Policy Statements Adopted by the Governing Council of the American Public Health Association, October 24, 2001

2001-2: Reducing Maternal-Fetal...

THE AMERICAN PUBLIC HEALTH ASSOCIATION,

Knowing that previous APHA policy recognizes the importanceof international prevention of perinatal HIV transmission,¹supports testing under prevailing guidelines for confidentialityand counseling, and is opposed to mandatory HIV testing of pregnantwomen²; and

Noting that APHA has no formal policy on rapid HIV testing inlabor and delivery; and

Realizing that the APHA Task Force on Rapid HIV Testing in Laborand Delivery recently provided to HRSA its recommendations supportingthe availability of rapid HIV tests in labor and delivery forwomen in labor of unknown HIV status whose fetus may be at riskfor maternal-fetal HIV transmission³; and

Understanding that those recommendations were based on the availabilityof the FDA-approved SUDS HIV test, which has since been withdrawnfrom the US market in October 2000 and returned in April 2001,a test that must be run in a CLIA-certified lab making it logisticallydifficult to provide timely results in a labor and deliverysetting; and

Being aware that other rapid HIV tests that are being manufactured,some that have been approved in other countries, have been evaluatedand found by the CDC and others to be more accurate than theSUDS test, roughly equivalent to standard EIA tests, and deliverresults in less than 10 minutes without laboratory equipment,potentially at the bedside,^4,⁵ and are not yet approved by theFDA, effectively leaving no available FDA-approved rapid HIVtest delivering timely results in labor and deliver; and

Recognizing that approximately 5% to 10% of the 4 million annualbirths in the US are to mothers with inadequate or no prenatalcare⁶ and that approximately 6000 HIV-infected women give birthin the US every year and an estimated 500,000 infants becomeinfected each year worldwide⁷; and

Realizing that the nation, as well as other countries, needsrapid HIV testing with informed consent in labor and deliveryto cost-effectively prevent hundreds, and potentially thousandsworldwide, of lethal maternal-fetal HIV transmissions to newborns⁸;and

Understanding that rapid HIV testing during labor and deliveryin mothers with unknown HIV status has been very well received,with over 85% consenting⁹; and

Sensing that, in the United States and Europe, the possibilityof preventing almost all new cases of pediatric HIV infectionis within reach¹⁰; and

Observing that the CDC¹¹ and others¹² recognize the urgent needfor rapid HIV tests and that ‘Fast track’ approvalof the HIV rapid tests through the FDA has been encouraged byother groups including the National Alliance of State and TerritorialAIDS Directors (NASTAD)¹³; therefore, APHA

Supports the development of rapid HIV test kits of appropriatelyhigh sensitivity and specificity to properly meet the needsof primary prevention;
Encourages the expedited and earlyFDA approval of rapid HIVtest kits; and
Strongly urges publicfunding for distribution of rapid HIVtest kits to hospitalsand birthing centers in developed anddeveloping countries toprevent maternal-fetal HIV transmissionin labor and deliveryof women in labor with an unknown HIVstatus; and
Urges therapid widespread dissemination by government agenciesof theAPHA Working Group guidelines for ethical and effectiveuseof rapid HIV tests in labor and delivery; and
Seeks the rapiduniversal adoption of this policy by local,state and federalauthorities, professional societies and hospitalassociations.

2. APHA Policy Statement 9520: Opposition to Mandatory HIV Testing of Pregnant Women. APHA Policy Statements; 1948—present, cumulative. Washington, D.C.: American Public Health Association; current volume. Available online: http://www.apha.org/legislative/policy/policysearch/index.cfm?fuseaction= view&id=115

3. American Public Health Association HIV Rapid Test Working Group, "The Use of Rapid HIV Tests During Labor and Delivery: Recommendations for Best Practices", Nov. 2000. Available online: http://www.apha-hivaids.org/

4. Giles RE, Perry KR, Parry JV. Simple/rapid test devices for anti-HIV screening: do they come up to the mark? J Med Virol. 1999 Sep;59(1):104–9.[Medline]

5. Webber LM, Swanevelder C, Grabow WO, Fourie PB. Evaluation of a rapid test for HIV antibodies in saliva and blood. S Afr Med J. 2000 Oct;90(10):1004–7.[Medline]

6. Kogan, MD, JA Martin, et al. The changing pattern of prenatal care utilization in the United States, 1981-1995, using different prenatal care indices. JAMA. 1998;279(20):1623–8.[Abstract/Free Full Text]

7. Fowler, MG, RJ Simonds, et al. Update on perinatal HIV transmission. Pediatr Clin North Am. 2000; 47(1):21–38.[Medline]

8. Grobman WA, Garcia PM. The cost-effectiveness of voluntary intrapartum rapid human immunodeficiency virus testing for women without adequate prenatal care. Am J Obstet Gynecol. 1999;181:1062–71[Medline]

9. Rajegowda BK, Das BB, Lala R, Rao S, Mc Neeley DF. Expedited human immunodeficiency virus testing of mothers and newborns with unknown HIV status at time of labor and delivery. J Perinat Med. 2000;28(6): 458–63.[Medline]

10. Fowler MG. Prevention of perinatal HIV infection. What do we know? Where should future research go? Ann N Y Acad Sci. 2000 Nov;918:45–52.[Medline]

11. Tao G, Branson BM, Kassler WJ, Cohen RA. Rates of receiving HIV test results: data from the U.S. National Health Interview Survey for 1994 and 1995. J Acquir Immune Defic Syndr. 1999 Dec 1;22(4):395–400.

12. Minkoff, H. and M. J. O'sullivan. The case for rapid HIV testing during labor. JAMA. 1998;279(21): 1743–4.[Free Full Text]

13. National Alliance of State and Territorial AIDS Directors (NASTAD) Letter to the FDA Urging Expedited Approval of Rapid HIV Tests. May 18, 2000. Available online: http://www.nstad.org/fda_rapidtest.htm.

	2001-3: Increasing Access to Out-of-Hospital Maternity Care Services through State-Regulated and Nationally-Certified Direct-Entry Midwives

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2001-3: Increasing Access to...

THE AMERICAN PUBLIC HEALTH ASSOCIATION,

Reaffirming its position on credentials for health occupations,that there should be alternative routes involving educationalsystems of selection and preparation, and legal systems of licensingby which people can prepare and qualify for health occupations¹;and

Reaffirming its recognition that many women seek birthing alternatives²;and

Recognizing that pregnancy and birth are normal life eventsfor a majority of women^3,^4,⁵; and

Reaffirming its endorsement of the philosophy of family-centeredmaternity care, the importance of continuity of care, and theuse of a variety of licensed care-givers⁶; and

Recognizing that Direct-entry Midwives encompass a diverse groupof midwives that have entered the profession directly throughmidwifery education and training, and not through a prerequisiteprogram such as nursing⁷; and

Recognizing that there are alternative educational systems ofselection and preparation for national certification of Direct-entryMidwives that include either the Certified Professional Midwife(CPM) credential and the Certified Midwife (CM) credential;and that both require didactic programs, written examinationsand clinical experience.^8,⁹ In the case of the Certified ProfessionalMidwives the didactic component consists of education in a programaccredited by an agency that is recognized by the US Departmentof Education or the Portfolio Evaluation Process program, theNorth American Registry of Midwives competency-based, educationalportfolio evaluation, and the clinical component is equivalentto one year of experience which includes more than a thousandcontact hours under the supervision of one or more preceptors,some of which must be in out-of-hospital settings, but noneof which need to be in hospital settings⁸; and in the case ofthe CM credential requires education in institutions of higherlearning accredited by an agency that is recognized by the USDepartment of Education to meet the same standards that CertifiedNurse Midwives must meet, completing core science requirementssimilar to those required for a nurse, and fulfilling core midwiferyrequirements that are a part of all accredited nurse-midwiferyeducation programs, and clinical experience that must includehospital experience, but is not required to include out-of-hospitalexperience.⁹

Recognizing that individual states interested in incorporatingdirect-entry midwives into their health care systems are movingtoward regulatory models based on national certification⁵; and

Recognizing evidence that many women seek alternatives to hospitalcare for normal pregnancy and birth, and

Recognizing the evidence that births to healthy mothers, whoare not considered at medical risk after comprehensive screeningby trained professionals, can occur safely in various settings,including out-of-hospital birth centers and homes^10–¹⁴;and

Noting that an epidemiological study of Certified ProfessionalMidwives (CPMs) is ongoing in order to investigate and evaluatepractice outcomes, safety, client satisfaction, and practitionercompetency¹⁵; and

Recognizing that out-of-hospital settings have the potentialfor reducing the costs of maternity care^7,^12,¹⁶; and

Recognizing evidence that access to quality maternity caregiversremains an important issue, particularly for underserved urbanand rural communities¹⁷; which may be addressed through out-of-hospitalmaternity services in some communities; and

Reaffirming that the APHA currently recognizes the value ofand promotes educational opportunities for nurse-midwifery,¹⁸and that many professionals recognize the contributions of direct-entrymidwifery; and

Reaffirming that APHA has been an innovator in public healthcare by supporting research on alternative and complementarymedicine^1,¹⁹ and increased access to midwifery services in theUnited States,²⁰

Recognizing that there should be alternative routes involvingeducational systems of selection and preparation, and legalsystems of licensing by which people can prepare and qualifyfor health occupations, including those direct-entry midwiveswho are nationally-certified and who have successfully completed"a recognized midwifery education process"^21–^23,²⁵; and

Recognizing evidence that direct-entry midwives have multipleeducational routes^22,²⁴ available to them in order to meet theentry-level requirements of knowledge, skills and experience^22,^24,²⁵;

Recognizing evidence that individual states interested in incorporatingdirect-entry midwives into the health care system are movingtoward regulatory models based on national certifications²²;

Therefore, APHA

Supports efforts to increase access to out-of-hospital maternitycare services and increase the range of quality maternity carechoices available to consumers, through recognition that legally-regulatedand nationally certified direct-entry midwives can serve clientsdesiring safe, planned, out-of-hospital maternity care services,and further:
Encourages the development and implementationof guidelinesfor the licensing, certification and practicefor direct-entrymidwifery practitioners for use by state andlocal health agencies,health planners, maternity care providers,and professionalorganizations;
Urges that there be increasedopportunities for supervised clinicallearning experiences,in a variety of settings, including bothhigh-risk and low-risk,incorporated into direct-entry midwiferyeducation programs;
Encourages an increase in cost effective maternal care servicesfor rural and underserved urban populations by advocating forincreases in funding of scholarships and loan repayment programstargeted at members of these communities;
Urges public andprivate insurance plans to eliminate barriersto the reimbursementand equitable payment of direct-entry midwiferyservices inboth public and private payment systems;
Encourages the NationalCenter for Health Statistics, the USDepartment of Health andHuman Services and State Vital RecordsOffices to add the CPMas a separate certifier category on birthcertificates to enableroutine collection of systematic data;
Urges HRSA, CDC andstate health departments to improve thecollection and qualityof vital statistics and other data toenhance the monitoringof birth outcomes (e.g., infant and perinatalmortality rates,maternal mortality rates, etc.) resulting fromservices providedby all practitioners including specific typesof midwife practitioners;
Urges Congress and appropriate Department of Health and HumanServices agencies to increase funding and other support forongoing research and evaluation of maternal health and birthoutcomes, practice outcomes, quality of care outcomes, and safetyrelated to the services provided by direct-entry midwives.

2. American Public Health Association Position Paper 8209: Guidelines for Licensing and regulating Birth Centers. APHA Public Policy Statements, 1948 to present, cumulative. Washington, D.C. current volume.

3. Stewart, David: The Five Standards of Safe Childbearing, NAPSAC International, 4th Edition, 1997.

4. Care in Normal Birth: a practical guide, Technical Working Group, World Health Organization. Department of Reproductive Health and Research, Section 1.1-1.6, 1999.

5. Rooks, JR: Midwifery and Childbirth in America. Temple University Press, Philadelphia, 1997.

6. American Public Health Association Position Paper 7924: Alternatives in Maternity Care. APHA Public Policy Statements, 1948 to present, cumulative. Washington, D.C. current volume.

7. Rooks JP. Unity in Midwifery? Realities and Alternatives. J Nurse-Midwifery 1998;43:315–319.

8. North American Registry of Midwives (NARM), How to Become a Certified Professional Midwife and Candidate Information Bulletin. Revised, June 2000.

9. ACNM Issue Brief February 1999 and ACNM Position Statement on Midwifery Education 1997.

10. Durand AM. The safety of home birth: The Farm Study. Am J Public Health 1992;82:450–453.[Abstract/Free Full Text]

11. MacDorman M, Singh G: Midwifery care, social and medical risk factors and birth outcomes in the USA. J Epidemiol Community Health. 1998;52:310–317.[Abstract]

12. Wagner M. Midwifery in the industrialized world. J Soc Obstet Gyn Canada. November 1998.

13. Mehl LE, Ramiel JR, Leininger B, Hoff B, Kroenthal K, Peterson G. Evaluation of outcomes of non-nurse midwives: matched comparison with physicians. Women & Health 1980;5:17–29.

14. Sullivan D, Weitz. Labor Pains: modern midwives and homebirth. Yale University Press, 1988.

15. Ken Johnson, PhD, and Betty Ann Daviss, MA. CPM Statistics Project 2000: A prospective study of births by certified professional midwives in North America. (Abstract #3042.0) Presented at 128th APHA Annual Meeting, Boston, MA, November 2000.

16. Blevins Medical Monopoly: Protecting Consumers or Limiting Competition? Policy Analysis by Cato Institute December 15, 1995;246:11-14. Burnette CA, Jones JA, SA.

17. Tennessee Commission on Children and Youth Report: The State of the Child in Tennessee: KIDS COUNT, 1996.

18. American Public Health Association Position Paper 9403: Increase support for education and practice opportunities for nurse-midwives. APHA Public Policy Statements, 1948 to present, cumulative. Washington, D.C. current volume.

19. American Public Health Association Position Paper 9714: Support for Research on Alternative and Complementary Practices. APHA Public Policy Statements, 1948 to present, cumulative. Washington, D.C. current volume.

20. American Public Health Association Position Paper 20004: Supporting Access to Midwifery Services in the United States. APHA Public Policy Statements, 1948 to present, cumulative. Washington, D.C. current volume.

21. Charting a course for the 21st century: The future of Midwifery. A joint report of the PEW Health Commission and the University of California, San Francisco Center for the Health Professions, April 1999.

22. Myers-Ciecko J. Evolution and current status of direct-entry midwifery education, regulation, and practice in the United States, with examples from Washington State. J Nurse-Midwifery 1999(Jul-Aug);44(4):384–392.

23. Midwifery Today. Paths to becoming a midwife: Getting an Education, Midwifery Today, Inc. 1998.

24. Haughton P, Windom KL. 1995 Job Analysis of the role of direct-entry midwives. June 1996.

25. Mahlman R. The Quality of the NARM Certification process, testimony before the Ohio Study Council on Midwifery, Associate Director of Assessment Services, Vocational Instructional Materials Laboratory, The Ohio State University, July 1997.

	2001-4: Hospital Emergency Department Closures

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2001-4: Hospital Emergency...

THE AMERICAN PUBLIC HEALTH ASSOCIATION,

Being cognizant of the pervasive and unrelenting crisis of thenation's approximately 43 million citizens who lack health insurance;¹and

Recognizing that the primary care facilities which constitutethe nation's health care safety net, including community healthclinics, local public health clinics, public hospital outpatientfacilities and the nation's nearly 5,000 hospital emergencydepartments, have historically borne a disproportionate shareof the responsibility for treating the uninsured;² and

Being aware that a recent Institute of Medicine report on America'shealth care safety net noted that it is "intact but endangered"as a result of the rising number of uninsured patients in theface of shrinking government subsidies;³ and

Acknowledging that the community hospital emergency departmentis unique among safety net providers due to its 24-hour accessfor medical and psychiatric emergencies, as well as its federalmandate under the Emergency Medical Treatment and Active LaborAct (EMTALA) to provide medical services to all individualsregardless of insurance status;⁴ and

Realizing that 18 percent of the nation's uninsured rely onthe hospital emergency department as their usual source of medicalcare;⁵ and

Understanding that the trend of hospital closures is accelerating,with 43 closures of general, short-term acute care hospitalsin 1998⁶ and 64 such closures in 1999;⁷ and

Recognizing that proximity to emergency services is affectedby hospital closures, with individuals having to travel morethan 20 miles to the nearest emergency department in 27 percentof the cases of rural hospital closures in 1998,⁶ and in 43percent of such cases in 1999;⁷ and

Showing concern that the closures of community hospital emergencydepartments impose significant risks to the public health andare different from closures of other safety net facilities becausethey affect not just the uninsured, but everyone, includingthose who are insured; and

Recognizing that the American College of Emergency Physicianshas adopted a policy concerning "Responsibilities of Acute CareHospitals to the Community," which begins by stating that "TheAmerican College of Emergency Physicians (ACEP) believes thatthe interests of communities are best served when acute carehospitals and members of their organized medical staffs worktogether to ensure unrestricted access to quality emergencycare for all individuals in their community service areas" andconcludes by affirming that "Hospitals must ensure that sufficientresources are committed to meet changing community needs. Reductionsin hospital emergency services, including closures of emergencydepartments, must not be undertaken without full considerationof the impact on the public's ongoing access to emergency care,"⁸and

Concluding that it is in the mutual interests of APHA and ACEPto work cooperatively in studying the effects of such closureson health care access and the impact on public health, therefore

Consider community hospital emergency departments as essentialresources for public health, especially in times of disasterand terrorist attacks;
Supports the principles embodied inACEP's policy on "Responsibilitiesof Acute Care Hospitals tothe Community"; and
Will work in cooperation with ACEP toadvocate for monitoringemergency department closures and theirimpact on access tohealth care.

2. Baxter RJ, Mechanic RE. The status of local health care safety nets. Health Affairs, July/August 1997; 16:7–23.

3. Institute of Medicine. America's health care safety net: intact but endangered. Washington DC: National Academy Press; 2000. Available at: http://www.nap.edu/readingroom.

4. Bitterman RA. Providing Emergency Care Under Federal Law: EMTALA. Dallas, TX: American College of Emergency Physicians; 2001.

5. Anon. National survey on the uninsured. Washington DC: The NewsHour with Jim Lehrer/Kaiser Family Foundation, April 2000. Publication #3013, available at: http://www.kff.org

6. Office of Inspector General. Hospital closure: 1998. Washington DC: Department of Health and Human Services, July 2000. Document # OEI-04-99-00330, available at: http://www.dhhs.gov/progorg/oei

7. Office of Inspector General. Hospital closure: 1999. Washington DC: Department of Health and Human Services, March 2001. Document # OEI-04-01-00020, available at: http://www.dhhs.gov/progorg/oei

8. American College of Emergency Physicians. "Responsibilities of Acute Care Hospitals to the Community." Policy statement adopted October 1999, available at http://www.acep.org/2,663,0.html.

	2001-5: Health Status of American Indians and Alaska Natives^*

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2001-5: Health Status of...

5. http://raceandhealth.hhs.gov/sidebars/sbinitOver.htm

THE AMERICAN PUBLIC HEALTH ASSOCIATION,

Recalling its longstanding commitment to the health of AmericanIndians and Alaska Natives (AIAN), we reaffirm and extend Resolutions9810, 9811, 9812 and 9904,^1–⁴

Observing that approximately 1.34 million AIAN belong to themore than 556 federally recognized tribes and qualify for IndianHealth Service and Bureau of Indian Affairs services, and thatrural/reservation and urban AIAN health status is lower thanthe general U.S. population,^1–⁴

Understanding that poverty, unemployment, inadequate education,unsafe water supplies, inadequate waste disposal facilities,and other social and economic factors play an important rolein influencing the health status of both reservation and urbanIndians,¹ for example, finding that the AIAN high school graduationrate is lower than the general U.S. population at 56% in 1980to 66% in 1990, compared to 67% to 75%⁴;

Recognizing tribal sovereignty and the unique Government-to-Governmentrelationship between Tribes and the U.S., including, The President'sMemorandum of April 29, 1994, titled, "Government-to-GovernmentRelationship with Native American Tribal Governments"⁴;

Affirming that the Federal trust responsibility for AIAN healthcare is grounded in treaty obligations, case law, the SnyderAct of 1921 (PL 83-568), the Indian Health Care ImprovementAct (PL 94-437 as amended), as well as other federal legislationand historical obligations,^3,⁴

Appreciating that AIAN are citizens of their Tribes, their statesand the United States of America and that the Tribes are governmentswith the inherent right to govern themselves^3,⁴;

Recognizing the health status and issues regarding (1) the growingneed for long-term care; (2) HIV/AIDS; (3) infant mortality;and (4) diabetes mellitus²; as described previously,^1–⁴and below, shall serve as a reference document to be updatedas necessary. Three out of four of the areas in this paper arein the President's initiative "Eliminating Racial and EthnicDisparities,"⁵ which commits the Nation to the goal of eliminatingdisparities in infant mortality, diabetes, HIV/AIDS, immunizations,cancer screening and treatment, and cardiovascular disease bythe year 2010.

A Growing Need for Long-Term Care
Acknowledging that the life expectancy of AIAN has increasedrapidly in the past thirty years. This increasing life expectancywill contribute to older persons (defined as age 65 and over)increasing from 5.6% of the AIAN population in 1990 to 12.6%of the AIAN population in 2050⁶;

Understanding that approximately one-half of AIAN age 65 andover report functional difficulties,⁷ indicating that demandfor long-term care services will continue to increase as theAIAN population increases from 156,000 to 321,000 over the nexttwenty years⁷;

HIV/AIDS Knowing that in 1996, the estimated acquired immunodeficiencysyndrome-opportunistic illness incidence rate was 10 cases per100,000 population for AIAN, compared to 11 per 100,000 fornon-Hispanic whites. The rate was four times higher for menthan for women (22 per 100,000 versus 5 per 100,000).⁸ Currentdata show that human immunodeficiency virus (HIV) is experienceddifferently in the AIAN population compared to the US All Races,in that a higher percentage of HIV (without acquired immunodeficiencysyndrome (AIDS)) cases occurred in women (33% versus 21%), inadolescents (5% versus 1%), and in persons aged 20-29 years(40% versus 21%)⁹;

Affirming that in order for HIV/AIDS prevention to work wellstate and local health departments must partner with local AIANpeople and organizations by creating community advisory boardsor steering committees, and utilize traditional and religiousconsultants ⁹;

Observing that there are many indications that AIAN populationsare at substantial risk for HIV (e.g., high rates of sexuallytransmitted diseases (STDs), teen pregnancy, and alcohol andother drug use). However, there are limited data on HIV prevalencerates. Current data on incidence, prevalence, and mortalitydata likely underestimate the impact of HIV in AIAN communities.This is due to underreporting and misreporting of AIAN racial/ethnicclassification^10,¹¹;

Infant Mortality Knowing that the infant mortality rate (IMR), as defined asthe number of infant deaths under 1 year of age per 1,000 livebirths, has dramatically decreased in the last century for allraces including AIAN.¹² The rate for AIAN infants is 10.9 per1,000 live births, after adjustment for racial misclassification,compared to 6.8 per 1,000 live births for the white populationin 1994.¹³ Although, the neonatal IMR for AIAN (5.0/1,000 livebirths) is slightly higher than the US All Races (4.8/1,000live births) and is higher than the white population (4.0/1000live births), the post neonatal mortality rate of 4.3 is overtwice that of the white population PNMR of 2.0.

Acknowledging that Sudden Infant Death Syndrome (SIDS) (definedas the sudden death of an infant under one year of age whichremains unexplained after a thorough case investigation, includingthe performance of a complete autopsy, examination of the deathscene, and review of the clinical history¹⁴) has, until recently,been the leading cause of post neonatal infant death among AmericanIndians. Although, the rate for SIDS has declined across allraces, the ratio of AIAN rate (1.51/1,000) to the white SIDSrate (0.66/1,000) is 2.3 times higher and is higher than anyother race including African Americans.¹⁵ In some areas of thecountry, the rate for SIDS is almost 6 times higher at 3.8/1,000live births in the Aberdeen Area and almost 5 times higher at3.1 per 1,000 live births in Alaska compared to the white population.¹⁶If SIDS deaths could be reduced in AIAN infants, the resultingdifference between AIAN and non-Hispanic whites would be reducedby one fourth.¹⁵

Understanding that smoking during pregnancy is a known riskfactor for SIDS and alcohol during pregnancy is a suspectedrisk factor for SIDS and infant mortality.^17–¹⁹ In 1998linked birth record, 21% of American Indian women smoked duringpregnancy compared to 14% for white women, 9% African Americanwomen and 3% Asian/Pacific Islander.²⁰

Noting that using 1995 birth certificate information, Venturaet al.,²¹ showed that 1.5% women of all races drank alcoholduring pregnancy compared to 4.3% AIAN women, while Randallet al.,¹⁵ showed in their study that as many as 79% of mothersof SIDS babies drank before or during pregnancy. Faden et al.¹⁷looked at the relationship of drinking to birth outcome usinga large national data set, and using multivariate logistic regression,showed that alcohol was significant for low birth weight, fetaldeath and infant death for all races.

Affirming that if these two issues could be addressed in AIANcommunities, the risk of SIDS could be significantly reduced,and that working with the Tribal communities to address culturallycompetent ways to deal with these issues is the only tenablesolution.

Seeking to understand and eliminate disparities in the healthof AIAN populations, therefore;

Calls on the President and Congress to take all necessary stepsto eliminate these health disparities including proposing andenacting legislation utilizing Government-to-Government consultation;
Supports efforts that will (1) address and provide long-termcare for AIAN elders; (2) prevent and control the spread ofHIV/AIDS; (3) decrease infant mortality; (4) decrease diabetesmellitus, and other health issues and concerns for the AIANpopulation;
Pledges to maintain a high priority on activitiesrelated tothe health of this population including to developand enhanceunderstanding of and support for the needs of AmericanIndiansand Alaska Natives; and
Maintains its belief thatno American Indian or Alaska Nativefrom any Tribe, no matterhow small or remote, should be withoutidentifiable and realisticaccess to the benefits of healthcare and public health protection.

Footnotes

^* This is the first in a series of position papers requested bythe American Public Health Association on the health statusof special American populations. Future papers will focus onNative Hawaiians, and on other health conditions including cancers,cardiovascular disease, injury, alcohol, oral health, and otherconditions that affect native health.

2. American Public Health Association Policy Statement No. 9812, 1998: Diabetes Among American Indian, Alaska Natives, and Native Hawaiians (AI/AN/ NH). Washington, D.C: American Public Health Association.

3. American Public Health Association Policy Statement No 9810, 1998. Health Services for American Indians and Alaska Natives. Washington, D.C: American Public Health Association.

4. American Public Health Association Policy Statement No 9904, 1999. Federal Policies Impacting American Indians and Alaska Natives and the Reauthorization of the Indian Health Care Improvement Act P.L. 94-437. Washington, D.C: American Public Health Association.

6. U.S. Bureau of the Census. 1996. "Population Projections of the United States by Age, Sex, Race, and Hispanic Origin: 1995 to 2050." Current Population Reports, P25-1130. Washington, DC: U.S. Government Printing Office.

7. U.S. Bureau of the Census. 1999. "Americans with Disabilities, 1994-95. Table 1D, Disability Status of Persons 65 Years Old and over by Race and Hispanic Origin: 1994-95 Data from the Survey of Income and Program Participation." http://www.census.gov/hhes/www/disable/sipp/disab9495/ds94t1d.html. Revised 22 June 1999.

8. CDC. "HIV/AIDS Among American Indians and Alaskan Natives—United States, 1981—1997." MMWR Morb Mortal Wkly Rep.1998;47(8):154–160.[Medline]

9. Satter, Delight. 1999. Cultural Competent HIV/ AIDS Prevention for American Indians and Alaska Natives. In: Cultural Competence for Providing Technical Assistance. Evaluation and Training for HIV Prevention Programs. CRP, Inc. Washington D. C. funded by the Centers for Disease Control and Prevention, Contract #200-97-0644.

10. Satter D, Seals B, Dooley S, Tullier C. 1998. "The CDC, Division of HIV/AIDS' American Indian, Alaska Native and Native Hawaiian HIV Prevention Partnership Initiative." Presented at the Annual Conference of American Public Health Association. Washington, D.C.

11. Metler R, Conway G, Stehr-Green J. "AIDS Surveillance among American Indians and Alaska Natives." Am J Public Health.1991;8(11):1469–1471.

12. Guyer B, Freedman MA, Strobino DM, Sondik EJ. Annual Summary of Vital Statistics: Trends in the health of Americans during the 20th Century. Pediatrics.2000;106(6):1307–1317.[Abstract/Free Full Text]

13. Indian Health Service. Regional Differences in Indian Health, 1997. Rockville, MD: Indian Health Service, Program Statistics Team. 1998.

14. Willinger, M, James LS, Catz C. Defining the sudden infant death syndrome (SIDS): deliberations of an expert panel convened by the National Institute of Child Health and Huamn Development. Pediatr Pathol. 1991;11:677–684.[Medline]

15. Mathews TJ, Curtin SC MacDorman MF. Infant mortality statistics from the 1998 period linked birth/infant death data set. National vital statistic reports; vol 48 no. 12. Hyattsville, MD: National Center for Health Statistics, 2000.

16. Brennerman GR. Maternal, Child, and Youth Health. In: American Indian Health: Innovations in Health Care, Promotion, and Policy. Ed. Rhoades, ER. The Johns Hopkins University Press, Baltimore, MD. 2000.

17. Randall LR, Welty TW, Iyasu SI, Willinger M. Mi Cinca kin towani ewaktonji kte sni, I will never forget my child: Results of the Aberdeen Area Infant Mortality Study. DHHS, PHS, CDC. Atlanta, GA. 1998.

18. Godel JC, Pabst HF, Hodges PE, Johnson KE, Froese GJ, Joffres MR. Smoking and Caffeine and alcohol intake during pregnancy in a northern population: effect on fetal growth. Can Med Assoc J 1992, July 15; 147(2):181–8.[Abstract]

19. Faden VB, Graubard BI, Dufour M. The relationship of drinking and birth outcome in a U.S. National sample of expectant mothers. Pediatric and Perinatal Epidemiology 1997;11:167–180.[Medline]

20. Pamuk E, Makuc D, Heck K, Reuben C, Lochner K. Socioeconomic status and health chartbook. Health, United States, 1998. Hyattsville, MD: National Center for Health Statistics. 1998.

21. Ventura SJ, Martin JA, Curtin SC, Mathrews TJ. 1995. Report of final natality statistics, 1995. Monthly vital statistics report; vol 45 (11), supp 2. Hyattsville, MD: National Center for Health Statistics, 1997.

	2001-6: Global Campaign to Eliminate Avoidable Blindness

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2001-6: Global Campaign to...

THE AMERICAN PUBLIC HEALTH ASSOCIATION,

Recognizing the enormous burden that communities' failure toaccommodate the loss of sight places on individuals, familiesand their communities, and affirming the World Health Organization(WHO) global initiative for the elimination of avoidable blindnessby the year 2020;¹ and

Affirming the challenges of health systems throughout the worldthat have inadequate and unfairly distributed resources whichthreaten to result in the potential doubling of blindness by2020;² and

Recognizing that the WHO VISION 2020—The Right to Sightcampaign offers an unprecedented opportunity as a worldwidepartnership to marshal the resources and experiences of a broadglobal coalition of public and private nongovernmental organizationswho are dedicated to the shared goal of eliminating avoidableblindness by the year 2020;³ and

Noting that there is an estimated 180 million individuals globallywho are visually impaired; that approximately 45 million areblind; that 9 out of 10 of the world's blind live in developingcountries; and that 60 percent of these individuals live inIndia, China and sub-Saharan Africa;^4–⁵ and

Recognizing that a comprehensive program for the preventionof blindness requires a community-based strategy that incorporatesattention to trachoma, blinding malnutrition, onchocerciasis,cataract, ocular trauma, glaucoma, and diabetic retinopathy;^6–⁷and

Affirming the importance of expanding prevention of blindnessprograms to include refractive errors and low vision; recognizingthat uncorrected refractive errors are a significant sourceof avoidable visual disability and functional blindness, especiallyin developing countries; and that there are approximately 35million persons needing low vision services;^8–¹⁰ and

Observing that a number of cost-effective models for the deliveryof vision care, which utilize new technologies and deliveryparadigms, such as the SAFE strategy for the control and eliminationof blinding trachoma, offer the promise of significantly expandingaccess to vision care, especially in underserved communitiesin both developed and developing countries;^11–¹⁵ and

Recognizing the value of mobilizing optometrists, ophthalmologists,other vision care personnel, and community health workers; thecritical importance of forging strategic alliances among theseprofessionals, their organizations and the significant numberof non-governmental organizations working in the field of blindnessprevention;^16–¹⁸ and

Noting the global health challenge of addressing the significantdisparities in access to vision care, in both developed anddeveloping countries;^19–²⁰ therefore

Recommends support of WHO's VISION 2020: The Right to Sightglobal initiative for the elimination of avoidable blindnessby encouraging educational programs that increase awarenessof the broad societal impact of blindness and visual disability;
Suggests that eye care professional organizations promotecoordinatedprevention and primary care strategies that advanceglobal partnershipswhich transcend political boundaries andemphasize a team approach;and
Calls for targeted projectsthat address racial, ethnic, geographicand economic disparitiesin access to primary vision care.

2. The World Health Report 2000. Health Systems: Improving Performance. Geneva: WHO, 2000.

3. Prevention of Blindness Program. Global Initiative for the Elimination of Avoidable Blindness: Vision 2020—The Right To Sight. Geneva: WHO, PBL/97.61 Rev. 1, 1997.

4. Thylefors B, Negrel D, et al. Global data on blindness. Bulletin of the World Health Organization 1995:73(1):115–121.[Medline]

5. Thylefors B, Negrel D, et al. Available data on blindness. Ophthalmic Epidemiology 1995:2(1):5–39.[Medline]

6. Strategies for the Prevention of Blindness in National Programs. Geneva: WHO, 1997.

7. Sommer A: Vitamin Deficiency and its Consequences. Geneva: WHO, 1995.

8. Prevention of Blindness Program. Control of Major Blinding Diseases and Disorders. Geneva: WHO, Fact Sheet 214, 2000.

9. Ellwein LB, Negrél A. Scope of refractive errors as a cause of visual disability. Informal Planning Meeting on the Elimination of Avoidable Visual Disability due to Refractive Errors. Geneva: WHO, July 2000.

10. Pokharel GP, Negrel D, et al. Refractive error study in children: results from Mechi Zone, Nepal. Am J Ophthalmology 2000;129(4):436–444.[Medline]

11. World Health Organization. Future Approaches to Trachoma Control: Report of a Global Scientific Meeting WHO/PBL/96.56. Geneva: WHO, 1996.

12. Pizzarello L, Tilp M, et al. A new school-based program to provide eyeglasses: ChildSight. J AAPOS 1998;2(6):372–374.

13. Holden B, Stretton S, et al. Technology: core requirements. Informal Planning Meeting on the Elimination of Avoidable Visual Disability due to Refractive Errors. Geneva: WHO, July 2000.

14. Berger IB, Pike S, et al. A new paradigm for primary eye care in developing countries. Presentation at the 128th Annual meeting of the APHA, November 2000.

15. Weissberg, EM, Moore B, et al. A simple and cost-effective plan for enhancing vision care in developing countries. Presentation at the 128th Annual meeting of the APHA, November 2000.

16. Di Stefano AF. Push to Prevent Blindness. World Optometry 2000;115:

17. Naidoo K. Towards a new model in training and delivery of optometric education. Optom Education 2000;25(2):59–61.

18. Marshall E. Optometry in Asia. World Optometry.2000;115:13–14.

19. Addressing racial, ethnic health gaps: National leaders commit to eliminating disparities. Nation's Health, American Public Health Association, November 2000.

20. Office of Disease Prevention and Health Promotion. Healthy People 2010: Vision and Hearing. Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of Health, 1999.

	2001-7: Research and Intervention on Racism as a Fundamental Cause of Ethnic Disparities in Health

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2001-7: Research and...

THE AMERICAN PUBLIC HEALTH ASSOCIATION,

Understanding that in the United States, ethnic disparitiesin health have persisted during the 20th century and even increasedfor certain health outcomes, despite major advances in publichealth, biotechnology, and economic prosperity and wealth;^1–⁷and

Understanding that "race"-associated differences in health outcomesare routinely documented in this country but the basis of thosedifferences remains poorly explained, and many investigatorssimply statistically adjust for "race" or restrict their studiesto a single "racial" group rather than vigorously investigatingthe basis of those differences;^8–⁹ and

Understanding that "race" is not a biological measure reflectinginnate differences but a social construct capturing the socialclassification of people in a "race"-conscious society,^10–¹⁷and that present day inequalities between so-called "racial"groups are not consequences of their biological inheritancebut are products of historical and contemporary sociopoliticaland economic systems;^18–²⁰ and

Understanding racism as the system of structures, processes,and values that results in differential outcomes by "race",and that racism is manifest on cultural, institutional, interpersonal,and internalized levels;^21–²³ and

Acknowledging that ethnic disparities in health may arise onthree levels:

Differences in social, political, economic, or environmentalexposures that result in differences in disease incidence;^24–²⁶
differences in access to physical and mental health care includingpreventive and curative services;^27–^30a and
differencesin the quality of care received within the physicaland mentalhealth care delivery system;^31–³⁹ and

Acknowledging the importance of identifying the underlying causesof ethnic disparities so that these disparities can be mosteffectively addressed; and

Realizing that the perception of the occurrence and extent ofethnic disparities in health and health care differs betweenwhite and ethnic minority populations in the United States;⁴⁰and that many people in the United States believe that racismis no longer a problem, while others deal with its manifestationsdaily;^41–⁴³ and

Recognizing that the science on racism as a risk factor foradverse health outcomes in the United States is still scantbut growing;^10–^12,^25–^26,^44–⁴⁷ and

Recalling that in 1965, the American Public Health Associationpassed a resolution on "The Health of Minorities and the Relationshipof Discrimination Thereto,"⁴⁸ and further recalling that in1974, the American Public Health Association passed a resolutionon "Racism in the Health Care Delivery System" which states,"Minority health, as affected by institutional racism, can onlyimprove when efforts from the entire complex of human and publicservices are purposefully applied to accomplish that specificgoal";⁴⁹ and

Recognizing that the American Public Health Association hasalso previously condemned the expression of racism in othercountries;^50–⁵¹ and

Cognizant that Mayor Bob Knight of Wichita, Kansas has calledfor a National Campaign Against Racism as President of the NationalLeague of Cities that challenges and assists city and town governmentsin becoming Cities Striving to Promote Racial Justice;^52–⁵³and

Noting the Department of Health and Human Services' Initiativeto Eliminate Racial and Ethnic Disparities in Health by theYear 2010 and recognizing this as an opportunity to investigateand address the underlying causes of these disparities;⁵⁴ and

Recognizing that the American Public Health Association hasrecently joined with the Department of Health and Human Servicesin a national Campaign to Eliminate Racial and Ethnic HealthDisparities;⁵⁵ and

Cognizant that the recent congressional passage of the MinorityHealth and Health Disparities Research and Education Act of2000, which established a National Center on Minority Healthand Health Disparities at the National Institutes of Health,provides an opportunity for coordinated research on the impactsof racism on health,⁵⁶ therefore:

Reaffirms previous American Public Health Associations policiesthat have condemned racism and its impacts on health and healthcare;
Commends the National League of Cities on their effortsto launcha Campaign to Promote Racial Justice;
Calls on thePresident and the Congress of the United Statesto endorse aNational Campaign Against Racism;
Calls on the Congress tofund the Institute of Medicine to preparea report that summarizesour current knowledge on the impactsof racism on health and,by analyzing the processes that mediatethese impacts, identifiespoints of intervention;
Calls on the Department of Healthand Human Services to explicitlyaddress racism as a part ofits national Initiative to EliminateRacial and Ethnic Disparitiesin Health by the Year 2010;
Calls on the Centers for DiseaseControl and Prevention, theAgency for Healthcare Research Quality,the Health Resourcesand Services Administration, and the NationalInstitutes ofHealth to place a high priority on research onthe impacts ofracism on the health and well-being of the nation;
Calls on the Congress of the United States to appropriatefundsfor investigating the impacts of racism on the healthand well-beingof the nation;
Calls on the Congress of theUnited States to appropriate additionalfunds for developingevidence-based programs to eliminate ethnichealth disparities;and
Calls on the President and the Congress of the UnitedStatesto recognize and promote legal redress for discriminationinhealth and health care.

2. National Center for Health Statistics. Health: United States. Hyattsville, MD: US National Center for Health Statistics, 1976.

3. National Center for Health Statistics. Health, United States, 2000 with Adolescent Health Chartbook. Hyattsville, MD: Public Health Service, 2000. http://www.cdc.gov/nchs/data/hus00.pdf

4. U.S. Department of Health and Human Services, Task Force on Black and Minority Health. Report of the Secretary's Task Force on Black and Minority Health. Volume I: Executive Summary. Washington, DC: Government Printing Office, 1985.

5. Centers for Disease Control and Prevention. Chronic Disease in Minority Populations: African-Americans, American Indians and Alaska Natives, Asians and Pacific Islanders, Hispanic Americans, 1994. Atlanta, GA: Centers for Disease Control and Prevention, 1994.

6. Collins KS, Hall A, Neuhaus C. U.S. Minority Health: A Chartbook. New York, NY: The Commonwealth Fund, 1999.

7. U.S. Department of Health and Human Services. Healthy People 2010, 2nd edition, with Understanding and Improving Health and Objectives for Improving Health. 2 volumes. Washington, DC: U.S. Government Printing Office, November 2000. http://www.health.gov/healthypeople/Document/tableofcontents.htm#volume1; http://www.health.gov/healthypeople/Document/tableofcontents.htm#Volume2

8. Jones CP, LaVeist TA, Lillie-Blanton M. "Race" in the epidemiologic literature: An examination of the American Journal of Epidemiology, 1921-1990. Am J Epidemiol 1991;134(10):1079–1084.[Abstract/Free Full Text]

9. Jones, CP. "Race", racism, and the practice of epidemiology. Am J Epidemiol 2001;154(4):299–304.[Free Full Text]

10. DuBois WEB. Mortality Among Negroes in Cities. Proceedings of the Conference for Investigation of City Problems. Atlanta, GA: Atlanta University Publications, 1896.

11. DuBois WEB. The Health and Physique of the Negro American. A Social Study Made Under the Direction of the Eleventh Atlanta Conference. Atlanta, GA: Atlanta University Publications, 1906.

12. Lewis JH. The Biology of the Negro. Chicago, IL: The University of Chicago Press, 1942.

13. Cooper R, David R. The biological concept of race and its application to public health and epidemiology. J Health Polit Policy Law 1986;11(1):97–116.

14. Navarro V. Race or class versus race and class: Mortality differentials in the United States. Lancet 1990;17:1238–1240.

15. Williams DR. Race and health: Basic questions, emerging directions. Ann Epidemiol 1997;7(5):322–333.[Medline]

16. American Anthropological Association Statement on Race, adopted May 17, 1998. http://www.aaanet.org/stmts/racepp.htm

17. Rivara FP, Finberg L. Use of the terms Race and Ethnicity. Arch Pediatr Adolesc Med 2001;155(2):119.[Free Full Text]

18. Cavalli-Sforza LL, Menozzi P, Piazza A. The History and Geography of Human Genes. Princeton, NJ: Princeton University Press, 1994, pages 19-20.

19. Byrd WM, Clayton LA. An American Health Dilemma: A Medical History of African Americans and the Problem of Race, Beginnings to 1900 (Volume 1). New York, NY: Routledge, 2000.

20. Byrd WM, Clayton LA. An American Health Dilemma: Race, Medicine, and Health Care in the United States, from 1900 to the Dawn of the New Millennium (Volume 2). New York, NY: Routledge, 2000.

21. Carmichael S, Hamilton CV. Black Power: The Politics of Liberation in America. New York, NY: Random House, 1967.

22. Batts VA. Modern Racism: New Melody for the Same Old Tunes. Cambridge, MA: EDS Occasional Papers, May 1998.

23. Jones CP. Levels of racism: A theoretic framework and a Gardener's Tale. Am J Public Health 2000;90(8): 1212–1215.[Abstract/Free Full Text]

24. Blau PM, Duncan OD, Tyree A. The American Occupational Structure. New York, NY: Wiley, 1967.

25. David RJ, Collins JW Jr. Bad outcomes in Black babies: Race or racism? Ethnicity Dis 1991;1(3):236–244.[Medline]

26. Kennedy BP, Kawachi I, Lochner K, Jones C, Prothrow-Stith D. (Dis)Respect and Black Mortality. Ethnicity Dis 1997;7(3):207–214.[Medline]

27. Graham NM, Jacobson LP, Kuo V, Chmiel JS, Morgenstern H, Zucconi SL. Access to therapy in the Multicenter AIDS Cohort Study, 1989-1992. J Clin Epidemiol 1994;47(9):1003–1012.[Medline]

28. Leigh WA, Lillie-Blanton M, Martinez RM, Collins KS. Managed care in three states: Experiences of low-income African Americans and Hispanics. Inquiry 1999;36(3):318–331.[Medline]

29. Morehouse Medical Treatment Effectiveness Center (MMEDTEC). A Synthesis of the Literature: Racial and Ethnic Differences in Access to Medical Care. Menlo Park, CA: The Henry J. Kaiser Foundation, October 1999.

30. Lillie-Blanton M, Hoffman C. Racial and ethnic inequities in access to medical care: Introduction. Med Care Res Rev 2000;57 (Suppl 1):5–10.[Free Full Text]

30. Zito, JM, Safer, DJ, dos Reis, S, Riddle, HA, Racial disparity in psychotropic medications prescribed for youths with Medicaid insurance in Maryland. J. Am. Acad. Child Adolescent Psychiatry 37:179–182, 1998[Medline]

31. Johnson PA, Lee TH, Cook EF, Rouan GW, Goldman L. Effect of race on the presentation and management of patients with acute chest pain. Ann Intern Med 1993;118(8):593–601.[Abstract/Free Full Text]

32. Oddone EZ, Horner RD, Monger ME, Matchar DB. Racial variations in the rates of carotid angiography and endarterectomy in patients with stroke and transient ischemic attack. Arch Intern Med 1993;153 (24):2781–2786.[Abstract/Free Full Text]

33. Moore RD, Stanton D, Gopalan R, Chaisson RE. Racial differences in the use of drug therapy for HIV disease in an urban community. N Engl J Med 1994; 330 (11):763–768.[Abstract/Free Full Text]

34. Giles WH, Anda RF, Casper ML, Escobedo LG, Taylor HA. Race and sex differences in rates of invasive cardiac procedures in US hospitals: Data from the National Hospital Discharge Survey. Arch Intern Med 1995;155(3):318–324.[Abstract/Free Full Text]

35. Chung H, Mahler JC, Kakuma T. Racial differences in treatment of psychiatric inpatients. Psychiatr Serv 1995;46(6):586–591.[Abstract/Free Full Text]

36. Lillie-Blanton M, Parsons PE, Gayle H, Dievler A. Racial differences in health: Not just black and white, but shades of gray. Ann Rev Publ Health 1996;17:411–448.[Medline]

37. Ramsey DJ, Goff DC, Wear ML, Labarthe DR, Nichaman MZ. Sex and ethnic differences in the use of myocardial revascularization procedures in Mexican Americans and non-Hispanic whites: The Corpus Christi Heart Project. J Clin Epidemiol 1997;50(5):603–609.[Medline]

38. van Ryn M, Burke J. The effect of patient race and socio-economic status on physicians' perceptions of patients. Soc Sci Med 2000;50(6):813–828.

39. Rhoades ER (editor). American Indian Health: Innovations in Health Care Promotion and Policy. Baltimore, MD: Johns Hopkins University Press, 2000.

40. The Henry J. Kaiser Family Foundation. Race, Ethnicity and Medical Care: A Survey of Public Perceptions and Experiences. Menlo Park, CA: The Henry J. Kaiser Family Foundation, October 1999. http://www.kff.org/content/1999/19991014a/Toplines.PDF

41. Essed P. Understanding Everyday Racism: An Interdisciplinary Theory. Sage Series on Race and Ethnic Relations, Volume 2. Newbury Park, CA: Sage Publications, 1991.

42. Feagin JR. The continuing significance of race: Antiblack discrimination in public places. Am Sociol Rev 1991;56:101–116.

43. Yen IH, Ragland DR, Greiner BA, Fisher JM. Racial discrimination and alcohol-related behavior in urban transit operators: Findings from the San Francisco Muni Health and Safety Study. Publ Health Rep 1999;114(5):448–458.[Medline]

44. James SA, Hartnett SA, Kalsbeek WD. John Henryism and blood pressure differences among black men. J Behav Med 1983;6(3):259–278. A7-9[Medline]

45. Williams DR. Racism and health: A research agenda. Ethnicity Dis 1996;6(1 and 2):1–6.[Medline]

46. Krieger N, Sidney S. Racial discrimination and blood pressure: The CARDIA Study of young black and white adults. Am J Publ Health 1996;86(10):1370–1378.[Abstract/Free Full Text]

47. Krieger N. Embodying inequality: A review of concepts, measures, and methods for studying health consequences of discrimination. Int J Health Serv 1999;29(2):295–352.[Medline]

48. APHA Policy Statement 6502: The Health of Minorities and the Relationship of Discrimination Thereto. APHA Public Policy Statements, 1948-present, cumulative. Washington, DC: American Public Health Association, current volume.

49. APHA Policy Statement 7424: Racism in the Health Care Delivery System. APHA Public Policy Statements, 1948-present, cumulative. Washington, DC: American Public Health Association, current volume.

50. APHA Policy Statement 8225: Apartheid Policy of the Republic of South Africa. APHA Public Policy Statements, 1948-present, cumulative. Washington, DC: American Public Health Association, current volume.

51. APHA Policy Statement 8523: Apartheid and Its Impact on Health in the Republic of South Africa. APHA Public Policy Statements, 1948-present, cumulative. Washington, DC: American Public Health Association, current volume.

52. National League of Cities Advisory Council. Undoing Racism: Fairness and Justice in America's Cities and Towns. Washington, DC: National League of Cities, 1999.

53. National League of Cities. Campaign to Promote Racial Justice. http://www.nlc.org/nlc_org/site/programs/race_and_ethnic_relations/index.cfm

54. U.S. Department of Health and Human Services. The Initiative to Eliminate Racial and Ethnic Disparities in Health. http://www.raceandhealth.hhs.gov

55. American Public Health Association. Campaign to Eliminate Racial and Ethnic Health Disparities. http://www.apha.org/ppp/racial_disparities.htm

56. United States 106th Congress. Minority Health and Health Disparities Research and Education Act of 2000 (S. 1880). http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi? dbname=106_cong_bills&docid= f:s188 0enr.txt.pdf

	2001-8: Establishment of a Medicare Prescription Drug Benefit

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2001-8: Establishment of a...

THE AMERICAN PUBLIC HEALTH ASSOCIATION;

Acknowledging that prescription drug coverage for Medicare beneficiaries,many of whom are on fixed incomes, has become a salient policyand political issue because the cost of prescription drugs isbecoming an increasingly significant financial burden for manyMedicare beneficiaries;¹

Observing that since June 2000 several bills addressing Medicareprescription drug coverage have been introduced in Congress;⁵

Recognizing that prescription drugs are an essential tool inpreventing and managing many acute care conditions and chronicdiseases;

Realizing that almost one in three (31%) Medicare beneficiarieshad no prescription drug coverage in 1998;²

Knowing that U.S. spending for prescription drugs has tripledsince 1990 and is estimated to double from the current levelof $112 billion to $243 billion by 2008;³

Noting that older adults are disproportionately affected byrising drug costs as evidenced by the fact that while they comprise13% of the population they account for over a third of the nation'stotal drug expenditures;⁷

Knowing that those without drug coverage consistently fill fewerdrug prescriptions than their insured counterparts and thereforeunderutilize prescribed medications, thereby endangering theirhealth;³

Recognizing that the continued rapid escalation in prices particularlyof newer drugs, the prodigious expenditures by manufacturererson direct-to-consumer advertising, the resulting tendency ofmany consumers to prefer higher priced newer medications, andthe growth in the average number of prescriptions utilized perperson are trends which will continue into the foreseeable future;⁸

Therefore, APHA urges the President and Congress to enact aMedicare prescription drug coverage benefit which incorporatesthe following set of principles:^4,^6,⁷

Access
Medicare should guarantee access to a prescription drug benefit.

Coverage
The Medicare prescription drug benefit should be available toall Medicare eligible older adults and individuals with disabilities,regardless of income or health status.

Affordability
The benefit should provide protection against premium and outof pocket costs for low income beneficiaries and provide catastrophicprotection for all beneficiaries.

Administration
The Medicare prescription drug benefit should be administeredby HCFA, now called Centers for Medicare and Medicaid Services,and not relegated to private insurers. It should include efficientmanagement, appropriate cost containment and reflect the purchasingpower of the Medicare beneficiary pool.

Quality
The Medicare prescription drug benefit should have defined qualityof care standards, including documented effectiveness data,and appropriate monitoring and quality assurance activities.

The Medicare program should work to ensure the prevention ofoveruse, underuse and misuse of prescription drugs.

2. Kaiser Family Foundation, "Prescription Drug Trends," September 2000.

3. Kaiser Family Foundation, "Prescription Drug Trends—a chartbook," July 2000.

4. Leadership Council of Aging Organizations, Prescription Drug Benefit Principles, February 2000.

5. Congressional Research Office Report for Congress, "Medicare: Selected Prescription Drug Proposals," September 2000.

6. Congressional Research Office Report for Congress, "Medicare: Prescription Drug Coverage for Beneficiaries," April 1999.

7. AARP Public Policy Institute, "Prescription Drug Benefits: Cost Management Issues for Medicare," Peter Fox, August 2000.

8. "Protecting and Strengthening Medicare: Financing and Prescription Drug Issues," APHA Policy Statement 9934(PP).

	2001-9: Protection of Child and Adolescent Workers

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2001-9: Protection of Child...

THE AMERICAN PUBLIC HEALTH ASSOCIATION,

Knowing that employment for youth can provide valuable learningopportunities as well as economic benefits; and

Acknowledging growing concern about child and adolescent workersand work-related injury and illness;¹ and

Knowing that an estimated 5.5 million youth between the agesof 12 and 17 years are employed in the United States in agriculturaland nonagricultural jobs and that some 250 million children5-14 years-old working in economic activity in developing countriesare often exposed to hazardous and unsafe environments thatresult in disability or death;²^-13,2^4–²⁹ and

Recognizing that employment and injury data available on childrenand adolescents in the workplace, even though incomplete, identifythat there is a serious problem of workrelated injuries andillnesses among young workers;^4–¹⁹ and

Knowing that most work-related illness, injuries, and fatalitiesare preventable; and

Recognizing that incomplete injury data on young workers preventadequate identification of the magnitude and nature of problemsamong young workers and hinders efforts to develop and implementpreventive interventions; and

Knowing that child labor regulations have been established inthe U.S. and other countries to protect young workers from thehazards of work, such as injuries and long work hours, as wellas other adverse effects on school performance and other age-appropriateactivities; and,

Knowing that many work-related injuries and fatalities occurringin young workers are the result of violations of these regulations,^11,^12,^14,¹⁵that increases in the number of violations of these regulationshave been identified,^20,²¹ and that the working conditions thatcontribute to many workplace injuries among youth are not adequatelyaddressed by current regulations^22,²³; and

Knowing that the concern regarding child labor is not only adomestic issue but also is international in scope and that childrenare at greater risk in some developing countries²⁴; and

Knowing that illegal employment of children under unsafe andunhealthy conditions in industries producing products for exportis increasing in many countries;²⁵ and

Knowing that the International Labor Organization (ILO) in 1999adopted the Worst Forms of Child Labor Convention No. 182 callingfor the prohibition and immediate action against the worst formsof child labor,²⁰ which has been adopted by 80 countries includingthe United States as of July 2001,³⁰ and

Knowing that the U.S. Presidential Executive Order 13126 ofJune 12, 1999 prohibits the manufacture or importation of goodsproduced wholly or in part by forced or indentured child labor, but excludes foreign countries who are a party to certainagreements annexed to the North American Free Trade Agreement(NAFTA),³¹ and the World Trade Organization (WTO), and

Recognizing the need to establish and effectively enforce uniformoccupational health and safety standards at the internationallevel;²⁹ therefore

Recommends that existing U.S. and International Labor Organizationchild labor regulations be reviewed periodically to update andexpand prohibitions and limitations on work activities basedon research findings and knowledge about adolescent developmentalcapabilities, and where appropriate to reduce the number ofallowable work hours and adjust the allowed working time-of-day;
Recommends the integration of child labor and occupationalSafetyand Health Administration (OSHA) regulations in the U.S.inorder to maximize the protection of young workers and thestrengtheningof enforcement efforts;
Recommends that theUS Department of Labor reinstitute, andCongress fund, its ChildLabor Advisory Committee and that apublic health representativewith a background in occupationalhealth and safety be includedas a member of this committee;
Recommends that federal andstate labor departments and publichealth agencies work witheducators of youth to incorporatecomprehensive health and safetytraining modules in their schoolcurricula; and that statesinvolved in the Workforce InvestmentAct of 1998 require childlabor, workplace rights, and youngworker safety and healtheducational components in the WorkforceInvestment Board (WIB)and Youth Council systems³⁰;
Recommends that additional resourcesbe provided to NIOSH andother institutions to improve datasources, expand researchand evaluation activities, and identifyintervention strategiesleading to prevention;
Encouragesthe coordination of public health efforts with theUS Departmentsof Labor, Health and Human Services and Educationto controland prevent workplace injuries among minors througheffortsthat improve education and training about the hazardsassociatedwith work for children and adolescents for educators,parents,teens, employers, health care providers, occupationalhealthand safety professionals, and others in the field ofpublichealth;
Encourages the promotion of youth employment opportunitiesthatprovide a safe and healthy work environment, adequate pay,andvocational development;
Urges Congress to pass legislationto ban the import of productsmade by underage children as definedin the International LaborOrganization Convention No. 13819and
Endorses mandates that make trade benefits and/ or developmentaid contingent on compliance with internationally recognizedworker rights, which include acceptable working conditions anda prohibition against the use of child labor, defined in theInternational Labor Organization's Conventions No. 138 and No.182 and the United Nations' Rights of the Child.^26,^31,³²

2. Child Labor Coalition from The National Longitudinal Survey of Youth 1997. Washington, DC: The National Consumer League, www.stopchildlabor.org, 2001.

3. Ashagrie, K. Statistics on Working Children and Hazardous Child Labor in Brief, Geneva: International Labour Office, http://www.ilo.org/public/english/comp/child/stat/stats.htm, (First published 1997, revised April 1998)

4. Banco L, Lapidus G, Braddock M. Work-related injury among Connecticut minors. Pediatrics.1992; 89(5):957–960.[Abstract/Free Full Text]

5. Heyer N, et al. Occupational injuries among minors doing farm work in Washington. Am J Public Health.1992;82(4):557–560.[Abstract/Free Full Text]

6. Belville R, Pollack S, Godbold J, Landrigan P. Occupational injuries among working adolescents in New York state. JAMA.1993;269(21):2754–2759.[Abstract/Free Full Text]

7. Parker D, Carl W, French L, Martin F. Characteristics of adolescent work injuries reported to the Minnesota Department of Labor and Industry. Am J Public Health.1994;84(4):606–611.[Abstract/Free Full Text]

8. Pollack S, Landrigan P. Child labor in 1990: prevalence and health hazards. Ann Rev Public Health.1990;11:359–375.[Medline]

9. Richter E, Jacobs J. Work injuries and exposures in children and young adults: review and recommendations for action. Am J Ind Med.1994;19:747–769.

10. Schober S, et al. Work-related injuries in minors. Am J Ind Med.1988;14:585–595.[Medline]

11. Suruda A, Halperin W. Work-related deaths in children. Am J Ind Med.1991;19: 739–745.[Medline]

12. Dunn K, Runyan C. Deaths at work among children and adolescents. Am J Dis Child.1993;147:1044–1047.[Abstract/Free Full Text]

13. Castillo D, Landen D, Layne L. Occupational injury deaths of 16- and 17-year olds in the United States. Am J Public Health.1994;84(4):646–649.[Abstract/Free Full Text]

14. Employment Standards, Apprenticeship and Crime Victims Compensation Division. Protecting Children in the Workplace. Olympia, Washington: Department of Labor and Industries; 1990.

15. Child Labor: Increases in Detected Child Labor Violations throughout the United States. Washington, DC: General Accounting Office, GAO publication HRD-90-116, 1990.

16. By the Sweat and Toll of Children: The Use of Child Labor in American Imports. A Report to the Committee on Appropriations. Washington, DC: US Dept of Labor, Bureau of International Labor Affairs; 1994.

17. American Public Health Association Policy Statement 8312: International Occupational Health and Safety Standards. APHA Policy Statements, 1948-present, cumulative. Washington, DC: APHA; current volume.

18. Workforce Investment Act of 1998. Washington, DC: U.S. Congress, P.L. 105-220,1998

19. Minimum Age Convention, Concerning the Minimum Age for Admission to Employment. Geneva: International Labor Organization, C138, 1973.

20. Worst Forms of Child Labor 1999 Convention, Concerning the Prohibition and Immediate Action for the Elimination of the Worst Forms of Child Labor. Geneva: International Labor Organization, C182, 1999

21. Convention on the Rights of the Child adopted by the United Nations General Assembly. Geneva: United Nations, G.A. resolution 44/25, annex, 44 U.N. GAOR supp. (No.49) at 167, U.N. Doc. A/44/49, 1989

22. Dunn, KA, Runyan, CW, Cohen, L, Schulman, M. Teens at work: A statewide study of jobs, hazards, and injuries. J Adolescent Health.1998;22:19–25.[Medline]

23. Knight, EB, Castillo, DN, Layne, LA. A detailed analysis of work-related injury among youth treated in hospital emergency departments: A national representative sample. Am J Industrial Med. 1995;27:793–805[Medline]

24. Miller, ME, Kaufman, JD. Occupational injuries among adolescents in Washington State, 1988-1991. Am J Industrial Med.1998;34: 121–132.[Medline]

25. Brooks, DR, Davis, LK. Work-related injuries to Massachusetts teens, 1987-1990. Am J Industrial Med.1996; 24:313–324.

26. Castillo, DN, Mallit, BD. Occupational injury deaths of 16- and 17-year-olds in the United States: trends and comparisons to older workers. Injury Prevention.1997; 3:277–281.[Abstract/Free Full Text]

27. Castillo, DN, Davis, L, Wegman, DH. Young Workers. Occupational Medicine: State of the Art Reviews. 1999; Vol. 14, No. 3, pg 519-536

28. Calvert, GM. Acute occupational pesticide-related illness and injury among U.S. children, 1988-1999. Presentation at the North American Congress of Clinical Toxicology, Montreal Quebec, Canada, 2001 (submitted for publication).

29. National Research Council: Protecting Youth at Work: Health and Safety and Development of Working Children and Adolescents in the United States. Committee on the Health and Safety Implications of Child Labor; Board on Children, Youth, and Families; Commission on Behavioral and Social Sciences and Education; National Research Council; and the Institute of Medicine. Washington, DC, National Academy Press, 1998.

30. Reported by the Child Labor Coalition, www.Stopchildlabor.org, October, 2001.

31. Executive Order 13126 of June 12, 1999. Federal Register, Vol. 64, No. 115.

	2001-10: Support for National Nutrition Monitoring and Continuation of CSFII Food and Health Behavioral Data

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2001-10: Support for National...

THE AMERICAN PUBLIC HEALTH ASSOCIATION,

Recognizing that nutrition monitoring is a system of coordinatedsurveys, surveillance systems, and other monitoring activitiesthat provide information about the dietary, nutritional, andhealth related status of Americans; the relationships betweendiet and health; and the factors affecting dietary and nutritionalstatus,¹ with surveys including, but not limited to, the ContinuingSurvey of Food Intakes by Individuals (CSFII) conducted by theUnited States Department of Agriculture and the National Healthand Examination Survey (NHANES) conducted by the United StatesDepartment of Health and Human Resources; and

Being aware that the National Nutrition Monitoring and RelatedResearch Act of 1990 clearly states that the nutrition monitoringTen-year Comprehensive Plan shall include components to maintainand coordinate the federal nutrition monitoring activities;²and

Recognizing that the Food and Nutrition Board found that a singledietary survey, either CSFII or NHANES would not provide theinformation required by users;³ and

Being aware that nutrition monitoring is vital to policy makingand research including identifying high risk groups and locationsthat need food assistance and nutrition programs, assessingprogress toward achieving Healthy People objectives, evaluatingfood assistance and nutrition programs, assessing microbiologicaland environmental risks in food, and contributing to developmentof the Dietary Guidelines for Americans and Dietary ReferenceIntakes;⁴ and

Recognizing that public health nutritionists and other publichealth professionals rely on nutrition monitoring data to trackchanges in health in their communities and states; and

Being concerned that nutrition monitoring is now reduced toNHANES data collection only, resulting in decreased food-baseddata, reduced sample size and elimination of data linking dietand health behavior¹; and

Concluding that nutrition monitoring is a vital component toimproving public health; therefore:

Supports participation of APHA in coalition efforts to supportnutrition monitoring;
Urges Congress to support funding forcontinuation of CSFIIfood and health behavior data and theongoing collection ofnutrition monitoring data;
Urges theadministration and Congress to support appropriationsto researchbetter methods of nutrition monitoring data collectionand analysisincluding aggregation of data for state, localand tribal use;
Supports review of the National Nutrition Monitoring and RelatedResearch Act including coordination of the nutrition monitoringreport to Congress review of the Dietary Guidelines.

2. U.S. Congress. Pub. L. 101-445. National Nutrition Monitoring and Related Research Act of 1990. Washington: 101st Congress. 1990 NRC, Food and Nutrition Board report, National Survey Data on Food Consumption: Uses and Recommendations

3. Interagency Board for Nutrition Monitoring and Related Research. Nutrition Monitoring in the United States, National Nutrition Monitoring and Related Research Program. September 1992

4. Agricultural Research Service Report to Congress. Integration of the National health and Nutrition Examination Survey and Continuing Survey of Food Intakes by Individuals. US Department of Agriculture. January 2001.

	2001-11: Support of the Labeling of Genetically Modified Foods

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2001-11: Support of the...

THE AMERICAN PUBLIC HEALTH ASSOCIATION,

Recognizing that in 1998 the European Union ruled that foodmanufacturers must state on a label when genetically modifiedingredients have been used; and

Recognizing that genetically modified organism^* labeling regulationsare now (1999-2000) in effect in the European Union^1,²; and

Recognizing that the British Medical Association has recommendedthat genetically engineered foods be labeled; and

Recognizing that Australia, New Zealand³ and Japan have requiredmandatory labels for genetically engineered foods; and

Recognizing that substantially this same resolution regardinggenetically modified organisms recently was adopted by the NationalEnvironmental Heath Association Council of Delegates; and

Recognizing that the National Environmental Heath Association'scounterpart in the United Kingdom, the Chartered Institute ForEnvironmental Health, has adopted a policy position that supportsa five-year freeze against genetically modified organisms; and

Recognizing that the current Codex, the international food regulatorycommission of the World Health Organization/Food and AgricultureOrganization, is considering recommendations for the Labelingof Food and Food Ingredients Obtained Through Certain Techniquesof Genetic Modification/Genetic Engineering⁴; and

Further recognizing that data from 2000 show that 54% of soybeanand 25% of corn planted in the United States were geneticallymodified⁵; and

Recognizing that the report of the Scientific Advisory Panelto the US Environmental Protection Agency on genetically engineeredcrops expressed concerns related to human exposure to and consumptionof these plant proteins⁶; and

Recognizing that legislation has now been introduced into theUnited States Congress that calls for the labeling of productsthat contain genetically engineered crops⁷; and

Recognizing that food labeling both upholds and is consistentwith the principle of consumer choice and labeling in placefor organic foods in some states; and

Recognizing that any opposition to labeling based on findingsthat genetically modified food products are safe discounts issuesof consumer choice and bioethical concerns; and

Recognizing that food labeling makes possible a range of legitimateconsumer interests ranging from a desire to avoid allergic reactionsto the opportunity to exercise informed buying decisions; and

Recognizing the 1992 interim report on a survey by the U.S.Department of Agriculture's Extension Service revealing that85% of the American public that was surveyed felt it importantto label foods if biotechnology is used^8,⁹; and

Recognizing a 1999 Time magazine poll finding 81% of respondentswanted genetically engineered food labeled, Therefore,

Resolves that APHA declare its support that any food productcontaining genetically modified organisms be so labeled.

   Footnotes

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INTRODUCTION
2001-1: Improving Early...
References
2001-2: Reducing Maternal-Fetal...
References
2001-3: Increasing Access to...
References
2001-4: Hospital Emergency...
References
2001-5: Health Status of...
References
2001-6: Global Campaign to...
References
2001-7: Research and...
References
2001-8: Establishment of a...
References
2001-9: Protection of Child...
References
2001-10: Support for National...
References
2001-11: Support of the...
Footnotes
References
2001-12: Discontinuing the Use...
References
2001-13: APHA Resolution on...
Footnotes
References
2001-14: APHA Supports the...
References
2001-15: Recognition and Support...
References
2001-16: Recognizing the Role...
References
2001-17: Support the Framework...
References
2001-18: Support for Curricula...
References
2001-19: Opposition to National...
References
Public Health Impact Statement
2001-20: Support for Culturally...
References
2001-21: Threats to Global...
References
2001-22: Opposition to Coercion...
References
2001-23: Protection of the...
References
2001-24: Trust Fund for...
References
2001-25: Participation of Health...
References
2001-26: Condemnation of...
References
INTERIM POLICY STATEMENTS
LB01-1: Improving the Nutrition...
References
LB01-2: Alert on the...
References
LB01-3: Occupational Safety and...
LB01-4: Resolution Supporting...
References
LB01-5: Preserving Worker and...
References
LB01-6: Opposing War in...
References
LB01-7: Call for United...
References
Public Health Impact Statement

^* Genetically modified organism (GMO) means an organism in whichthe genetic material has been altered in a way that does notoccur naturally by mating or natural recombination. (From definitionof GMO in EEC Council Directive 90/220/EEC 23 April 1990 ‘Onthe Deliberate Release into the Environment of GMOs.’)

2. European Commission. Regulation (EC) No. 2000/ 49. 2000.

3. CX/FL 01/7 Proposed draft recommendations for the Labelling of Food and Food Ingredients Obtained Through Certain Techniques of Genetic Modification/ Genetic Engineering (originated from Alinorm 99/22, Appendix VIII)

4. ANZFA (Australia New Zealand Food Authority). Standard A18—Food produced using Gene Technology. 1999.

5. USDA National Agricultural Statistics Service Crop Production—Acreage supplement (PCP-BB), 2000 Cr Pr 2-5 (6-00)a (available at http://usda.mannlib.cornell.edu/reports/nassr/field/pcp-bba/acrg0600.txt).

6. SAP Report No. 2000-7c, March 12, 2001 Set of Scientific Issues Being Considered by the Environmental Protection Agency Regarding: Bt Plant Pesticides Risk and Benefit Assessments, "The consensus of the Panel was that there were two concerns related to exposure/consumption of proteins—acute toxicity and allergenicity. The Panel believed that it is not possible to establish an exposure threshold for all proteins, but that well established protocols exist for testing individual proteins for acute toxicity. The Panel consensus was that it is not currently possible to identify conservative threshold levels for allergenicity." P. 71

7. Report to Extension Service, US Dept. of Agriculture, TJ Hoban, and PA Kendall. 1992. A survey of consumer attitudes about the use of biotechnology in agriculture and food production.

8. Time Magazine, "Brave New Farm—What People Think," J Walsh. January 11, 1999.

	2001-12: Discontinuing the Use of Fluoroquinolone Antibiotics in Agriculture

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2001-12: Discontinuing the Use...

THE AMERICAN PUBLIC HEALTH ASSOCIATION,

Recognizing that fluoroquinolone antibiotics are the treatmentof choice for some human gastrointestinal infections, particularlysevere food-borne illness caused by Campylobacter or Salmonellaebacteria; and that fluoroquinolones also are used to treat urinarytract infections, bone and joint infections, some types of pneumonia,and other human illness; and

Further recognizing that Campylobacter, as the most common causeof food-borne illness in the U.S., accounts for nearly two millionillnesses and about 100 deaths each year, according to estimatesby the Centers for Disease Control;¹ while Salmonellae bacteriaare the leading cause of food-borne disease in many other countries,²and in the U.S. account for an estimated 1.3 million food-borneillnesses and around 550 deaths each year;³

Understanding that fluoroquinolones closely related to thoseused in humans are also used in poultry, which are a leadingsource of human food-borne illnesses,⁴ and that use in poultryhas contributed to the generation of fluoroquinolone-resistantCampylobacter,⁵ as well as resistant Salmonellae;¹ and

Acknowledging that while treatment of human disease with fluoroquinolonesbegan in 1986, little resistance developed in the U.S. untilthe first fluoroquinolone was approved for use in poultry in1995, but resistance has since increased rapidly. By 1998, forexample, the Centers for Disease Control found that over 13percent of food-borne Campylobacter was resistant to fluoroquinolones,a figure which had risen to nearly 18 percent by 1999;^7,⁸

Acknowledging that for immunocompromised and other vulnerablepatients, such as children and the elderly, antibiotic resistantstrains of Campylobacter and Salmonellae can pose a seriousand potentially fatal problem;⁹ also acknowledging that evenin otherwise healthy patients, infection by fluoroquinolone-resistantstrains of Campylobacter can lead to longer duration of symptoms;and

Recognizing that fluoroquinolone resistance is only part ofa more widespread problem that has resulted in bacterial resistanceto all available antibiotics,¹⁰ and that this widespread problemis addressed by APHA policy #9908; and

Recognizing that of the two fluoroquinolones used in poultryover the last five years, Abbott Laboratories requested thatFDA withdraw authorization for use of one while the other, enrofloxacin,manufactured by Bayer Corporation, remains on the market;¹¹

Recognizing that at the time FDA first approved the applicationfor use of enrofloxacin in poultry, the potential for antibioticresistance was anticipated, and a stipulation was added to theapplication that the drug's sponsor had to agree to participatein a surveillance program for antibiotic resistance;¹²

Recognizing that on October 31, 2000, the Food and Drug Administration'sCenter for Veterinary Medicine issued a Notice of Opportunityfor Hearing on a proposed withdrawal of authorization for useof enrofloxacin;¹³ understanding that the FDA docket for thisNotice provides extensive scientific evidence supporting theproposed action;¹⁴ and noting that Bayer Corporation has electedto challenge the FDA proposal by requesting a hearing, ratherthan voluntarily withdraw its fluoroquinolone product; therefore

Strongly supports the FDA's proposed withdrawal of remaininguses of fluoroquinolones in poultry as a firm step to meetingrecommendations in APHA Policy #9908 that urged "the Centerof Veterinary Medicine of the FDA to work for regulations eliminatingthe non-medical use of antibiotics and limiting the use of antibioticsin animal feeds."
Supports the FDA action as being firmlygrounded in existingscience and in public health protection;
Calls upon the manufacturers of enrofloxacin to voluntarilywithdraw their product from use in poultry, recognizing thatto do so constitutes the quickest, most responsible way to addressthe public health threat.
Urges that the FDA immediately finalizea date for a hearingon its proposed ban of fluoroquinoloneproducts in poultry.

2. Malorny B, Schrotter A, Helmuth R. Incidence of quinolone resistance over the period 1986 to 1998 in veterinary Salmonella isolates in Germany. Antimicrob Agents Chemother. 1999;43:2278–2282.[Abstract/Free Full Text]

3. Mead et al. 1999.

4. Altekruse SF, et al. Campylobacter jejuni—an emerging foodborne pathogen. 1999 Jan-Mar 5(1). Available at: URL: http://www.cdc.gov/ncidod/eid/vol5no1/altekruse.htm.

5. Smith KE, Besser JM, Hedberg CW, Leano FT, Bender JB, et al. Quinolone-resistant campylobacter jejuni infections in Minnesota, 1992-1998. N Engl J Med 1999;340:1525–32.[Abstract/Free Full Text]

6. Malorny et al. 1999.

7. Centers for Disease Control and Prevention, 1998 Annual Report NARMS National Antimicrobial Resistance Monitoring System: Enteric Bacteria. Available at http://www.cdc.gov/ncidod/dbmd/narms/annuals.htm

8. Centers for Disease Control and Prevention, 1999 Annual Report NARMS National Antimicrobial Resistance Monitoring System: Enteric Bacteria. Available at http://www.cdc.gov/ncidod/dbmd/narms/annuals.htm.

9. Wegener HC (editorial). The consequences for food safety of the use of fluoroquinolones in food animals. N Engl J Med May 20, 1999;340(20). Available at: http://www.nejm.org.

10. Levy SB. Clinical Care. Resistant Organisms: Global Impact on Continuum of Care. International Congress and Symposium Series 220, 1998.

11. Food and Drug Administration, HHS, FR Notice Vol. 66, No. 83, 21400-21401, Docket No. 01N-0170, April 30, 2001. http://www.fda.gov/OHRMS/DOCKETS/98fr/043001h.htm.

12. New Animal Drug Application (NADA) 140–828, for Baytril 3.23% Concentrate Antimicrobial Solution, approved by the Food and Drug Administration, Department of Health and Human Services, October 4, 1996.

13. Food and Drug Administration, HHS, FR Notice Vol. 65, No. 211, 64954-64965, docket no. 00N-1571, October 31, 2000, http://www.fda.gov/OHRMS/DOCKETS/98fr/103100co.htm.

14. Food and Drug Administration, HHS, docket no. 00N-1571, http://www.fda.gov/OHRMS/DOCKETS/.

	2001-13: APHA Resolution on Overweight in Childhood

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2001-13: APHA Resolution on...

THE AMERICAN PUBLIC HEALTH ASSOCIATION,

Recognizing that the prevalence of overweight in childhood^*is increasing in all sex, age, and racial/ethnic groups in theUnited States, particularly in Hispanic, African-American, andAmerican Indian Children;^1–⁴ and

Whereas severe overweight in childhood is related to increasedstress on weight-bearing joints,⁵ increased blood pressure anddyslipidemia,^6,⁷ risk of type 2 diabetes,⁸ and Pickwickian syndromeor breathing difficulties;⁹ and

Whereas type 2 diabetes due to overweight is the fastest growingchildhood disease in the United States; and

Whereas overweight children are subject to discrimination, socialstigmatization, low self-esteem, and depression, as well asreduced earnings and educational achievement in adulthood;^13–²⁰and

Whereas social prejudice and stigmatization also contributeto unhealthy weight loss practices that have negative physicaland psychosocial consequences^21,^22,¹⁷

Whereas early childhood overweight is significantly associatedwith later childhood and adult obesity and related morbiditiesin adults;^23–²⁹ and

Whereas the costs of diseases and conditions related to obesityamounted to $99.2 billion in 1995;³⁰ and

Whereas the health of overweight children is compromised bythe lack of treatments known to be consistently effective andsafe during periods of growth as well as the limited availabilityof insurance coverage for family-based treatments;^3,^31–³³and

Whereas the childhood overweight epidemic is linked to environmentalfactors such as increased accessibility to calorie dense foods,decreased daily physical activity and increased sedentary behavior;^34–³⁸and

Whereas promising intervention strategies to address childhoodoverweight include limiting hours of television viewing, increasingphysical activity, and consuming lower calorie, nutrient richdiets;^39–⁴¹ and

Whereas there is a lack of state specific data systems availableto monitor the prevalence of overweight in children and youth,

Resolved, to encourage urban designs and other environmentalchanges in schools and communities to create opportunities fora healthy lifestyle for children of all sizes, including thepromotion of alternatives to sedentary activity and increasesin access to healthier foods.

To promote increases in the quantity and quality of physicaleducation programs offered in grades K-12 with attention givento culturally appropriate, appealing, non-competitive activitiesthat reflect the diversity of abilities and interests of America'schildren.

To support the integration of food and nutrition education intoschool curricula and to support legislation and policies thatincrease the accessibility, appeal, and healthy choices availablein USDA school breakfast, lunch and after-school snack programs,and that limit the availability of high-calorie, nutrient-poorfoods and beverages in school stores, vending machines and ala carte offerings.

To support programs which enable parents to model and supporthealthy lifestyles for their children.

To encourage the media to reduce or eliminate messages whichpromote unhealthy eating, sedentary lifestyles and body dissatisfaction.

To encourage food manufacturers to limit marketing of high-calorie,nutrient-poor food products to children.

To support legislation, policies and practices to ensure accessto health services for children of all ages and to require insurancecoverage for family-based prevention^** and treatment of childhoodoverweight.

To encourage prevention efforts that begin in early childhoodbefore habits that promote overweight are established.

To support funding for large-scale collaborative efforts atthe national, state, local and tribal community levels to promotehealthful lifestyles for parents and children.

To promote the funding of applied research to identify successfulintervention to prevent childhood overweight in the generalpopulation of children and youth, as well as within specificethnic groups, and to support the large-scale application ofthese interventions.

To support CDC leadership in establishing new data collectionsystems to allow states to monitor the geographic distribution,secular trends and progress in reducing the prevalence of childhoodoverweight.

   Footnotes

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INTRODUCTION
2001-1: Improving Early...
References
2001-2: Reducing Maternal-Fetal...
References
2001-3: Increasing Access to...
References
2001-4: Hospital Emergency...
References
2001-5: Health Status of...
References
2001-6: Global Campaign to...
References
2001-7: Research and...
References
2001-8: Establishment of a...
References
2001-9: Protection of Child...
References
2001-10: Support for National...
References
2001-11: Support of the...
Footnotes
References
2001-12: Discontinuing the Use...
References
2001-13: APHA Resolution on...
Footnotes
References
2001-14: APHA Supports the...
References
2001-15: Recognition and Support...
References
2001-16: Recognizing the Role...
References
2001-17: Support the Framework...
References
2001-18: Support for Curricula...
References
2001-19: Opposition to National...
References
Public Health Impact Statement
2001-20: Support for Culturally...
References
2001-21: Threats to Global...
References
2001-22: Opposition to Coercion...
References
2001-23: Protection of the...
References
2001-24: Trust Fund for...
References
2001-25: Participation of Health...
References
2001-26: Condemnation of...
References
INTERIM POLICY STATEMENTS
LB01-1: Improving the Nutrition...
References
LB01-2: Alert on the...
References
LB01-3: Occupational Safety and...
LB01-4: Resolution Supporting...
References
LB01-5: Preserving Worker and...
References
LB01-6: Opposing War in...
References
LB01-7: Call for United...
References
Public Health Impact Statement

^* Overweight in childhood is defined as body mass index over theage and gender-specific 95th percentile.

^** Family-based treatment is differentiated from treatments focusingon children without involvement of family members. Family-basedtreatment has been demonstrated effective for a substantialnumber of children.^42,⁴³

2. Troiano RP, Flegal KM, Kuezmarski RH, Campbell SM, Johnson CL. Overweight prevalence and trends for children and adolescents. Arch Pediatr Adolesc Med, 1995;149:1085–91.[Abstract/Free Full Text]

3. Troiano RP, Flegal KM. Overweight children and adolescents: Description, epidemiology and demographics. Pediatrics.1998;101:497–503.[Abstract/Free Full Text]

4. Crawford PB, Story M, Wang MC, Ritchie LD, Sabry ZI Ethnic issues in the epidemiology of childhood obesity. Ped Clin North Am. In Press.

5. Bray GA. Complications of obesity. Ann Int Med.1985;103:1052–62.

6. Morrison JA, Barton BA, Biro FM, Daniels SR, Sprecher DL. Overweight, fat patterning, and cardiovascular disease risk factors in black and white boys. J Pediatr.1999;135:451–7.[Medline]

7. Morrison JA, Sprecher DL, Barton BA, Waclawiw MA, Daniels SR. Overweight, fat patterning, and cardiovascular disease risk factors in black and white girls: The National Heart, Lung, and Blood Institute Growth and health Study. J Pediatr.1999;135:458–64.[Medline]

8. Gower BA, Nagy TR, Trowbridge CA, Dezenberg C, Goran MI. Fat distribution and insulin response in prepubertal African American and white children. Am J Postgrad Med.1990;87:123–33.

9. Leung AK, Lane W, Robson M. Childhood obesity. Postgrad Med.1990;87:123–33.

10. Rosenbloom AL, Joe JR, Young RS, Winter WE. Emerging epidemic of type 2 diabetes in youth. Diabetes Care.1999;22:345–54.[Abstract/Free Full Text]

11. Dabelea D, Pettitt DJ, Jones KL, Arslanian SA. Type 2 diabetes mellitus in minority children and adolescents. An emerging problem. Endocrinol Metab Clin North Am.1999,28:709–29.[Medline]

12. American Diabetes Association. Type 2 diabetes in children and adolescents. Diabetes Care.2000;23: 381–9.[Medline]

13. Strauss RS. Childhood obesity and self-esteem. 2000; 105(1). URL http:/www.pediatrics.org/cgi/content/full/105/1/e15.

14. Neumark-Sztainer D, Story M, Faibisch L. Perceived stigmatization among overweight African and Caucasian adolescent girls. J Adolesc Med.1998;23: 264–70.

15. Hill AJ, Silver EK. Fat, friendless and unhealthy: 9-year old children's perception of body shape stereotypes. Int J Obesity.1995;19:423–30.

16. French SA, Story M, Perry CL. Self-esteem and obesity in children and adolescents: a literature review. Obes Res.1995;3:479–80.[Medline]

17. Gortmaker SL, Must A, Perrin JM, Sobol AM, Dietz WH. Social and economic consequences of overweight in adolescence and young adulthood. N Engl J Med.1993;329:1008–12.[Abstract/Free Full Text]

18. Sobal J, Nicolopoulos V, Lee J. Attitudes about overweight and dating among secondary school students. Int J Obesity.1995;19:376–81.

19. Pesa JA, Syre TR, Jones E. Psychosocial differences associated with body weight among female adolescents: the importance of body image. J Adolesc Med.2000;26:330–7

20. Sargent JD, Blanchflower DG. Obesity and stature in adolescence and earnings in young adulthood. Arch Pediatr Adolesc Med.1994;148:681–7.[Abstract/Free Full Text]

21. Johnston FE. Health implications of childhood obesity. An Int Med.1985;103:1068–72.

22. Melbin T, Vullie JC. Rapidly developing overweight in school children as an indicator of pychosocial stress. Acta Pediatr Scand.1989;78:568–75.[Medline]

23. Charney E, Goodman HC, McBride M, Lyon B, Pratt R. Childhood antecedents of adult obesity. Do chubby infants become obese adults? N Engl J Med. 1976;295:6–9.24.[Abstract]

24. Durnin JV, McKillop FM. The relationship between body build in infancy and percentage body fat in adolescence: A 14-year follow-up on 102 infants. Proc Nutr Soc Engl.1978;37:81.

25. Mumford P, Morgan JB. A longitudinal study of nutrition and growth of infants initially on the upper and lower centile for weight and age. Int J Obes.1982;6: 335–41.[Medline]

26. Shapiro L, Crawford PB, Clark MJ, Pearson DL, Raz J, Huenemann RL. Obesity prognosis: A longitudinal study of children from the age of 6 months to 9 years. Am J Public Health.1984;74:968–72.[Abstract/Free Full Text]

27. Hulman S, Kushner H, Katz S, Falkber B. Can cardiovascular risk be predicted by newborn, childhood, and adolescent body size? An examination of longitudinal data in urban African Americans. J Pediatr.1998; 132:90–7.[Medline]

28. Dietz WH. Childhood weight affects adult morbidity and mortality. J Nutr.1998;128:411S–4S.

29. Must A, Spadano J, Coakley EH, Field AE, Colditz G, Dietz WH. The disease burden associated with overweight and obesity. JAMA.1999;282:1523–9.[Abstract/Free Full Text]

30. Wolfe AM and Colditz GA, Current Estimates of the economic costs of obesity in the United States. Obes Res.1998;6:97–106.[Medline]

31. Tershakovec AM, Watson MH, Wenner WJ, Marx AL. Insurance reimbursement for the treatment of obesity in children. J Pediatr.1999;134:576–8.

32. Dietz WH, Nelson A. Barriers to the treatment of childhood obesity: A call to action. J Pediatr.1999;134: 535–6.[Medline]

33. National Institutes of Health. NIH Technology Assessment Conference on Methods for Voluntary Weight Loss and Control. Ann Intern Med.1992;116:942–9.

34. Waxman M, Stunkard AJ. Caloric intake and expenditure of obese boys. J Pediat.1980;96:187–93.[Medline]

35. Sallis JF, Patterson TL, Buono MJ, Nader PR. Relation of cardiovascular fitness and physical activity to cardiovascular disease risk factors in children and adults. Am J Epidemiol.1988;127:933–41.[Abstract/Free Full Text]

36. Obarzanek E, Schreiber G, Crawford P, Goldman S, Barrier P, Frederick M. Energy intake and physical activity in relation to indices of body fat. Am J Clin Nutr.1994;60:15–22.[Abstract/Free Full Text]

37. Harsha DW. The benefits of physical activity in childhood. Am J Med Sci.1995;310:S109–13.

38. Moore LL, Nguyen USDT, Rothman KJ, Cupples LA, Ellisun RC. Preschool physical activity level and change in body fatness in young children. Am J Epidemiol.1995;142:982–8.[Abstract/Free Full Text]

39. Gortmaker SL, Must A, Sobol AM, Peterson K, Colditz GA, Dietz WH. Television viewing as a cause of increasing obesity among children in the United States, 1986-1990.

40. Gortmaker SL, Peterson K, Wiecha J, Sobol AM, Dixit S, Fox MK, Laird N. Reducing obesity via a school based interdisciplinary intervention among youth: Planet Health. Arch Pediatr Adolesc Med.1999; 153:409–18.[Abstract/Free Full Text]

41. Robinson TN. Reducing children's television viewingto prevent obesity. A randomized controlled trial. JAMA.1999;282:1561–7.[Abstract/Free Full Text]

42. Epstein LH, Valoskmi A, Wing RR, McCurley J. Ten-year outcomes of behavioral family-based treatment for childhood obesity. Health Psychology.1994; 13:373–83.[Medline]

43. Mellin LM, Slinkard LA, Irwin Jr, CE. Adolescentobesity intervention: validation of the SHAPEDOWN program. JADA.1987;87:333–8.

	2001-14: APHA Supports the Health and Human Services Blueprint for Action on Breastfeeding

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2001-14: APHA Supports the...