warning signs of heart attack

ladies and gentlemen. thank you for standingby and welcome to the making the economic case for health equity ã± tribal and statesolutions webinar. during the presentation all participants will be in a listen onlymode. afterwards we will conduct a question and answer session. at that time if you havea question please press the one, followed by the four, on your telephone. and if youneed to reach an operator at any time please

warning signs of heart attack, press star zero.as a reminder this conference is being recorded friday, june 22, 2012, and i would now liketo turn the conference over to dr. terry cline. please go ahead sir.great. thank you very much. this is terry cline, and welcome to the webinar, makingthe economic case for health equity ã± tribal

and state solutions. we have a great lineup for you today. i have the great fortune of moderating the webinar. iã­m the secretaryof health and human services in the state of oklahoma, as well as the commissioner ofhealth. in the state of oklahoma itself we have 38federally recognized tribes, and very, very fortunate to have great leadership and greatpartnerships between state departments of health and the sovereign nations that existwithin the oklahoma boundaries. we have many opportunities that are availableto us through these partnerships, and a lot of challenges. in the webinar today weã­llhear some specifics about some research which has taken place, as well as some of thosepartnerships and some of those relationships

in two different locations.most of us when we think about health equity weã­re thinking about health equity in termsof social justice and, which are very near and dear to our hearts and very visible tous. we also realize, and weã­ll highlight today, some of the economic issues associatedwith health equity. and we need to find a common language; we need to make sure thatpeople have ways to talk about the economic impact of health inequities that are easyto understand. as we talk with different target audiences we may need a different languagefor those different groups. hopefully this webinar will help provide uswith some of that language as well as highlighting some of the issues.we also know that there are significant equities

and disparities that exist between differentracial ethnic groups, social economic classes, geographical locations, and differences inthe, in the social determinance of health such as poverty, education, inadequate housing,and unsafe working conditions. a very concrete example, my office is on ahealth sciences center at campus. we have the highest concentration of healthcare inthe state of oklahoma in this one location. yet in our surrounding area we also have theworst health outcomes in the entire state. so it really speaks to the complexity of theseissues when we look at the health inequities. the burden of health inequities constitutesa very large, a huge financial and social cost to our nation. we know, and i think dr.smedley will address some of this, approximately

$23 billion in direct medical care expendituresand more than one trillion dollars in indirect costs are associated with illness and prematuredeath for the years 2003 to 2006. those dollars could have been saved by eliminating healthdisparities for racial ethnic minority groups. we also know that economically segregatedneighborhoods are more likely to have limited economic opportunities, unhealthy optionsfor food and physical activity, and environmental hazards, substandard housing, lower performingschools, and higher rates of crime, incarceration. the lineup today we have four individualswho will be presenting. each will have a different perspective that they will bring to the webinarrelated to health equity. first weã­ll hear from a researcher with expertisein economic, making the economic case of health

equity. then weã­ll hear from state levelleadership who have boots on the ground experience who will be able to talk about the importanceof tribal collaborations and state public health.i will introduce each of those individuals prior to their segment of the presentation.and first we will start with dr. brian smedley, and he will set the stage and provide backgroundcontext for our webcast. then weã­ll have questions at the very end of the presentation.dr. smedley is the vice president and director of health policy institute for the joint centerfor political and economic studies in washington d.c. he oversees all the operations of theinstitute, which was started in 2002 with funding from the w.k. kellogg foundation.the institute has dual focus to explore disparities

in health and to generate policy recommendationson long-standing health equity concerns. formerly, dr. smedley was a research directorand co-founder of a communications research and policy organization, the opportunity agenda,where he led that organizationã­s effort to center equity and state and national healthreform discussions. he holds an undergraduate degree from harvarduniversity and ph.d. in psychology from ucla, and dr. smedley, the floor is yours. welcome.well thank you very much dr. cline. i want to thank astho for having me with this importantwebinar. you very nicely teed up this conversation, dr. cline, in that there is an economic caseto be made to address health inequities. iã­ll briefly review the research that we have conductedon that topic.

and then i will focus on local and state levelstrategies, particularly to address the issue that you raised of segregation and the importanceof place. we think that there is some important opportunities for tribal governments, forstate governments, and local governments to begin to address some of the issues associatedwith the concentration of poverty and to begin to advance equity across a range of sectors,and iã­ll briefly review some of the promising directions that weã­re looking at.could i ask that the next slide be advanced please? so first, talking about the economicburden of health inequalities in the united states, iã­m going to refer specifically tothe report, the economic burden of health inequalities that we at the joint center releasedin september of 2009. this can be accessed

at our website at www.jointcenter.org. thisresearch was done by dr. thomas laveist of the johns hopkins university, as well as dr.darrell gaskin, also of the johns hopkins university, and we thank them for their importantcontributions to this research. this was the first research to our knowledgethat attempted to assess both the direct medical costs associated with health inequalities.in other words, what, what are the total amount of dollars that we as a nation are spendingto address the higher burden of disease and disability in communities of color. obviouslyto the extent that people of color have a higher burden of chronic disease and disability,potentially there are higher costs associated with these inequities. and so we attemptedto quantify what those direct medical costs

were.but of course the economic burden is not limited to just the higher health care costs for thosepopulations that have a higher burden of poor health. there are also indirect costs of healthinequalities. so for example, if people are too sick to work, obviously we lose productivityin workplaces. and to the extent that people die prior to their healthy productive workingyears are over, then there are costs to the nation in the form of things like lost taxrevenue at state, local, and federal level. so we attempted to quantify both these directcosts as well as these indirect costs. next slide please. first in talking aboutthe direct costs associated with health inequalities, drs. laveist and gaskin accessed the federalmedical expenditure panel survey data, which

are compiled by the agency for health careresearch and quality to come up with these estimates.what they did was to look at the burden of chronic disease, in other words, the prevalenceof chronic disease and the actual medical expenditures associated with diseases suchas asthma, cardiovascular disease, cancer, diabetes, etcetera, and looked at the excesscosts associated with direct medical care for african americans, asian americans, andlatinos. obviously to the extent that it was possible, we tried to include other populationgroups such as american indians, but the data did not allow for reliable estimates for smallerpopulations. what we found in that four year period between2003 and 2006 was that over 30 percent of

the direct medical care costs for africanamerican, african americans, asian americans, and latinos were excess costs due to the higherburden of chronic disease and disability across a range of disease areas.the total costs approached nearly $230 billion for these direct medical care expendituresin that four year period. and if we were to add in those indirect expenses, such as lostwages and productivity, lost tax revenue at local, state, and federal levels, we estimatethat the total combined cost approached $1.24 trillion in that four year period.so obviously this research suggests that our efforts to contain health care costs to bendthe health care cost curve, as some put it, are impaired to the extent that we cannotreduce the burden of disease among many populations

that have a higher burden of disease and disability.and, to the extent that these health inequities affect our productivity and our state, federal,local budgets and tax revenue, then clearly these have important implications for theeconomy as a whole. what we suggest is that the, in addition to the important moral imperativethat we as a nation tackle, the higher burden of, of poor health for many populations ofcolor, is that thereã­s also an economic case that we all pay a cost, both in terms of directmedical expenses. in other words, everyone who pays into a private health insurance premiumor into public health insurance, obviously thereã­s a cost that we all pay, but thento the extent that the nation is still trying to come out of the economic downturn, thatis also impaired by the higher burden of disease

and disability from many populations of color.next slide please. i want to focus now on the lens that we use in our work to advancehealth equity, and that is to focus on geography, that is place. many scholars have noted thatthere is an important geography of opportunity in that the spaces and places where peoplelive, work, and play powerfully shape not only their health, but also their life opportunities.in general, a large body of research points to the fact that the places and spaces occupiedby people of color tend to host a disproportionate cluster of health risks, and have a relativelack of health enhancing resources, and iã­ll say more about this shortly.next slide please. first, we need to understand the role of segregation. we, in our work,agree with scholars such as david williams

at the harvard school of public health, whoargue that segregation is a root driver of many of the racial and ethnic health inequitiesthat we see. certainly as a nation weã­ve come a long wayin terms of desegregating our communities. we no longer have jim crow laws on the books.and there are ostensibly no longer conditions that are tolerable from a legal perspectiveto, to reinforce patterns of segregation. but segregation persists at high levels, particularfor african americans, american indians, and many hispanic population groups.and so it is the, the problems associated with segregation for many of these communitiesof color are among the underlying risk for poor health that these populations face.next slide please. when we consider the problem

of segregation in the u.s. it is importantthat we consider how deeply segregated many of our american cities and metropolitan areasare many, many years after efforts to dismantle jim crow and to enforce fair housing laws.this slide presents data from doug masty and other demographers who have looked at thelevel of segregation in the united states in several major metropolitan areas relativeto a country like south africa, which in 1991, of course, enforced state sanctioned segregationthrough apartheid. the measure that these demographers are usinga measure called the dissimilarity index, which represents the percentage of a populationthat would need to move in order to create complete segregation between two populationgroups. so in south africa in 1991 while apartheid

was still in effect, south africa had a dissimilarityindex of 90, meaning that 90 percent of white and black south africans would have neededto move to create integration in the country at that time.unfortunately, as late as 2010 many u.s. cities were not far behind the level of segregationfound in south africa. so in detroit, for example, the dissimilarity index is 85, meaningthat 85 percent of white and black detroiters would need to move to desegregate that city.similarly in milwaukee, new york, chicago, and newark we find dissimilarity indices of80 or higher in each of these cities, meaning that four out of every five individuals, blackand white would need to move to create integration in these cities.next slide please. the issue of segregation

is not that people of color living togetheris problematic in and of itself. in fact, we have many instances historically in thiscountry where so-called ethnic enclaves or other instances of segregation can actuallyprove to offer protective effects for, particularly new, new immigrants to this country.the problem with segregation is that it concentrates poverty. it tends to exclude and isolate communitiesof color from the mainstream resources needed for success. we know that african americans,latinos, and american indians are more likely to reside in poorer neighborhoods regardlessof their own income level. so we have many instances of middle and even upper middleincome people of color who are more likely to live in communities with higher concentrationsof poverty as a result of residential segregation.

segregation restricts socioeconomic opportunityby channeling people of color into neighborhoods with poorer public schools, fewer employmentopportunities, and smaller returns on real estate. these are so-called opportunity structures.in other words we know that in communities with high concentrations of poverty, highlevels of segregation that these schools tend, on average, to be under resourced. they tendto have crumbling physical infrastructure. they tend to have outdated textbooks; teacherswho are not credentialed to teach in the subjects that they teach in; fewer college preparatorycourses such as advanced placement courses. these are the kinds of schools that face highdropout rates and are less likely to prepare students for success in higher education,which obviously has important implications

for socioeconomic mobility.these kinds of neighborhoods have fewer employment opportunities, less capital for business investment.and, very, very significantly, the issue of the value of real estate. most american families,their wealth is tied to the value of their home or their property. for people of colorliving in communities characterized by high levels of segregation, on average we knowthat their homes, even when they are comparable to homes in majority white communities, thatthese homes are going to have smaller returns over time. they appreciate in value at a lowerlevel than homes in majority white communities. again, even for comparable properties.and when we consider the home, the recent home foreclosure crisis, which of course isan ongoing crisis, itã­s important that we

recognize that the, this crisis has been oneof the major drivers of the growing wealth gap between white and non-white communities.for example, ten years ago we know that the wealth gap between blacks and whites was about10 to one; that is for every dollar of white wealth, african americans had about ten cents.for every dollar of white wealth, latinos had about 11 cents. today that gap is muchwider as a result of the disproportionate burden of the home foreclosure crisis in communitiesof color. so today for every dollar of white wealth, african americans have about a nickel.for every dollar of white wealth latinos have about six cents.and of course given the important relationship between socioeconomic status and health, theseare among the major drivers, the major structural

inequities that contribute to poorer healthamong populations of color relative to whites. and arguably, these kinds of factors are themajor factors that contribute to the, to the very vast and growing gap in wealth and socioeconomicopportunity between whites and nonwhites. next slide please. we know that there areother problems associated with segregation. we know that people of color are less likelyto live in communities with supermarkets or grocery stores selling healthy products suchas fresh fruits and vegetables. in contrast, many of these families are more likely tolive in communities that are literally overrun with vendors selling things that are harmfulfor people, such as fast food outlets, liquor stores, convenient stores, carry out stores.thereã­s also a disproportionate tobacco and

liquor advertising in many of these communities.these neighborhoods also have fewer parks and green spaces, fewer safe places for walking,biking, exercise, and recreation. the point here is that we have spent quitea bit of time and resources in this country trying to educate people about the importanceof leaving, of living a healthy lifestyle, eating a healthy diet, exercising. of coursethese things are important, but they are often difficult to do in highly segregated communitiescharacterized by high levels of poverty because these neighborhoods tend not to reinforceor even to present opportunities for people to enjoy a healthy lifestyle.next slide please. we know that many of these communities are more likely to be exposedto environmental health hazards. we know,

for example, from the important research ofthe united church of christ that disproportionately neighborhoods with sources of environmentaldegradation such as _____ waste facilities are more likely to house people of color thanwhites. and disproportionately people of color areexposed to sources of air, water, and soil pollution in their neighborhoods relativeto majority white neighborhoods. and then thereã­s the poverty tax. peoplein poorer communities have to pay more for the same goods and services than those inhigher income communities. so on average you pay more for auto loans, auto insurance, furniture,appliances, bank fees ã± that is if you can find a bank. in many of these communitiesyou cannot find a bank branch and, so as a

result, people are unbanked. and in orderto cash a paycheck you have to go to a payday cashing outlet, which takes out a significantchunk of that pay, paycheck in order to provide cash.next slide please. just as an example of the depth of poverty concentration that we seein many metro areas, iã­m, iã­m going to present some examples of two different metro areaswhere children of color are disproportionately in neighborhoods with high poverty concentration,and i donã­t mean to pick on cities such as cleveland and the other city that iã­m goingto provide an example of, but they are representative of many, many major metropolitan areas wherewe see children of color disproportionately in neighborhoods with high, high poverty concentration.these are data from the website diversitydata.org,

which i highly recommend to anyone interestedin demographic trends such as racial and ethnic trends and poverty concentration.what we see here is that children in metro cleveland live in dramatically different neighborhoodsbased upon their race or ethnicity. as you can see from this slide the set of bars onthe far left shows who live in neighborhoods with between zero and 20 percent poverty concentration.these are neighborhoods that are on average healthier for people to live in. they havebetter retail food environments. they tend to have better quality housing, less environmentaldegradation, better public transportation, etcetera.over 90 percent of white and asian american children in metro cleveland live in theseneighborhoods with low poverty concentration,

a little over half of latino kids, and a littleover 40 percent of african american kids in metro cleveland live in these neighborhoods.in contrast, black and latino kids are disproportionately concentrated in neighborhoods with between20 and 40 percent poverty concentration. as you can see, over 40 percent of african americanand nearly 40 percent of latino kids in metro cleveland live in these neighborhoods. incontrast, relatively few white or asian american kids live in these neighborhoods.and at the most extreme end, neighborhoods with poverty concentrations over 40 percent,we can see again that a disproportionate share of black and latino kids live in these neighborhoods,which are literally toxic for the health and human development of these kids.now you might argue that these findings are

not surprising given wealth, and education,and income differences between people of color and whites. but as the next slide shows, evenwhen we control for differences in the family income, we still see dramatic differences.so this slide shows the poverty concentration of neighborhoods of poor children only - thatis black, latino, white, and asian american kids who are living below the poverty level.so among poor white kids, over 70 percent of poor white children in metro clevelandlive in neighborhoods with a very lower poverty concentration, between zero and 20 percent.about two-thirds of poor asian american kids live in these neighborhoods. but relativelyfew poor black and latino kids live in these neighborhoods. only about one, one in fivepoor black kids live in these neighborhoods,

and about 28 percent of poor latino kids livein these neighborhoods. again, however, when we look at neighborhoodswith higher poverty concentration disproportionately, this, these are the neighborhoods where wefind poor black and latino children. so as these data show, the experience of povertycan be very different based upon a childã­s race or ethnicity.next slide please. next slide shows metro detroit. again, iã­m not trying to pick ondetroit or cleveland. detroit, in fact, is my home town. but again, we see a very disturbingpattern where disproportionately white children are in neighborhoods with very low levelsof poverty concentration, whereas black and latino kids are much more likely to be foundin neighborhoods with very high levels of

poverty concentration.and again, if we were to control for differences in family income by just looking at childrenbelow the poverty line, as the next slide shows, again we see that kids of color arefar more likely to live in neighborhoods with a high level of poverty concentration thanwhite kids. next slide please. so just to briefly highlightsome key policy opportunities. again, many of these opportunities exist at tribal, state,and local levels. so we can, for example, expand place based opportunity by reducingresidential segregation. we can, for example, harness the many housing mobility programssuch as portable rent vouchers and tenant based assistance to ensure that people whoseek housing vouchers can move to communities

with lower levels of poverty concentration.we can also vigorously enforce existing anti-discrimination laws in home lending, rental markets, andreal estate transactions. and we can encourage greater commercial business and housing developmentin communities that have suffered from disinvestment. we also need to expand public transportationto connect people in job rich areas to, in job poor areas to communities with high levelsof job growth. this is often critically important because in many metro areas, areas with highjob growth are not in urban inner cities, but are in suburban and exurban communities.weã­ve got to expand our public transportation to ensure that people who need jobs can getto these communities. next slide please. we can also improve education.education from a public health standpoint,

of course, is critically important to closeequity gaps. one of the most important opportunities is to expand high quality preschool programs.thereã­s now abundant evidence that high quality early childhood enrichment programs can effectivelyinoculate children from the affects of living in high poverty neighborhoods because theyhave long lasting effects through adulthood. we know this from the many very successfullongitudinal studies such as the perry preschool project and the abecedarian project that havefollowed children using a randomly assigned experimental design of following childreninto adulthood showing that those that were in early enrichment programs have better outcomesas adults in terms of their education, their career and employment opportunities, etcetera.next slide please. we can also invest more

in creating healthier communities. doing thingslike improving conditions in the environment, reducing environmental degradation throughmore aggressive regulation, and enforcement of laws and the use of tools such as consolidatedenvironmental review which allows policy makers to consider the cumulative effects of manydifferent sources of environmental degradation on health and human development.we can also structure land use and zoning policies to reduce the concentration of healthrisks. for example, limiting the siting of fast food stores and other vendors sellingunhealthy products, and creating incentives for vendors such as grocery stores or farmerã­smarkets to open in so-called food deserts. and instituting policies such as health impactassessments to determine the public health

consequences of policies and practices acrossa range of sectors, including housing, transportation, education, and other policies.next slide please. thereã­s a very important experiment going on on housing mobility, thefederal moving to opportunity experiment conducted by the department of housing and urban development.itã­s being implemented in five cities. this study is now following families some 15 yearsafter providing housing assistance to help people move out of distressed communitiesand into neighborhoods with lower levels of poverty concentration.what weã­re finding is that when these families are away from concentrated poverty theyã­vetended to fare better in terms of their physical and mental health. adolescence report lessrisky behavior, such as risky sexual behavior.

and we know from a recent study publishedin the new england journal that some of these families have reported lower levels of obesityand diabetes subsequent to moving to neighborhoods with better opportunity structures.next slide please. i just want to conclude with a quote from the world health organizationcommission on the social determinance of health. they wrote in their report of 2008 that ã¬inequitiesin health and avoidable health inequalities arise because of the circumstances in whichpeople grow, live, work, and age, and the systems put in place to deal with illness.the conditions in which people live in die are in turn shaped by political, social, andeconomic forces.ã® in other words, the health inequalities thatwe see are not naturally occurring. they are

the result of policies and practices thatwe have put into place, and sometimes market forces, which unintentionally have hurt thehealth and development of those living in neighborhoods with high levels of povertyconcentration. and we can undo these conditions through smart policies, smart growth thatallows us to consider health and equity in all policy decisions.thank you, and i look forward to the discussion to follow.great, dr. smedley. thank you very much for those sobering statistics and research, andit really speaks to the magnitude of the challenge to improve health equity across our countryand also giving us some ideas about how we might eliminate those health inequality areasthat are so prevalent.

next we have two presenters who will sharewith us state and tribal perspectives. i will provide you with both of their introductions,because theyã­ll be presenting together. anna whiting-sorrell is the director of themontana department of health and has been since 2008. sheã­s responsible for overalldepartment policy development, management, and coordination of programs. she previouslyserved four years as governor schweitzerã­s policy advisor on families. she spent herprofessional career working for the confederated salish and kootenai tribes where sheã­s anenrolled member. and she also worked in tribal administration overseeing a number of programs,including the tribesã­ efforts in self-governance and other legislative efforts.sheã­s developed and implemented a nationally

recognized substance abuse prevention andtreatment program, and sheã­s a graduate of the university of montana with a b.a. in politicalscience and a masterã­s in public administration. joining her in this segment of the presentationwill be jane smiley, whoã­s worked for the state of montana for more than 30 years. sheserved as the administrator of the public health and safety division at the departmentof public health and human services since 2004, and has provided leadership to a varietyof public health efforts through the years, including public health system improvementaccreditation, public health emergency preparedness, tobacco usage prevention, and chronic diseaseprevention and control. she holds a masterã­s degree in public health from the universityof washington.

and anna and jane, the floor is yours.a. whiting-sorrell well thank you very much dr. cline. this is anna whiting sorrell, andiã­m going to start with a brief overview, and then jane is going to actually walk youthrough some of our efforts in working specifically with tribes.so can everybody hear ã± i hope iã­m being heard. itã­s kind of an odd, odd format forme here. i ã± sounds, sounds good from here anna.a. whiting-sorrell i, i have to say that i do a lot of talking across the state and thecountry. montana has seven reservations and very large reservations, and we have one staterecognized tribe. and so with the governorã­s appointment of me into this position, iã­mreally the first native american to ever be

appointed to run a health office in the country.it, it has put a tremendous amount of responsibility, i believe, on myself, iã­ve putten that on,to make this the absolute best opportunity to really look at how do states and tribes,and indian people interact in a public health system, in a health program. i also am fortunateenough to run the state medicaid department and many, many other programs. so lookingat that as an opportunity. in preparing for this i spent a significantamount of time actually trying to understand the material that was presented, and justnow presented by our previous presenter, and tried to make that relate to indian country.and i have to say that it was difficult for me.and it wasnã­t until dr. cline just said we

really need to be aware of, that thereã­sdifferent language that is spoken with different groups of people. and that clearly came forwardin the presentation as i read it, as i tried to do research on this topic, and as i listento the presentation. and i also really think itã­s important forus to take the last statement that was made about policies and practices of the researchthatã­s available out there, how do you put that in place in indian country? you know,the best example that i have is that as a native person, as an indian woman, we donã­tusually refer to ourself as people of color. we donã­t see ourselves in that mainstreamlanguage about, about people of color. we look at ourselves as being very distinct andunique in our ability, and what our goals

and values, and what we believe is successin life. if, if you take what was just talked, whatwe were just told about how important location is and how that really helps determine economicsuccess, and if you donã­t have economic success, the impact on your health, my comment wouldbe of course indians have a horrible health disparity then, because we are a reservationbased system. and that reservation based system is what we work hard to protect every dayas sovereign nations within this country. there isnã­t anything more important for indianpeople than to protect their sovereignty and the treaty rights that got us to have thisreservation based system. i, i would share a brief example about howimportant that is to indian people. iã­ve

had the wonderful opportunity to work forgovernor schweitzer for about seven and a half years now, and i have driven 150,000miles over that time so that i can go home every weekend to my reservation home. i wantto be there. i want to be practicing the culture and traditions that are retained in thosereservation communities. so weã­re almost the exact opposite of wantingintegration. we strive for segregation and the strength that we believe comes from beingour tribal people. i, i also want to go back about land ownership.you know, collectively we donã­t own, we own our land collectively not individually, andso itã­s whole nother way of thinking about the language that weã­re using when we talkabout indian, indian communities.

and so i think that, that becomes, those becomereally important predictors. if those are the important predictors of poverty and healthequity, then we have to really figure out a whole new language in which we build offof the research that we know that exists, but the reality of, of what we find in ourreservations and tribal communities. the last thing i would talk about is the,the reporting issues which we, when we were reading through we didnã­t even get nativeamerican data in the report that was, that was put forward, and as i tried to go do theresearch to see if i could come up with indian information i realized that because we areso small in numbers, and certainly the last speaker spoke to this, it is hard to get thatinformation out. weã­re rural, weã­re a small

number, and i would also contend that becauseso much of our healthcare comes from indian health service, a terribly underfunded systemthat doesnã­t always connect to the larger system, that our data is even more cumbersometo find. and, and so i think that what we find today,and have the wonderful opportunity ã± thank you ashtal for bringing this to light, thecontradictions that we need to come together to understand if weã­re really going to understandhealth inequities, the economics around it for indian country.the one thing that i think we have done here in montana is to really take time to understandwhat government to government is. how do you engage tribal governments, tribal people intothis solution? because, and ultimately thatã­s

what we want. we want to improve. and whatweã­ve come to understand in montana is itã­s about building relationships, personal onthe ground relationships in indian country where we really can understand all of whati just talked about. so jane is going to take over and sheã­s gotsome wonderful examples that weã­re going to put forward. so. and then iã­m certainlyavailable for questions when that period comes up.thanks anna. and i think anna touched on, but i also wanted to just reiterate, we suredonã­t have really the resources. we donã­t have economists to perform the kind of analysisspecific to montana that was just presented for the country in some major metropolitanareas.

so i, i will tell you that what you will hearfrom me may sound sort of basic. iã­m really talking about the burden of health disparities,but not in terms of dollars. if youã­ll advance the slide please. thankyou. no surprise here, same sources of health inequity that were mentioned in the previousslide effect our montana population, and american indians are obviously way more affected inour state. go ahead. looking at some key social determinantsof health inequities in montana, clearly american indian residents have much higher rates ofunemployment and poverty. go ahead. in terms of access to healthcare,we have a higher proportion of american indians reporting no insurance for going, healthcaredue to cost, and not having a usual healthcare

provider.on average montana american indians die 20 years earlier than our white residents.- leading causes of death in montana that you see here represent approximately halfof all deaths, and american indian residents die at a higher rate from each of them.smoking is the primary, and entirely preventable risk factor for heart disease, stroke, lungcancer, and 13 other cancers. it has adverse affects on pregnancy and on infants and childrenwho are exposed to second hand smoke. obese and lack of physical activity are major preventablerisk factors for many chronic diseases. and as you can see in this slide, american indiansexperience higher prevalence of all of these modifiable risk factors for chronic diseases.in terms of cancer incidents, lung cancer

and colorectal cancer, the rates are statisticallysignificantly higher for american indians. the breast cancer rates are not differentfor american indian women. - american indian women are screened at aboutthe same rate as white women for breast cancer, and youã­ll see, as i said in the last slide,our rates of breast cancer in that population are not different than among whites. however,american indians participate in colorectal cancer screening at only about half the rateas whites. and as was shown in the last slide, have higher rates of colorectal cancer.so we see these as the critical interventions really for chronic disease ã± tobacco cessation,risk factor management, and cancer screening. and in terms of our outreach to american indiansin some of the work that weã­re doing, we

do provide funding to every tribe and to twourban indian centers for tobacco use prevention, including youth prevention, policy work, especiallyto prevent exposure to second hand smoke, and then promoting cessation through our stateã­stobacco quit line. our cardiovascular health program works withtribes on community specific education campaigns, and those are about the warning signs of heartattack and stroke and the importance of calling 911. i think anna has presented on those campaignspreviously and i hope you had a chance to see some of the beautiful materials weã­veproduced. in addition, we work with the tribes and withindian health service to achieve systematic change in and management of blood pressureand cholesterol.

and finally, our diabetes prevention programoffers technical assistance and training to the tribes, and to our urban indian centersas well to assist them in implementing an adapted version of the nih diabetes preventionprogram. thatã­s a program that weã­ve implemented successfully in montana. we have 15 sitesup and running. and right now we are, weã­re also proud ofsome work to address a disparate group, and thatã­s our medicaid population. weã­ve receiveda medicaid incentive grant, and through that grant weã­re actually able to reimburse forthis lifestyle intervention on a pilot basis. so weã­re very proud of that work as well.in terms of cancer screening, since 1996 weã­ve been providing breast and cervical cancerscreening to low income and uninsured women

in montana. our outreach specifically to americanindian women has included our development of the montana american indian womenã­s healthcoalition and it includes representatives from all of the tribes. and i think it reallyis a key to our success having had those women help us develop the outreach to get womenscreened. weã­ve now achieved almost 20 percent of allscreenings are among american indian women. and our most recent effort we also are usingthat group to help guide our outreach, but we are now trying to move into colorectalscreening and really trying to work with the american indian population.this gives a view of the three major risk factors for poor pregnancy outcome, and youã­llsee that fully half of american indian women

enter prenatal care after the first trimester.our teen pregnancy rates are, are very high among american indian as compared to our whitepopulation, as is smoking in pregnancy. looking at some interventions that we thinkwe need to really promote to make a dent in this inequity, reducing teen pregnancy, especiallythrough promoting access to highly effective contraceptives, and promoting delay in sexualactivity, and them home visiting programs for high risk families.weã­re working with two tribes to implement teen pregnancy and sti prevention curriculain middle schools and high schools, and this is through a fairly new grant, so we reallyconsider this to be new and pilot projects. the curricula weã­re suing are called drawthe line and respect the line for middle schools,

and then reducing the risk for, for high school.and in addition to that our human and community service division is providing grants to everytribe that supports services for parenting teens. and we think these services are importantnot just in terms of supporting the current situation and providing much needed services,but also in terms of prevention and affecting outcomes of subsequent pregnancies.our outreach to american indians through home visiting, weã­ve provided funding to everytribe for development of community specific home visiting programs. right now those communitiesare developing community based coalitions and really trying to connect the dots amongall of the various service providers and create a system of home visiting in communities.and we expect that those programs will promote

smoking cessation and early entry into prenatalcare. then finally, looking at communicable diseasein montana, the reported incidents of chlamydia is higher among american indian residentsthan whites, although we are very sure that part of the difference is due to aggressivescreening among american indian providers. the overall incidents of gonorrhea of courseis lower than chlamydia; however, american indians have higher incidents rates than whitemontanans. the interventions that we promote are screeningand early detection, of course, case investigation, contact tracing, and treatment, includingpartner delivered patient therapy. and our work really has involved close workwith tribal health departments and indian

health service units on screening, contacttracing, and treatment with the goals of preventing spread and serious long-term complications.in terms of childhood immunizations, our vaccine for children program provides three vaccines.we have some good news here. our tribal clinics actually have higher, in our clinic reviews,actually have higher up to date rates with 68 percent of children fully immunized comparedto statewide rate of 52 percent. so work to do all the way around, but the tribal clinicsactually are doing better than the clinics serving the general population.so finally, just some conclus-, conclusions here. american indian residents obviouslyexperience more barriers to improved health. we think that our effective outreach activitieshave been those that have involved the community

and have been community based in terms ofdelivery and where we have tried to use proven effective interventions. weã­ve had a lotof help from anna over the last five years, a lot of leadership, and i think what sheã­staught us is that we are going to be most successful if this work isnã­t assigned toan office of american indian health, or an office of minority health, but rather whenitã­s integrated into the work of all of our programs and becomes everyoneã­s responsibility.so thatã­s kind of the, the situation in montana and just a few highlights of what weã­re doing.great. well jane and anna, thank you very much for your presentation. youã­ve reallybrought to life the data and research that dr. smedley was talking about, but reallybringing it to life at the state and tribal

level speaking about the challenges as wellas successful implementation on many of the programs, so, which is quite encouraging.so next for our, our last speaker we will now turn to john auerbach, and john was appointedmassachusetts commissioner of public health in april 2007. under his leadership the departmentdeveloped new and innovative programs to address racial and ethnic disparities, to promotewellness, to combat chronic disease, and support the successful implementation of the stateã­shealthcare reform initiative. prior to his appointment as commissioner,john was the executive director of the boston public health commission for almost a decade.in that role he was noted for groundbreaking work toward the elimination of racial andethnic disparities, implementing one o the

nationã­s strongest tobacco controlled bans,and initiative citywide asthma, cardiovascular, and cancer programs.and finally, john has led the asthoã­s presidentã­s challenge, which was focused specificallyon health equity, took place in 2010 and 2011, obviously demonstrating a longstanding commitmentto this issue. so with that, i will turn it over to john auerbach, commissioner of massachusettsdepartment of public health. thanks very much terry. iã­m going to quicklygo through sli-, the slides i have, and what iã­m going to try to do is just highlightsome suggestions for those of you who are on the call that are wondering where to beginin terms of making the economic case beginning to make, or beginning to make health promotiona priority within your department.

weã­re all strapped for resources now, soiã­ve tried to make some suggestions about activities that are relatively easy to doeven in difficult economic times. next. i think we all should just be really preparedto know the data very well that reinforced the fact that the health disparities exist,and the next few slides are just examples of that from massachusetts. you can go throughthose pretty quickly. they just are, the ones ã± and next one, and, and third.and those are just every state has some version which illustrates the disparities. itã­s,itã­s great if the - thereã­s a special publication that you can put out that pulls those out,focuses on them, and draws people attention to them, and also just makes it part of theroutine discussions within the departments

about the very specific data that begins tolay the groundwork for putting the other pieces together of making the economic case. so havingthe data at your fingertips. next. we, we make the case in our state that workingon the issue of health equity is really a data driven approach. itã­s based upon ourprioritizing those areas where we know thereã­s an unfair or a heavier burden of disease andpremature death. and so we need to look at all areas where that may exist. next.and so in addition to looking at the areas of race and ethnicity where we know the dataare clear, weã­ve also identified that there are other variables we should be mindful of.this, this is the chart that just illustrates how education, educational levels sometimesalso relate to healthcare disparities. next.

and this chart illustrates people with disabilitiesare at greater risk for a variety of different health factors not directly related to theirdisability. and there are other populations as well, gobt populations, for example, weã­reweã­ve seen a pattern of, of issues related to disparities. next.letã­s see. next, so next please. so, so i would say the next step in terms of makingthe economic argument is really taking a bit of a look at whatã­s behind some of thosedisparities and, and trying to find local data to do that when possible. this was anindication that poverty is often strongly correlated with certain health indicators.this found, for example, that our analysis of people with diabetes in massachusetts isthat people who are poor in massachusetts

were more than three times as likely to bediagnosed with diabetes. next. and then we, we found this correlate alsowith education. this often is confounding and making even more intense the disparitiesassociated with race and ethnicities. next. and then we, weã­ve tried to gather very specificcommunity based examples of the kind of place based factors that dr. smedley was referringto doing sometimes many studies that look at where fast food restaurants are, wherestores that sell fresh fruits and vegetables are located so that we can draw on specificand concrete local examples. there also are other types of groups, includingplanning organizations and economic organizations that sometimes gather data that are relevantto our drawing into our health analysis. next.

one area that often i think is overlookedinvolves data regarding employment statistics, and weã­ve worked well with our occupationalhealth and surveillance team at our department to try to identify areas where there are workrelated disparities that exist. i think thatã­s sometimes overlooked, but itã­s very muchrelated to looking at the social determinants of health, and this is just one indicationwhere this, this particular chart of where we saw greater, much greater fatalities thatwere work related among latinos in the state. next.and then of course we shouldnã­t lose track of the fact that their access to healthcaremakes a difference too. this is, these are national statistics which just to illustratethat thereã­s a much higher percentage of

people who are uninsured among the black,hispanic, and asian populations. theyã­re the ones indicated here. next.whenever possible itã­s good for us to gather information that illustrates that discriminationitself is a factor in peopleã­s lives. thereã­s a growing body of written material and publishedmaterial, including the article thatã­s listed in this slide, which makes the case that thereis, we can demonstrate a relationship between discrimination related stress in peopleã­slives and physiological differences that lead to a variety of different health factors.we also know that some specific injuries are related to discrimination, such as violence,and that certain behaviors that are coping mechanisms in response to discrimination canalso create health problems such as tobacco

use or substance use. so wherever possiblefactoring in the impact or discrimination is good.so the next few slides just illustrate where to begin, where in addition to gathering thisdata. next. next. you know i think our departments donã­t oftenreflect the diversity of the race and ethnicities of the populations that we serve. clearlyhere in montana with the changes that have been made there and how that has been a bigfactor in crafting policies that are effective. so whenever possible, having diverse leadershipin our departments that reflect the diversity and diverse leadership at all levels and notjust in some specific areas that focus on say racial and ethnic disparities. next.and then simply speaking out on it, speaking

out on the issue i think is critical in usingthe bully pulpit where possible. many departments, including our own, have set up offices ofhealth equity at high levels so that they can help to influence policy and not be pigeonholed in certain but particular segments of the department. next.one of the easiest things to do is to publish a quick study using data you already haveon disparities and just pulling it out. this has been helpful in our state and other statesi know for drawing the attention of the policy makers. next.and that, this is just another example of where weã­ve, weã­ve developed that kind ofapproach. next. the federal class standards, the culturallyand linguistic appropriate standards are definitely

something we can take advantage of. weã­venow incorporated a requirement around class standards in all of our contracts, and thatã­shelping to ensure that services are provided in a more appropriate manner. next.the next slide focuses on whenever possible providing specialized funding. thatã­s moredifficult. there are some great examples where funding has recently become available, forexample, in, in those areas where community transformation grants have been received.those allow a real focus on the social determinants of health, the conditions in peopleã­s lives,and trying to alter those conditions so that theyã­re less likely to contribute to thehealth risks that people face. the notion of health in all policies alsodoes mean that whenever possible i think we

should be thinking about training our staffor freeing them up so that they can work in other sectors, whether those sectors be attendingmeetings on transportation planning, working with the school department, sometimes eveneconomic development in order to try to have a, an impact on policy development as it occursin those other sectors. not easy to do, but, but part of what the challenge is if weã­regoing to recognize that community factors and work factors, and school, what happensat schools all contributes to peopleã­s health. itã­s important as a way of shifting our attention.next. just other inexpensive things to do are localscreenings of such things as unnatural causes. those can be done quickly and quietly, quicklyand inexpensively in community settings. next.

and from a cost effective perspective we arenow challenging our program people to only do media campaigns that really target thepopulations that are at highest risk for the different health concerns. we, we have foundthat it hasnã­t been cost effective to do population wide campaigns when what weã­rereally trying to do is reach the populations that are at greatest risk within that largergeneral population. and so weã­ve, weã­ve increasingly moved awayfrom general population campaigns to ones that are specifically crafted to reach a certainpopulation in terms of language, cultural image, etcetera next.and, and you know we, there, regardless of what happens with the supreme courtã­s decisionaround the affordable care act, i think weã­re

all going to be seeing many more experiencesto, where insurance opportunities may occur. and in terms of efforts around expanding insuranceopportunities, thatã­s an area where we can either see greater disparity result if, or,or we can close the gaps. weã­re happy ã± weã­ve seen in massachusettsthat weã­ve closed, as you can see from this chart, weã­ve significantly closed the gapbetween those who are insured and uninsured among the white and the black population wherepreviously the black population was significantly more likely to be uninsured. however, we havenã­tclosed it with regard to the latino population. their uninsured rate has gone down, but thegap still exists. so thatã­s an example where we, we want tocontinue to focus some specific targeted attention

with department of public healthã­s involvementin doing outreach to latino populations determining what are the factors that contribute to thecontinuing gap, and then helping to close those.and then finally, all of these different factors come together to take the kind of presentationthat dr. smedley presented as the broader philosophical perspective for us to embrace,but allowing us to adapt those arguments so that they reflect the specific conditionsin our own communities and we can make sure that weã­re making those arguments in concreteand specific ways that resonate with our residents as well as our policy makers.thanks. great. john, thank you very much for thatpresentation, for the several examples demonstrating

the importance of collecting data, understandingthe data that we have, and using the data to make the case, as well as several examplesof programs, concrete strategies, targeted specific interventions.iã­d like to thank everyone for your thoughtful presentations, all of our presenters todayon this very important topic. and now iã­d like to open up the floor for questions fordiscussion with our speakers. operator, would you please deliver instructionsfor us. certainly sir. ladies and gentlemen, if youwould like to register a question please press the one followed by the four on your telephone.you will hear a three toned prompt to acknowledge your request. and if your question has beenanswered and you would like to withdraw your

registration, please press the one followedby the three. once again, to register a question pleasepress the one followed by the four. and one moment please for our first question.as a reminder ladies and gentlemen, if you would like to register for a question pleasepress the one followed by the four. just while weã­re ã±i do indeed have a question on the line sir, just one moment please.okay, great. and our first question comes from the lineof george. please go ahead. male: thank you. iã­m in albuquerque, newmexico, and i think weã­ve got really good data that shows the health disparities andthe health inequities, but we donã­t have

a really good way to tie those health outcomesto dollar amounts to try to describe at a local level what the economic costs are orwhat the economic losses are, or the economic consequences. iã­m just looking for a littlebit of guidance on how we could, is there some kind of a formula we could use, or wherecould i look for more resources to try to tell the economic story locally?so weã­ll turn that over to our presenters. if any of you would like to address the questionin new mexico. well, hi, um, this is john. you know i, oneway that weã­ve approached that is weã­ve tried to whenever possible take advantageof our medicaid data. so for example when weã­ve looked at, weã­ve looked at the costof treating a person with full blown diabetes

for a year, and then when weã­ve, so we, weutilized that dollar amount, and then look at the gap in terms of the disproportionatenumber of cases of diabetes in say the black community we can quantify those cases andthen try to project out the added expenses related to the number of cases that existbecause of the gap, and if the gap was closed how many fewer cases there would be.itã­s just one example. itã­s a crude, itã­s a crude way of doing it, but it, but it doesillustrate that there are specific costs associated with the specific illnesses where the disparitiesare particularly notable. dr. smedley, is there anything youã­d liketo add to that given some of the similarities. no, i think thatã­s an excellent suggestion.so greetings george to you and the folks out

there. i think also we, we do obviously everybodyon the call understands the need for quantitative data, but i also think itã­s important notto overlook qualitative or even anecdotal stories. these can be powerful from, for example,a small business owner who has high rates of absenteeism due to health inequities, orfamilies themselves that are hurt by the poor health of a breadwinner.so i would add that in addition to the great suggestion that john offered that sometimesthe powerful stories or examples can be helpful as well.operator, other questions? we do indeed have another question sir. mynext question comes from the line of laguanta. please go ahead.female: hi, thank you. thank you all. my name

is laguanta smalley and iã­m calling frommaryland. i have a question for the panel. thank you ms. sorrell, anna, for pretty muchbeing a cultural broker for the indian population in your state, but iã­m just curious how othersor how do you all in montana and massachusetts incorporate cultural brokers or communityhealth workers who help facilitate the work that you do for your state and/or to bringback feedback from your consumers of course for quality improvement efforts to improvehealth equity situations in your state? a. whiting-sorrell- so this is anna, and ithank you for your kind words. you know when youã­re dealing with tribes the most importantthing that you can do is understand who in the community is the gatekeeper. and thosegatekeepers are very different in different

programs and, you know, so you canã­t justsay well if you go to community health reps or the tribal health director theyã­ll getyou the information. you really have to have your feet on the ground and spending timethere. you know i, i, because montanaã­s a very,very big state sometimes you will fly in and spend two hours and then fly out. when yougo and spend three days you get enough information and people will share things with you thatyou would never get if you made five trips at two hours a day, or two hours at a time.and i think that thatã­s really important when youã­re, when youã­re, when youã­re workingwith a community that has very unique cultural differences, different languages, differenttypes of governments. and so getting to understand

who are the gatekeepers and building a relationshipwith them. this is john. i would, i think thatã­s a great,that annaã­s suggestions, observations are really excellent. i also would, i appreciatethe question, the question mentioning community health workers, because we really have seenthat community health workers where the health workers represent the communities weã­re tryingto reach can be critical brokers and leaders in terms of having an impact on health.the dilemma that we found over time is that there, there, community health workers tendto be grant funded and so itã­s, itã­s difficult for us to have enough of them to do the kindof work thatã­s necessary. and often theyã­re grant funded with categorical or disease specificapproach when a broader approach to the health

of the population that the community healthworker is involved in would be, would be preferable. so weã­re taking some steps in our state tosee if we can expand opportunities to actually make community health workers a part of thereimbursement system as we move to, away from fee for service to more global payments andanticipating accountable care organization approaches.we are encouraging providers to think about the common and regular use of community healthworkers, and weã­re creating a statewide board of registration for community health workerswith specific curricular and training so that we can guarantee that when pe-, when theyare hired thereã­s a level of training and professional knowledge that will be useful.and we think that expanding, expanding their

availability and usage as members of the publichealth and clinical teams will help to overcome some of the cultural barriers that the questionerwas mentioning. female: thank you.thank you john. other questions? our next question comes from the line of gail.please go ahead. female: yes, this question is, my questionis for each of the panel members, but in particular dr. smedley. you gave a great example of thehousing and urban development moving to opportunity demonstration program. and iã­m wonderingif there are some other really long term health outcomes when an intervention has addressedat least one or more social and economic factors. thank you for that question. thatã­s a greatquestion. you know in talking about potential

intervention strategies like moving to opportunityor other housing mobility strategies i think itã­s important that we contextualize it.that these strategies in and of themselves are not likely in my view to be particularlyeffective unless theyã­re also accompanied by other comprehensive investments.so in general we call for two broad categories of interventions to address segregation andhigh levels of poverty concentration and their effects on health and human development. oneare people based strategies. in other words, housing mobility strategies to help thosewho would like to move out of communities that are suffering from disinvestment. butwe think that has to be accompanied at the same time by place based investments. thekinds of examples that i provided earlier,

for examples strategies to attract vendorsselling healthy foods into food deserts, efforts to reduce environmental degradation in communitiesof color, efforts to improve the quality of housing and transportation, efforts to improveaccess to spaces for recreation and play. all of these strategies should be employedsimultaneously as part of a comprehensive multi pronged strategy. the challenge of courseis in assessing the return on investment, but we think that that return is likely tobe much stronger when we realize that potential synergistic effects of all of these strategiesbeing implemented simultaneously. the other reason, of course, to look comprehensivelyand not just to focus on housing mobility is that many metropolitan communities areseeing significant demographic shifts. some

communities are experiencing significant gentrificationwhile other communities are experiencing growing concentration of poverty.so in order to ensure that we donã­t inadvertently advantage some and disadvantage others wethink itã­s important to employ both people based and placed based strategies at the sametime. thank you dr. smedley. additional questions?and our next question on the line comes from the line of amy. please go ahead.female: yes, my name is jamie and i work on a five year grant, on a diabetes grant, andmy question is as part of our grant we are to work with the state diabetes preventionand control programs. what is the best way to facilitate or establish the relationshipsbetween the state health departments and the

native communities within their state?anna or john, turn that one to you. a. whiting- this is anna. and what i wouldrecommend is is that you go there and you take time to figure out what are the cultural,what are the cultural protocols of that particular community, and then you honor them. but youreally, really have to spend the time with your feet on the ground.john or jane, anything youã­d like to add to that?no, i, i think anna, annaã­s experience really, sheã­s the expert in terms of building thoseties, and i think her guidance is sound, is the best.right on the money. additional questions? as a reminder ladies and gentlemen, if youwould like to register a question please press

the one followed by the four.iã­m thinking we might have time for one or two more questions and then weã­ll need toclose out in respect, or out of respect for peopleã­s time.certainly sir. we do indeed have a question on the line. one moment please.okay. and our next question comes from the lineof candace. please go ahead. female: hi. this is candace. my question isiã­d like, iã­m sorry, iã­d like to start by thanking everyone for their presentation,and then ask as a person who is coming up in the health disparities field and lookingforward in terms of training, there seems to be a lot of kind of interdisciplinary happeningin the field and i wanted to get everyoneã­s

kind of advice on how individuals should trainin terms of whether it be formal education or informal opportunities like webinars goingforward in health disparities work. great question. panelists?well this is brian. i would just say that your, thank you for your excellent observation.the field is definitely moving toward interdisciplinary and cross sector collaboration. this is criticallyimportant. and i know in the work that we do here at the joint center cross sector collaborationwe see as being critical. itã­s sort of step one in advancing community based equity work.i would say that both formal as well as any informal training opportunities are important,but it may be that there is no better training than actually getting on the ground and rollingup your sleeves communities. and so i couldnã­t

suggest any particular interdisciplinary trainingprogram, but i just think that there are many opportunities both formal and informal, andparticularly opportunities to learn from and work directly with communities.the major initiative that we run here at the joint center, place matters, thatã­s the coreto the work that we do and would encourage you, you could visit our website at www.jointcenter.org,or others iã­m sure, astho has pertinent information as well as naccho has some excellent resourcesfor learning about and training. in fact i think the nacho health equity training curriculumis excellent and you might want to look at that as well.thank you dr. smedley. and candace, i think i will use your question and that answer toactually close us out by saying thank you

for your interest in this field.and i think what weã­re seeing, and certainly is clear from the presentations that therewill be, there needs to be and there has to be incredible growth in their area in ourunderstanding and implementation of programs to eliminate health inequality in our country.and as we heard from dr. smedleyã­s report, we must bend the health curve, healthcarecost curve in our country. itã­s not sustainable as it is. and in fact our economic growthis entirely dependent on our ability to do that when you look at the numbers associatedwith lost productivity. we have several examples of programs thatmake a difference from jane and anna, and john, and often we get that question thatjohn posed, which is where do we begin. there

are many, many places where we can begin,sometimes in small steps, but know that big steps will be necessary to close the gapsthat exist today. i would like to close out by thanking theassociation of state and territorial health officials, astho, who is working very closelywith the u.s. department of health and human services office of minority health, as wellas the center for disease control and prevention, cdc. all three of those entities working togetherto make this webinar possible today. if you have any question, and we have otherpeople on the line who were not able to ask their question, i would encourage you to contactmeenoo mishra, spelled m-e-e-n-o-o, mishra, m-i-s-h-r-a, who is the senior analyst ofhealth equity at astho. you can go to the

astho website and contact her through thatwebsite. if you have any questions weã­ll do our best to get an answer to you. and appreciateeveryoneã­s interest in being on the webinar today.and with that, we will close out our webinar. thank you very much for your participationtoday. ladies and gentlemen, that does conclude thewebinar for today. we thank you for your participation and ask that you please disconnect your line.[end of audio]