Each of the agencies listed in Aim work; *RCW 70.14.010, with the exception of the department of IIP (4)City funds appropriated for the health department; labor and industries, which expends more than five hundred (5)All moneys received from any governmental agency, thousand dollars annually of state funds for purchase of local, state or federal which may contribute to the local health care shall identify the availability and costs of nonfee health department; and for service providers of health care,including preferred aide 70 RCW 13) (1994 Ed.) P 7u. litre 70 RCW: . . blic llli; and Safety Upon the petition of either or both new districts, the superior construed,in order to carry out the purposes and objects ft court in the county where they are located may take whatev- which this act is intended. When this act comes in confli er actions are reasonable and necessary to complete or with any provisions, limitation or restriction in any orb confirm the carrying out of such plan. [1982 c 84 § 8.] law, this act shall govern and control. [1945 c 264 : r RRS.] yr 70.44.400 Withdrawal of territory from public hospital district. Territory within a public hospital district 70.44.901 Severability—Construction-1974 ex.s. may be withdrawn therefrom in the same manner provided 165. If any section, clause, or other provision of this 197 by law for withdrawal of territory from water districts, as amendatory act, or its application to any person or circum provided by chapter 57.28 RCW. For purposes of conform- stance,is held invalid, the remainder of such 1974 amends ing with such procedure,the public hospital district shall be tory act, or the application of such section, clause, a deemed to be the water district and the public hospital board provision to other persons or circumstances, shall not b of commissioners shall be deemed to be the water district affected. The rule of strict construction shall have n board of commissioners. [1984 c 100 § 1.] application to this 1974 amendatory act, but the same shai be liberally construed,in order to cavy out the purposes ani 70.44.450 Rural public hospital districts— objects for which this 1974 amendatory act is intended Cooperative agreements and contracts. In addition to When this 1974 amendatory act comes in conflict with an: other powers granted to public hospital districts by chapter provision, limitation, or restriction in any other law, thi 39.34 RCW, rural public hospital districts may enter into 1974 amendatory act shall govern and control. [1974 ex.s cooperative agreements and contracts with other rural public c 165 § 6.1 hospital districts in order to provide for the health care needs of the people served by the hospital districts. These agree- 70.44.902 Severability-1982 c 84. If any provision ments and contracts are specifically authorized to, include: of this act or its application to any person or circumstance is (1) Allocation of health care services among the held invalid, the remainder of the act or the application o: different facilities owned and operated by the districts; the provision to other persons or circumstances is no (2) Combined purchases and allocations of medical affected. [1982 c 84 § 211 equipment and technologies; (3) Joint agreements and contracts for health care 70.44.903 Savings-1982 c 84. All debts, contracts service delivery and payment with public and private and obligations made or incurred prior to June 10, 1982, by entities; and or in favor of any public hospital district, and all bonds, (4) Other cooperative arrangements consistent with the warrants,or other obligations issued by such distrix• Allkill intent of chapter 161, Laws of 1992. The provisions of other actions and proceedings relating thereto don 111. n chapter 39.34 RCW shall apply to the development and by such public hospital districts or by their respec..ve implementation of the cooperative contracts and agreements. officers within their authority are hereby declared to be legal [1992 c 161 § 3.] and valid and of full force and effect from the date thereof. Intent-1992 c 161: "The legislature finds that maintaining the [1982 c 84 § 11.] - viability of health care service delivery in rural areas of Washington is a primary goal of state health policy. The legislature also funds that most 70.44.910 Construction-1945 c 264. This act [1945 hospitals located in rural Washington are operated by public hospital districts authorized under chapter 70.44 RCW and declares that it is not c 264 § 22] shall not be deemed or construed to repeal or cost-effective.practical.or desirable to provide quality health and hospital affect any existing act, or any part thereof, relating to the care services in rural areas on a competitive basis because of limited patient construction,operation and maintenance of public hospitals, volume and geographic isolation. It is the intent of this act to foster the development of cooperative and collaborative arrangements among rural but shall be supplemental thereto and concurrent therewith_ public hospital districts by specifically authorizing cooperative agreements [1945 c 264 § 22; no RRS.] and contracts for these entities under the interlocal cooperation act." [1992 c161 § l.l Chapter 70.46 70.44.460 Rural public hospital district defined. HEALTH DISTRICTS Unless the context clearly requires otherwise,the definition in this section applies throughout RCW 70.44.450. Sections "Rural public hospital district" means a public hospital 70.46.020 Districts of two or more counties—Health board— district authorized under chapter 70.44 RCW whose geo- Membership—Chairman. ofrship'-Conan' 70.46.030 graphic boundaries do not include a city with a population county—Board of health—Membership- greater than thirty thousand. [1992 c 161 § 2.] 70.46.040 Inclusion of a city over 100.000 population. Intent-1992 c 161: See note following RCW 70.44.450. 70.46.050 Representation on the district health board. 70.46.060 District health board—Powers and duties. • 70.46.080 Treasurer—District funds—Contributions by counties and • 70.44.900 Severability—Construction--1945c 264. cities. Adjudication of invalidity of any section,clause or part of a 70.46.085 Expenses of providing public health services--Payment b section of this act [1945 c 264] shall not impair or otherwise counties,cities,and towns—Procedure on failu^-• affect the validityof the act as a whole or any other part 70.46.090 Withdrawal of county'maintain,cityor town. 70.46.100 Power to acquire, or dispose of property— thereof. The rule of strict construction shall have no Contracts. application to this act, but the same shaii-'tar:liberally (1994 Ed.) frhi 70 BEVY—me:.9 Health Mari<;k Chapter 70.4 70.46.110 Disincorparacion of district totaled in county with a popula- whenever the county legislative authority of the county shat tion of two hundred ten thousand or more and inactive for five years. pass a resolution to organize such a health district unde 70.46.120 License or permit fees. chapter 70.05 RCW and RCW 70.46.020 through 70.46.090 • 70.46.130 Contracts foe sale or purchase of health services 1,ocat health dr authorized. The district board of health of such district shall consist o departments.provisions relating to health districts: Chapter not less than five members, including MOS RCW 8 the three members o the county legislative authority of the county: PROVIDED That if such health district consists of a county 1 '70.46.020 Districts of two or more counties--Health population of from seventy thousand to less thanwith board—Membership—firman (Effective until July 1, hundred twenty-five thousand, the district board of healtt 1995.) Health districts consisting of two or more counties shall consist of not less than six members, including the may be created whenever two or more boards of county three members of the county legislative authorityof commissioners shall by resolution establish a district for such county and one person who is a qualified voter of an purpose. Such a district shall consist of all the area of the unincorporated rural area of the combined counties including all cities and towns except by the legislative authorityof the coon d who�remainingg cities of over one hundred thousand population. The district members shall be re cities• and board of health of such a district shall consist of not less the district selected bymutual s agreement e of towns in than seven members, including two representatives from bodies of the cities antowns concerned the legislativeebr- each county who are members of the board of county ship, takingonncem�ive pula ions and commissioners and who are appointed by the board of financial contributions offs such c cities andmetowns populations and county commissioners of each county within the district. At the first meeting of a district board of health, the The remaining members shall be representatives of the cities members shall elect a chairman to serve for a and towns in the district selected by mutual agreement of the period of one legislative bodies of the cities and towns concerned from 51 5; 1945 c36 3 § 3;;1 Rem. Supp.; 1969 s 1c 945§ 6 99-1 .1 c their membership, taking into consideration the financial § 609 following contribution of such cities and towns and representation from 232.180. aptiofts not taw-1991 c 363: See nous RCW the several classifications of cities and towns. At the first meeting of a district board of health the �rerabltity-1%7 ex.s.c 51: See note following RCW 70.05.010. members shall elect a chairman to serve for a period of one Year. [1967 ex.s. c 51 § 6; 1945 c 183 § 2; Rem. Supp. 70.46.040 Inclusion of a city over 100,000 popuy_ 1945 § 6099-11.] bon (Effective until July 1, 1995.) Whenever a city of • Se.erabll;h--1967 exsover one hundred thousand population desires to be included .c 51: See note following RCW 70.05.010. in a health district and shall through its legislative authority 70.46.020 petition the district board of health to be included and the Districts of two or more counties--Health district board of health and the city legislative authority board—Membership..—Chair, (Effective July 1, 1995. agree as to the Health districts consisting of two or more counties may be health district moons tot performed for the city to the created whenever two or moreamount of financial contributions be ers shall by resolution establishsoft for county h purpose. includecommission- made d in the the ealthto tddieshealth �district 967 ex.s.such 51 city 7; 1945 c Such a district shall consist of all the area of the combined 183 § 4; Rem. Supp. 1945 § c counties. The district board of health of such a district shall Severability-1%71: n to consist of not less than five members for districts of two 'c 51: See note following RCW 70.05.010. counties and seven members for districts of more than two 70.46.050 Representation on the district health counties, including two representatives from each county �� who are members of the board of county commissioners and (Effective until July 1,1995.) Whenever a city of who are appointed by the board of coup co over one hundred thousand population is included in a health ry mmissioners of district it shall have equal representation with the board of each county within the district,and shall have a jurisdiction coup commissioners mmissioners of the county in which said city is coextensive with the combined boundaries At the first meeting of a district board of health the located, body city's thercity to its selected by the All members shall elect a chair to serve for a period of one ear, to of city from among hshllbemembership. de [1993 c 492 § 247; 1967 ex.s. c 51 § 6; 1945 c 183y 2; appointments the district board of health shall be made Supp. 1945 § § within thirty days after the formation of the district. Rem. Supp _ 1c 6099-11.]12: See notes Vacancies on the district board of health shall be filled by followingsue RCW 43.72.005. appointment within thirty days and made in the same manner o[lepatatl.e River--Effective dates-_1993 c ous t RCWb4 but—altercation as was the original appointment. Representatives on the through 43.72.915. district board of the various units of the district shall �Y-1%7 tis.a 51: See note following RCW 70.05.010. continue at the pleasure of the legislative body of the unit PROVIDED, That the representation on the local 70.46.030 of one count — health in existence at the time of theboards eor health--Membership--Chairman.Districts county—Board of 70.05 RCW gh enactment046. 0 chapter • (Effective untilJuly and RCW change i 0th20 through 70.46.090 may be d. 1,1995.) A health district to consist of one county only continued without in the discretion of the board. including all cities and towns therein except cities havinga Supp.and [1967 ex.s. c 51 § 8; 1957 c 100§ 1; 1945 c 183 § 5;Rem. population of over one hundred thousand maybe Supp. 1945 § 6099-)4.J created Sever/ability-1%7 ea.s.c 51: See note following RCW 70.05.010. (1994 Ed.) 70.46.Jam#h Title 70 RCW: Public Health ety i 70. District060 owersand duties. The determination of the proportionate share to be paid by (Effective until July1, 1995.) The district board of health a county, city or town shall be binding on all parties. shall constitute the local board of health for all the territory Payments into the fund of the district may be made by the included in the health district, and shall supersede and county or city or town members during the first Allpf exercise all the powers and perform all the duties by law membership in said district from any funds of the i vested in the county or city or town board of health of any county, city or town as would otherwise be availaole .or county,city or town included in the health district,except as expenditures for health facilities and services,and thereafter otherwise in chapter 70.05 RCW and RCW 70.46.020 the members shall include items in their respective budgets through 70.46.090 provided. [1967 ex.s. c 51 § 11; 1945 c for payments to finance the health district. [1971 ex.s.c 85 183 § 6; Rem. Supp. 1945 § 6099-15.1 § 10; 1967 ex.s. c 51 § 19; 1945 c 183 § 8; Rem. Supp. Severability-1967 ex.s.c 51: See note fol owing RCW 70.05.010. 1945 § 6099-17.1 Severabillty-1967 exs.c 51: See note following RCW 70.05.010. 70.46.060 District health board—Powers and duties. (Effective July 1, 1995.) The district board of health shall 70.46.080 District health funds. (Effective July 1, constitute the local board of health for all the territory 1995.) Each health district shall establish a fund to be included in the health district, and shall supersede and designated as the "district health fund", in which shall be exercise all the powers and perform all the duties by law placed all sums received by the district from any source, and vested in the county board of health of any county included out of which shall be expended all sums disbursed by the in the health district. [1993 c 492 § 248; 1967 ex.s.c 51 § district. In a district composed of more than one county the 11; 1945 c 183 § 6; Rem. Supp. 1945 § 6099-15.] county treasurer of the county having the largest population teat-1993 c 492: See notes following RCW 43.72.005. shall be the custodian of the fund,and the county auditor of S tions not Iaw-aaservatim said county shall keep the record of the receipts and dis- of legislative power—Effective dates-1993 c 492: See RCW'43.72.910 bursements, and shall draw and the county treasurer shall through 43.72.915. honor and pay all warrants,which shall be approved before Severability-1967 ems.c 51: See note following RCW 70.05.010. issuance and payment as directed by the board. Each county which is included in the-district shall 70.46.080 Treasurer—District funds—Contributions contribute such sums towards the expense for maintaining by counties and cities. (Effective until July 11, 1995.) and operating the district as shall be agreed upon between it Each health district shall establish a fund to be designated as and the local board of health in accordance with guidelines the "district health fund",in which shall be placed all sums established by the state board of health. [1993 c 492 § 249; received by the district from any source, and out of which 1971 ex.s.c 85 § 10; 1967 ex.s.c 51 § 19; 1945 c 1°110: shall be expended all sums disbursed by the district. The Rem. Supp. 1945 § 6099-171 county treasurer of the county in the district embracing only tr-1993 c 492: See notes following RCW 43.72.0 0. one county; or, in a district composed of more than one Short Oot county the county treasurer of the county having the largest of kgislatve power—Effective dates-1993 c 492: See RCW 43.72.910 population shall be the custodian of the fund,and dee county through 43.72.915. auditor of said county shall keep the record of the receipts Severability-1967 exs.c 51: See note following RCW 70.05.010. and disbursements, and shall draw and the county treasurer shall honor and pay all warrants, which shall be approved 70.46.085 Expenses of providing public health before issuance and payment as directed by the board: services—Payment by counties, cities,and towns— PROVIDED, That in local health departments wherein a city Procedure on failure to pay. (Effective until July 1, of over one hundred thousand population is a part of said 1995.) The expense of providing public health services shall department, the local board of health may pool the funds be borne by each county, city or town within the health available for public health purposes in the office of the city district,and the local health officer co ertify e70amount ount treasurer in a special pooling fund to be established and agreed upon or as determined pursuant 80. which shall be expended as set forth above. and remaining unpaid by each county, city or town to the Each county, city or town which is included in the fiscal or warrant issuing officer of such county,city or town. district shall contribute such sums towards the expense for If the expense as certified is not paid by any county, maintaining and operating the district as shall be agreed city or town within thirty days after the end of the fiscal upon between it and the local board of health in accordance year,the local health officer shall certify the amount due to with guidelines established by the state board of health after the auditor of the county in which the governmental unit is consultation with the Washington state association of situated who shall promptly issue his warrant on the county counties and the association of Washington cities. In the treasurer payable out of the current expense fund of the event that no agreement can be reached between the district county, which fund shall be reimbursed by the county board of health and the county,city or town,the matter shall auditor out of the money due said governmental unit at the be resolved by a board of arbitrators to consist of a represen- next monthly settlement or settlements of the collection of tative of the district board of health, a representative from taxes and shall be transferred to the current expense fund. the county,city or town involved,and a third representative [1967 ex.s. c 51 § 20.] to be appointed by the two representatives, but if they are Severability-1967 ex.s.c 51: See note following RCW • unable to agree, a representative shall be appointed by a F.rpe cses of enforcing health laws: RCW 7005.130. . judge in the county in which the city or town is located. [Tltsle 7 70) Health Districts 70.46.08? 70.46.085 County to bear expense of providing public health services. (Effective July 1, 1995.) The70 46.100 Power to acquire, tain, or . party—Contracts. In addition to all other powers anc expense of providing public health services shall be borne b 411) each county within the health district. [1993 c 492 § 250;d ' a health district shall have the power to own, con- 1967 ex.s. c 51 § 20.] struct, purchase, lease, add to, and maintain any real and personal property or property rights necessary for the Findings--Intent-1993 c 492: See notes following RCW 4172.005. conduct of the affairs of the district A health district may Short ti ''ty—S, ' not inn sell, lease, convey or otherwise dispose of any district real of legislative power—Effective dates-1993 c 492: See RCW through 43.72.915. 43.72.910 or personal property no longer necessary for the conduct of Severability-1967 eras `gt: See note following RCw 70.05.010. the affairs of the district. A health district may enter into contracts to carry out the provisions of this section. [1957 Expenses of enforcing health laws: RCW 7005.130. 100 § C 100 § 2.] 70.46.090 Withdrawal of county, city, or town. (Effective until July 1, 1995.) Any county or any city ®r 70.46.110 Disincorporation of district located in town may withdraw from membership in said health district �with a population of two hundred ten or any time after it has been within the district for a more and for five years. See chapter 57.90 RCW. two years, but no withdrawal shall be effective exceptat the end of the calendar year in which the county, city or town 70.46,120 Licensee or permit fees. (Effective until gives at least six months' notice of its intention to withdraw July 1, 1995.) In addition to all other powers and duties, at the end of the calendar year. No withdrawal shall entitle health districts shall have the power to charge fees in any member to a refund of any moneys paid to the district connection with the issuance or renewal of a license or nor relieve it of any obligations to pay to the district all permrt by law: PROVIDED,That the fees charged shall not exceed the actual cost involved in issuing or renewing the license or permit: PROVIDED FURTHER, sums for which it obligated itself due and owing by it to the ofdistrict for the year the end er which the withdrawal is to be effective: PROVIDED, That any county, city or town That no fees shall be charged pursuant to this section within which withdraws from membership in said health districtct the corporate limits of any city or town which prior to the shall immediately establish a health department or provide enactment of this section charged fees in connection with the health services which shall meet the standards for health ser renewal of a license or permit vices promulgated by the state board of health: PROVIDED toty or ordinance and where said city or town m makes at to ctdirecY FURTHER, That no local health department shall be deemed contribution to said health district, unless such city or town to provide adequate public health services unless there is at expressly consents thereto. [1963 c 121 § 1.1 least one full time professionally trained and qualified physician as set forth in RCW 70.05.050. [1967 ex.s. c 51 70.46.120 License or I § 21; 1945 c 183 § 9; Rem. Supp. 1945 § 6099-18.] permit fees. (EffectiveJuly 1, 1995.) In addition to all other powers and dutieess, health Severability-1967 ex.s.c 51: See note following -1 70.05.010. districts shall have the power to charge fees in connection with the issuance or renewal of a license or permit required 70.46.090 Withdrawsl of county. (Effective July 1, by law: PROVIDED, That the fees charged shall not exceed 1995.) Any county may withdraw from membership isaid the actual cost involved in issuing c renewing the license or health district any time after it has been within the district e permit. [1993 c 492 § 252; 1963 c 121 § 1.1 I for a period of two years, but no withdrawal shall be ffec- 1993 c 492: See notes foU° wifive except at the end of the calendar year in which the Shorttitle—Severability—Savings—Captions ►g burRC— 43.72005. Reservation county gives at least six months' notice of its intention toof legislative power—Effective dates-1993 c 492: See RCW 43.72.910 withdraw at the end of the calendar year. No withdrawal throught 43.72..915.915. shall entitle any member to a refund of any moneys paid to the district nor relieve it of any obligations to pay to the 70s suth ar Contracts for sale district all sums for which it obligated itself due and owing authorized. See RCW 70.05.150. or purchase of health by it to the district for the year at the end of which the withdrawal is to be effective. Any county which withdraws from membership in said health district shall immediately Chapter 70.47 R` C HEALTH PLAN—HEALTH CARE ACCESS establish a health department or provide health services which shall meet the standards for health services promulgat- ACT ed by the state board of health. No local health department sections may be deemed to provide adequate public health services 70.47.005 Transfer power,duties,and functions to Washington state unless there is at least one full time professionally trained health care and qualified physician as set forth in RCW 70.05.050. 70.47.O10 Legislative of findw qty' —Ad ealth m _ [1993 c 492 § 251; 1967 ex.s. c 51 § 21; 1945 c 183 § 9; �— p Rem. Supp. 1945 § 6099-18.1 soda!and l `es into istratcoo or anate nd deeliartgibili . 070.47.020 Definitions. —1993 c 492: See notes following RCW 43.72.005. 70.47.030 Basic health plan trust account—Basic health plan subscrip- Shutt�� � tion account. 70.47.040 Basic lea I of legislative power—Effective dates-1993 c 492: See RCW 43.72.9health plan—Health alth through 43.72.915. 'oft authority head to as- Severabili s. operations—Technical advisory committee. ty 1967 ex.s.c 51: See note following RCW 70.05.010. 70.47.050 Rule (1994 EdJ [Title 70 RCW—page 71)