O P P O R T U N I T I E S F O R A D V A N C E M E N T

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PUBLIC HEALTH IN TEXAS:

O P P O R T U N I T I E S F O R A D V A N C E M E N T

Texas Health Institute

2012

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Welcome to Public Health in Texas

Welcome to the challenging and rewarding world of public health in Texas. Originally published in 2010, this public health primer is a resource for anyone who wants to learn about public health in our state.

Public health is our “invisible guardian.” Everyone in Texas is dependent upon a cadre of

professionals throughout the state and nation who ensure safe drinking water, food and air, and who conduct a number of essential services to prevent disease and create environments to enable Texans to have healthy choices. However, we need an educated population to form public-private partnerships that accomplish this work in Texas.

This updated edition of the primer contains updated statistics, relevant public health issues and challenges, and presents options for solutions. We have collected evidence-based ideas that work, as well as advocacy agendas that coalitions of Texans and their organizations have tailored to address current and projected needs.

This publication intends to be a dynamic document that will continue to be updated and

republished every two years. It is a work in progress. We need your comments, ideas, suggestions, and updates to make this primer as relevant as possible.

Texas Health Institute (THI) is a statewide nonprofit with the mission to improve the health of Texans and their communities. THI thanks Methodist Healthcare Ministries of South Texas, Inc., for partnering and underwriting this project. Methodist Healthcare Ministries (MHM), based in San Antonio, is a faith-based, 501(c)(3), not-for-profit organization providing care through health-related programs and services to the least served throughout Texas. MHM also partners with other established organizations that are fulfilling the needs of the underserved in local communities. It supports policy advocacy and programs that promote wholeness of body, mind, and spirit. THI was fortunate to work with Sarah Monks, a 2012 program intern, who provided valuable research and writing support for this updated primer.

As Peter Drucker said: “The best way to predict the future is to create it yourself.” Please join THI’s efforts to improve the health of Texans and their communities.

Sincerely,

Camille D. Miller President & CEO

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INTRODUCTION

Our state is rich in natural resources, people being the most valuable and important resource of our future. For Texas to remain competitive with other states and nations, it is essential that we protect and sustain our people resource by making it possible for Texans to be as healthy as possible. Improved health leads to economic growth because healthy people are more productive.1

Medical care contributes to only 10 percent of an individual’s health status.2_{Our lifestyle, including}

smoking, eating, exercise, alcohol and substance use, accounts for 51 percent of our health status, the environment 19 percent, and human biology or our genetic makeup, the remaining 20 percent. With this knowledge about the “determinants of health,” (medical care, lifestyle, environment and genetic makeup) we must advance the health of Texans and our communities by improving both the healthcare system and the public health system. We must prevent disease and create

environments that enable Texans to adopt healthy behaviors; in other words, make healthy choices the easy choices. Complex conditions like childhood obesity cannot be solved by healthcare alone. Personal and community engagement efforts are required to focus on access to nutritious foods and participation in physical activity.

To advance public health, it is essential that attention is brought to all aspects of society that contribute to unhealthy living conditions such as: pollution, occupational hazards, substandard housing and inadequate basic education. In an increasingly diverse state, it is important to address the differences in the presence of certain diseases, health outcomes, and access to quality health care across racial, ethnic, and socioeconomic groups. Collaborating to improve these aspects has the promise of reducing health disparities that exist between socio-economic, geographic, racial and ethnic groups in Texas, thus improving the health of Texans.

This primer provides an overview of the public health system, its functions and its challenges, and proposes ways that the public health infrastructure can be strengthened. Additionally, by offering challenges and options for solutions, we hope to stimulate dialog and action to improve the health of Texans and their communities.

1

Stevens P. (2005) The Real Determinants of Health. London, United Kingdom: International Policy Network.

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WHAT IS PUBLIC HEALTH?

When it works well, public health is largely invisible. Public health practice ensures safe drinking water, food, and air. Public health practice works to design and engineer environments that are safe, and protects our communities from diseases such as diphtheria, measles, tetanus, smallpox, tuberculosis, syphilis, hepatitis, rabies, salmonella, botulism, malaria, shingles and many other preventable diseases. Public health creates an environment that enables people to adopt healthy behaviors; in other words: making the healthy choice the easy choice.

According to the Institute of Medicine, public health is “what we, as a society, do collectively to assure the conditions in which people can be healthy.”3_{Public health is the science of protecting and}

improving the health of a community through education, promotion of healthy lifestyles, environmental interventions and clean-up, and disease and injury prevention measures.

In 1995, the Public Health Functions Steering Committee co-chaired by David Satcher, M.D., Ph.D., then Surgeon General and Assistant Secretary for Health, United States Department of Health and Human Services, issued this Public Health in America Statement describing public health and its key functions:4

Vision: Healthy People in Healthy Communities

Mission: Promote Physical and Mental Health and Prevent Disease, Injury, and Disability Public Health

 Prevents epidemics and the spread of disease,  Protects against environmental hazards,  Prevents injuries,

 Promotes and encourages healthy behaviors,

 Responds to disasters and assists communities in recovery, and  Assures the quality and accessibility of health services.

3

Institute of Medicine (IOM). (1988). The Future of Public Health. Washington, DC, USA: The National Academies Press.

4

Public Health Functions Steering Committee. (1994). Public health in America statement. Retrieved October 21, 2009, from http://www.health.gov/phfunctions/public.htm.

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THE 10 ESSENTIAL PUBLIC HEALTH SERVICES

The Public Health Functions Steering Committee appointed by the US Department of Health and Human Services also outlined ten services that are essential for the public health system to provide. These essential services provide the foundation for the nation’s public health strategy, including Healthy People 2010 objectives for public health infrastructure and the development of National Public Health Performance Standards for state and local public health systems. In 1999, the Texas legislature passed HB 1444 (Representative Dianne Delisi and Senator Mike Moncrief) that defined and set a strategy for implementing the ten essential public health services in Texas. These

essential services, as defined for Texas, are:5

1. Monitor the health status of individuals in the community to identify community health problems,

2. Diagnose and investigate community health problems and community health hazards, 3. Inform, educate, and empower the community with respect to health issues,

4. Mobilize community partnerships in identifying and solving community health problems, 5. Develop policies and plans that support individual and community efforts to improve

health,

6. Enforce laws and rules that protect the public health and ensure safety in accordance with those laws and rules,

7. Link individuals who have a need for community and personal health services to appropriate community and private providers,

8. Ensure a competent workforce for the provision of essential public health services, 9. Research new insights and innovative solutions to community health problems, and 10. Evaluate the effectiveness, accessibility, and quality of personal and population-based

health services in a community.

TABLE 1: Differences Between

Public Health and Medical Care

PUBLIC HEALTH is

primarily proactive preventive and wellness (before disease also called “upstream”)

– Focuses on health status of populations

– Emphasizes prevention and health promotion – Prevents disease

exposures and injuries – Reduces the need for

medical care

MEDICAL CARE is primarily

acute and chronic care (when disease, also called “downstream”)

– Focuses on clinical improvement of individual patients

– Emphasizes diagnosis and treatment

– Addresses how better to treat individuals already exposed to diseases or injuries

– Improves the capabilities of medical systems to save lives

5

House Bill 1444, Seventy-sixth Legislature, Regular Session (1999), Bill files, Texas Legislature. Archives and Information Services Division, Texas State Library and Archives Commission.

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PUBLIC HEALTH & PREVENTION

Disease and injury prevention is fundamental to effective public health. Prevention includes activities undertaken to decrease or eliminate the risk of a disease or to alleviate the effects of disease once it has occurred. Public health and traditional medical care share the responsibilities of disease prevention, but retain unique points of intervention.6_{Public health practitioners use a}

proactive approach to prevent or postpone the onset of disease or injury. On the other hand, medical providers typically treat disease and injury after a diagnosis. Examples of prevention include disaster preparedness planning, nutrition standards and physical education in schools, health education, promotion of healthy behaviors, and immunizations.

DETERMINANTS OF HEALTH & CAUSES OF DEATH

Many factors influence individual and community health. Lifestyle factors have the greatest

influence on health, with social and economic environment, physical environment, medical care and individual characteristics also contributing. The determinants of health lead public health to develop “upstream” interventions that prevent the onset of disease. This is different from the traditional medical model that treats disease once it has occurred, i.e. “downstream”. Figure 1 illustrates the determinants of health and their contribution to the overall health of individuals. It shows us that 70 percent of the determinants of health can be directly influenced by public health interventions. Figure 2 demonstrates the relationship between the determinants of health and actual causes of death.

Figure 1: The Determinants of Health

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9 Figure 2: Actual Causes of Death7

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EXAMPLES OF PUBLIC HEALTH ACTIVITIES

DISEASE SURVEILLANCE: FIRST LINE OF DEFENSE

Our first line of defense against acts of bioterrorism, epidemics, food-borne illness and other disease based emergencies are state and local governments. State legislators are committed to enhancing their states’ ability to prepare for and respond to these events.

Disease surveillance is:

 Systematic collection of important health information,  Organization of data into patterns,

 Analysis determining trends and clues for control or prevention, and

 Dissemination of information to health care professionals, policy makers, and the general public.

Over 80 reportable conditions exist that must be reported to local or regional health departments. These include:

 Acquired immune deficiency syndrome (AIDS),  Anthrax,

 Asbestosis,

 Botulism (food borne),  Malaria,

 Measles (rubeola), and

 Staphylococcus aureus, vancomycin resistant.

Disease surveillance is important to the health of a community through:  Understanding the distribution of disease in the community,  Assessing the impact disease has on the community,

 Targeting prevention efforts to reduce disease in the community,

 Implementing control measures to minimize spread of disease in the community, and  Enabling people to make daily decisions impacting their health.

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HEALTH BEHAVIOR AND EDUCATION

Behavioral science and health education focuses on ways that encourage people to make healthy choices, including the development of community-wide education programs that promote healthy lifestyles and gathering data on complex health issues.

Examples include:

 Stopping the spread of sexually transmitted diseases, including herpes and HIV/AIDS,  Helping youth recognize the dangers of binge drinking,

 Promoting tobacco use cessation,

 Helping youth and adults recognize the importance of physical activity and eating nutritious foods,

 Prompting access to behavioral health services (mental health and substance abuse), and  Promoting seatbelt use.

Public health educators encourage people to make healthy choices by developing educational programs that promote healthy lifestyles and prevent disease and injury. They promote more efficient uses of health services, adoption of self-care practices, and active community participation in the design and implementation of health programs.

BEHAVIORAL HEALTH

Behavioral health is integral to overall health and can influence the onset, progression and outcome of other illnesses. Behavioral health often correlates with health risk behaviors such as substance abuse and physical inactivity, Mental health and substance abuse are collectively labeled behavioral health. The public health system addresses behavioral health promotion through chronic disease prevention efforts, surveillance and research to improve the evidence base on mental health and substance abuse. In addition, public health collaborates with partners to develop comprehensive behavioral health plans to enhance coordination of physical and behavioral health care. This is also referred to as “integrated health”, i.e. the recognition of the need to address the mental as well as the physical health of all people.

ENVIRONMENTAL HEALTH

Built and natural environments influence our health through factors such as air quality, water purity, human genetics and social surroundings. Focus areas in environmental health include:

 Air quality,

 Environmental control of recreational areas,  Food protection,

 Hazardous waste management,  Housing quality,

 Noise control,

 Radiation protection,  Solid waste management,

 Vector control (e.g. spread of disease by mosquitoes or rodents), and  Water quality.

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MATERNAL AND CHILD HEALTH

Professionals in maternal and child health improve the public health delivery systems specifically for women, children, and their families through advocacy, education, and research. State health departments administer Title V of the Social Security Act, which provides block grant funds to improve access to maternal and child health services, reduce infant mortality, improve immunization rates, support children with special health care needs, and implement other programs consistent with national maternal and child health priorities.8

In Texas, maternal and child health services provided through the Department of State Health Services include:

 Adolescent health,

 Children with special health care needs services,  Dental services and oral health,

 Family planning,  Audiology services,

 Newborn blood spot and hearing screening,  Perinatal and women’s health services,  School health,

 Vision screening, and

 Women, Infants, & Children (WIC) services.

NEWBORN SCREENING

State health departments partner with local hospitals, birthing centers, and health care providers to implement newborn screening programs that test all infants in the state for specified genetic diseases that, if detected early in life, can prevent severe disability or death. The Texas newborn screening program includes more than the required laboratory testing. Newborn screening programs also provide follow-up services and education to providers and the public. Providers partner with the Department of State Health Services to diagnose, treat, and manage the disease over the child’s life.9

Texas currently screens all babies for 29 endocrine, immune, hemoglobinopathy, and metabolic disorders, and for hearing loss. Improved laboratory technology, specifically the implementation of Tandem Mass Spectrometry for newborn screening, has enabled state newborn screening

laboratories to detect more diseases with relatively little increased cost to the laboratory. Although the costs to the laboratory may be minimal, expanded screening of newborns does require that the state health department have greater capacity to follow-up with those babies positively detected for a disorder, both in the short- and long-term. HB 1795 (Pierson, et al) required the newborn

screening program to include tests for 25 additional disorders, designated as the secondary panel by the American College of Medical Genetics. At present, the Texas newborn screening program does not screen for these secondary targets because funding has not been appropriated for such an expansion.

8_{Trust for America’s Health and Robert Wood Johnson Foundation. (2009, July). F as in fat: How obesity policies are failing in}

America. Washington, DC: Author

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Watson, M.S., Lloyd-Puryear, M.A., Mann, M.Y., Rinaldo, P., and Howell, R.R. (2006). Newborn screening: toward a uniform screening panel and system [Electronic Version]. Genetics in Medicine, 8(5, supplement), 12S-252S

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NUTRITION SERVICES

Public health nutrition promotes healthy eating and regular exercise, researches the effect of diet on the elderly, and teaches the dangers of over eating and over dieting. This field examines how food and nutrients affect the wellness and lifestyle of a population. Nutrition encompasses the combination of education and science to promote health and prevent disease. Texas state and local health departments also administer the WIC program, which provides nutrition education and counseling, nutritious foods, and assistance in accessing health care to low-income women, infants, and children.10

PANDEMIC AND ALL HAZARDS PREPAREDNESS

The U.S. public health system has defined clear goals for emergency preparedness and response since the terrorist and anthrax attacks in the fall of 2001. The objective of emergency preparedness is to improve the nation’s ability to detect and respond to public health emergencies including bioterrorism, emerging infectious diseases, and natural disasters. It also includes new initiatives for the rapid development of biological interventions (e.g. vaccines, drugs) for highly pathogenic influenza or other health hazards. The public health preparedness system was tested in the spring and fall of 2009 when the H1N1 influenza virus spread throughout Mexico, the U.S., and the world. While there were three deaths in Texas, this is far less than would have occurred had public health interventions not been deployed. Preparing for health and medical emergencies, both natural and man-made, is a continuous challenge for Texas given its proximity to “hurricane alley,” and the number of critical infrastructure and commercial interest targets located inland and along the Gulf Coast.

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Texas WIC. (2009). Texas Department of State Health Services. Retrieved October 22, 2009, from http://www.dshs.state.tx.us/wichd/.

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IMMUNIZATIONS

Immunizing the population is one of the most cost-effective solutions for preventing morbidity and mortality and protecting children and adults against many serious and potentially fatal diseases.11

By preventing the spread of these deadly diseases through immunizations, society can save resources that would be spent on medical treatment, quarantine and loss of productivity. Effective vaccine campaigns have eradicated diseases such as smallpox globally and eliminated polio from most countries.

Table 2 below shows the which immunizations are recommended for children, college students and adults.

Table 2 Recommended Immunizations by Age Group

Children. Aged 0-18 Yrs.

Diphtheria Measles

Tetanus Mumps

Pertussis Rubella

Polio (IPV) Hib

Hepatitis B Varicella Hepatitis A Pneumococcus Influenza Rotavirus College Students Tdap MMR HPV Hepatitis B Meningococcus Varicella Influenza Polio Hepatitis A Pneumococcus Adults Influenza Varicella Hepatitis B MMR Diphtheria Tetanus Pertussis Shingles Pneumococcus

11_{Centers for Disease Control and Prevention. (2007). Recommended schedules for children, adolescents, and}

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THE PUBLIC HEALTH SYSTEM

The public health system involves a variety of public and private partners including, but not limited to: governmental agencies, hospitals, physicians, businesses, schools, community based

organizations and the public. Authority and responsibility within the public health system is shared among federal, state and local agencies. Figure 3 below shows the relationships between the governmental public health partners and other agencies and organizations.

Figure 3: The Multi Sector Partners in the Public Health System12

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HEALTHY PEOPLE: NATIONAL GOALS FOR PUBLIC HEALTH

Healthy People 2020 is the most recent set of national goals developed by the U.S. Department of Health and Human Services and designed to identify the most significant preventable threats to health and to establish objectives to reduce these threats.13

Updated every ten years since 1979, Healthy People sets specific and aggressive objectives for disease prevention, health promotion and improved collaboration within the public health system. Healthy People 2020 has been recognized for its work to improve quality of life, increase lifespan, and reduce health disparities. The project’s website14_{lists the Proposed Healthy People Objectives}

covering 38 topic areas.

THE STRUCTURE OF THE PUBLIC HEALTH SYSTEM

FEDERAL STRUCTURE:

At the federal level, primary public health agencies are organized under the U.S. Public Health Service in the Department of Health and Human Services (HHS). HHS includes the following agencies:

 Office of the Secretary,

 Administration on Children and Families,  Administration on Aging,

 Agency for Healthcare Research and Quality,  Agency for Toxic Substances and Disease Registry,  Centers for Disease Control and Prevention,  Centers for Medicare and Medicaid Services,  Food and Drug Administration,

 Health Resources and Services Administration,  Indian Health Service,

 National Institutes of Health,  Office of the Inspector General,

 Substance Abuse and Mental Health Services Administration, and  United States Public Health Service.

13_{U.S. Department of Health and Human Services. (2009). Healthy people 2020: the road ahead. Retrieved October 21, 2009, from}

http://www.healthypeople.gov/hp2020/.

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STATE / TERRITORIAL STRUCTURE:

Each state or territory has a health department that identifies strategies to improve the health of their population and resources needed to meet identified needs. In Texas, the agency is Texas Department of State Health Services (DSHS).

Texas Department of State Health Services:

 Receives federal, state, and private funding,

 Collects health information (e.g. vital statistics and cancer registry),

 Enforces standards, delivers health services, and provides technical assistance to local health departments,

 Conducts disease surveillance and prevention efforts (e.g. monitors tuberculosis, influenza, and other infectious diseases and intervenes when necessary),

 Ensures adequate vaccine supply distribution,  Performs laboratory testing for infectious diseases,

 Provides newborn screening services, including laboratory testing and follow-up,  Conducts health promotion,

 Ensures food and drug safety,  Inspects for environmental hazards,

 Monitors natural and man-made disaster risks, plans for coordinated deployment of public health providers in the event of a disaster, and optimizes recovery efforts, and

 Provides oversight of health care delivery systems.

DSHS works with other state agencies to jointly improve the public’s health. These partners in Texas include other agencies within the Texas Health and Human Services Commission (HHSC) enterprise:

 Department of Aging and Disability Services (DADS),

 Department of Assistive and Rehabilitative Services (DARS), and  Department of Family and Protective Services (DFPS).

Several other Texas agencies not under the Texas Health and Human Services’ Commission also impact the health of Texans, including:

 Office of the Governor,

 Texas Attorney General’s Office,  Office of the State Comptroller,  Texas Legislature,

 State Auditor’s Office,

 Texas Department of Agriculture,  Texas Commission on Environmental

Quality,

 Texas Department of Criminal Justice,  Texas Department of Public Safety,  Texas Department of Transportation,

 Texas Education Agency,

 Texas Parks and Wildlife Department,  Texas Juvenile Probation Commission,  Texas Department of Housing and

Community Affairs,

 Texas Workforce Commission,  Texas Youth Commission,

 Texas Department of Rural Affairs,  Texas Veterans Commission, and  Texas Department of Corrections.

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Figure 4: Public Health Regions in Texas

LOCAL STRUCTURE:

STATE/REGIONAL STRUCTURE

DSHS has a statutory responsibility to address the health needs of the state and DSHS contracts with local health departments to deliver many of its prevention activities. Texas law provides counties and cities authority to create a health department within their jurisdiction; however, this is not a requirement. For a list of all city and county health departments, see Appendix C.

Each Texas county is assigned to one of eleven state designated health service regions as shown in Figure 4 below.

Each region supports ongoing, diverse public health functions and operations, and delivers coordinated public health services at the local, regional, and state level.

The role of the health service regions is to:15

 Provide essential public health services that promote and protect the health of all Texans;

 Serve as the local health department for any jurisdiction without one;

 Provide support and technical assistance as needed to local health departments or local health districts;

 Conduct regional disaster planning and preparedness activities for mitigating natural or manmade chemical, biological, radiological, nuclear or explosive events;

 Coordinate regional pandemic influenza preparedness planning; and

 Participate in regional and statewide disaster (all hazards) response and recovery efforts.

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Lawson, J.D. (2006). Texas Department of State Health Services, Division for Regional and Local Health Services (PPT). Retrieved October 21, 2009, from http://www.dshs.state.tx.us/council/agendas/013008/7b_RLHS.ppt.

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CITY AND COUNTY STRUCTURE

Local public health includes city or county health departments, joint city-county departments and public health districts. In some states, local health departments are field offices of the state health department, but in most states local health departments are separate agencies. In Texas, local health departments receive state and federal funding but are organizationally and politically autonomous from Texas Department of State Health Services. The majority of their funding comes from their city or county governments.

Local departments also:

 Track and investigate communicable diseases, injuries and health hazards in the community;

 Prepare for and respond to public health emergencies;

 Develop, apply and enforce policies, laws and regulations that improve health and ensure safety (e.g. conduct restaurant inspections);

 Lead efforts to mobilize communities around important health issues; and  Link people to health services.

There is a great diversity within local health departments in Texas. Some local departments offer a full array of services, while other local health departments offer limited services.

Like local police and fire departments, local health departments are the first responders at the local level and for a wide variety of health threats. They prevent disease, promote prevention and

healthy behaviors and protect the public’s health. When the local public health agency does not have the capacity to respond, the local public health authority or county judge can request

assistance from Texas Department of State Health Services, who in turn can request expert support from federal partners like the Centers for Disease Control and Prevention.

Of the 254 counties in Texas, 140 have a health department. The eight regional offices of the Texas Department of State Health Services fill the role for the 114 counties without local health

departments:

Figure 5: Delivery of Public Health Services in Texas

 Sixty-three full-service local health departments provide basic services to approximately 80 percent of Texans.

 The eight regional DSHS offices cover all eleven public health regions provide services to the remaining 20 percent* *The Texas Department of State Health Services contracts with local health departments to provide public health services.

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Local health department directors and health authorities are collectively represented in Texas by the Texas Association of Local Health Officials (TALHO), a membership organization which conducts membership meetings several times per year. DSHS staff works collaboratively with TALHO on strategic issues relevant to the statewide public health system such as state and federal program funding, public health policy decision making, and legislation.16_{TALHO is an affiliate of the}

National Association of County and City Health Officials.

The Texas Public Health Association (TPHA) is a non-profit, state-wide association of public health professionals dedicated to public health in Texas. TPHA was organized in 1923 and is an affiliate of the American Public Health Association. TPHA’s mission is to improve the health and safety of Texas through leadership, education, training, collaboration, mentoring and advocacy.

TEXAS PUBLIC HEALTH CHALLENGES AND SOLUTIONS

The size and diversity of Texas provides a challenge to the delivery of public health services. With anticipated workforce shortages and an uncertain economy, Texas faces many challenges including improvements in immunization rates, rural access to care, public health information technology infrastructure, chronic diseases, workforce strategies and other significant health concerns. The 10 essential public health services should be available to every Texan regardless of where they live, work or visit.

Funding, as well as infrastructure and workforce development, is needed to ensure that high-quality essential public health services are delivered throughout the state and accessible in every locality.

All local and regional health departments in Texas should work in partnership to accomplish voluntary accreditation. The purpose of accreditation is “to improve and protect the health of the public by advancing the quality and performance of all health departments in the country – state, local, territorial and tribal. It will be performed by the Public Health Accreditation Board, an independent national organization; but DSHS and local health departments can collaborate on developing and offering training and technical assistance to support the entities that are interested in becoming accredited.

Accreditation will drive public health departments to continuously improve the quality of the services they deliver to the community”17_{Accredited status will assist public health agencies to}

form or enhance partnerships with other accredited health facilities and to offer new services. In the future, accredited health departments are expected to have an advantage when pursuing competitive funding opportunities from the federal government or philanthropic organizations. Health Information Exchanges (HIE) between electronic health records (EHRs) and public health information systems (e.g., cancer registries, immunization registries, and reportable disease surveillance systems) are essential to public health improvements. Public health needs to be at the table to ensure that common data standards, cooperative agreements and interoperability

16

Fussell, M. (July 2006). Final CDC portfolio assessment, Texas. US Department of Health and Human Services, Centers for

Disease Control and Prevention. 17

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standards are conducive to a seamless integration of these public health systems to improve reporting and surveillance.

Texas should seek opportunities for additional resources to fund essential public health services in all areas of the state. Such opportunities may include:

 Increase taxes on tobacco, alcohol and snack foods and drinks(high caloric foods with minimal nutritional value),

 Enable local governmental entities to charge additional fees or taxes on restaurants, lodgings, and other venues requiring inspections, and

 Increase Medicaid and CHIP reimbursement rates for providers of essential public health services such as newborn screening, immunizations, preventive health care services, and behavioral health services.

Texas should promote the establishment of community collaboratives (public-private partnerships) at the local level to address specific priority public health problems and issues, e.g., obesity, mental health/substance abuse, veterans’ issues, diabetes, low education attainment and high dropout rates, substandard housing, and lack of built environment to support healthy behaviors. Funding, training, and technical assistance is needed to support these infrastructure development efforts.

PUBLIC HEALTH FUNDING

The U.S. Department of Health and Human Services, through the Centers for Disease Control and Prevention (CDC) and the National Institutes of Health (NIH), plays an important role in supporting state and local public health infrastructures. Funding support is provided through grants and cooperative agreements to state and local governments for research and technical assistance. In Texas, public health is supported through a combination of revenue streams from local, state and federal sources, as well as fee-generating programs and activities. State general revenue (GR) and local revenue directed to local public health represent the backbone of public health financing in Texas. Public health financing for local health departments across Texas at city, county, district and regional levels varies greatly, with budget composition affected primarily by population size, programs delivered and services offered.

Figure 6 below illustrates the summary of funding sources for local health departments in Texas. The data, gathered in 2005, are from a representative group of 47 Texas local health departments in Texas. The majority generate funding from local sources and receive funding from CDC grants and cooperative agreement funds through the Department of State Health Services.18

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Figure 6: Distribution of Public Health Funding, Texas19

Public health faces financial challenges as budget cuts occur at all levels of government.

Governmental agencies, hospitals, academia and health departments, to name a few, will have to strategically position themselves to be ready for funding challenges. It is important to ensure adequate funding for public health especially in tough economic times.

SOLUTIONS:

 Position the state and Texas communities for federal funding opportunities, and  Prioritize a reallocation of resources to benefit populations and communities with the

highest prevalence of chronic diseases and at high risk for developing chronic diseases.

PUBLIC HEALTH WORKFORCE

In 2000, the Health Resources and Services Administration (HRSA) estimated the public health workforce in the United States at 450,000 – 500,000 workers, including workers at the local, state, and federal levels.20_{The HRSA report estimates that there are about 18,687 public health workers}

in Texas.21_{This is approximately three percent of the total health workforce in Texas.}

19

Ibid.

20

Bureau of Health Professions, National Center for Health Workforce Information and Analysis, Health Resources and Services Administration. (2000). The Public Health Work Force: Enumeration 2000. Retrieved October 22, 2009, from

ftp://ftp.hrsa.gov//bhpr/nationalcenter/phworkforce2000.pdf.

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Bureau of Health Professions, National Center for Health Workforce Information and Analysis, Health Resources and Services Administration. (2000). The Public Health Work Force: Enumeration 2000. Retrieved October 22, 2009, from

ftp://ftp.hrsa.gov//bhpr/nationalcenter/phworkforce2000.pdf. Local (city/county) 37% Generated Fees 15% TX DSHS 27%

Other (state agency grants) 5% Other (federal/private grants) 15% Medicare/Other 1%

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Compared to the nation as a whole, Texas has a lower per capita ratio of public health workers:  U.S.: 158 per 100,000 population; and

 TX : 93 per 100,000 population.

In addition only seven percent of the Texas public health workforce has formal training and

education in public health, compared to 20 percent in the nation. 22,23_{A recent study by the Health}

Professions Resource Center (HPRC) at DSHS surveyed public health agencies and facilities to examine and estimate public health employment in Texas. The survey found significantly fewer public health workers in rural and border communities, compared to urban and non border areas. Table 3 summarizes these data. Therefore, not only does Texas have lower workforce ratios, but the public health workforce within the state is unevenly distributed between urban and rural or border and non-border communities, and is less educated and trained in public health. Table 4 shows the different types of professionals in the Texas public health workforce in Texas.

Table 3: Ratio of Providers per 100,000 Population – 2008, by geographic location24

Note: The Health Professions Resource Center (HPRC) reviewed numerous public health reports and studies from other institutions, and learned that there are many more professions that can be considered public health professions than could be covered by this project. HPRC limited the survey to just 39 professional categories: primarily those that were determined to be the most consistent with the types of professions for which HPRC routinely collect data.

22_{32 United States Department of Health and Human Services, Health Resources and Services Administration,}

http:/bhpr.hrsa.gov/publichealth/

23_{Virginia C. Kennedy, William D. Spears, Hardy D. Loe, Jr., and Frank J. Moore, “Public Health Workforce Information: A}

State-Level Study,” Journal of Public Health Management and Practice, May 1999, p.10

24

Texas Health Professions Resource Center, Center for Health Statistics. (2009). Enumerating the Public Health (PH) Workforce. Presentation at Texas Public Health Association Annual Meeting.

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Table 4:

Public Health Workforce Examples in Texas Include: • Administrators

• Biostatisticians

• Environmental Health Professionals

• Environmental Engineering Technicians and Technologists • Environmental Scientists and Specialists

• Epidemiologists • Health Educators

• Health Service Managers or Administrators • Occupational Safety & Health Specialists

• Occupational Safety & Health Technicians / Technologists • Public Health Policy Analysts

• Physicians, Nurses, Dentists, Dental Workers, School Nurses, etc. • Medical Health Professionals

With challenging public health issues like infectious diseases such as H1N1 and chronic diseases caused by obesity, local public health departments need highly specialized professionals in areas like epidemiology, laboratory science, health information technology and health education. Of Texas’ 254 counties, approximately 70 percent are designated as Medically Underserved Areas (MUA). An MUA is a federal designation based on underserved levels of care related to the ratio of primary care physicians, infant mortality rate, percentage of population with incomes below poverty, and percentage of the population age 65 years or older.25_{Approximately 45 percent of}

Texas’ 254 counties are designated whole-county Health Professions Shortage Areas (HPSAs) by the federal government.26_{The purpose of a HPSA is to identify areas of greater need for health care}

services in order to direct limited healthcare professional resources to people in those areas. The HPSA designation process identifies, by ZIP code or county, areas that lack sufficient clinicians to meet the primary care needs of the residents. Qualification for Federal assistance programs, such as the Medicare HPSA bonus for physicians, is based upon the HPSA determination27_{Of Texas’ 254}

counties, 177 are rural; of the 32 border counties, 28 are rural. Rural areas and border areas with HPSA or MUA designations are significantly impacted by health care workforce shortages.

These health care shortages further require the presence of strong regional and local public health systems that can adequately prevent disease and address health disparities.

25

Texas Department of State Health Services, Texas Primary Care Office. (n.d.). MUA and MUP Designations. Retrieved October 22, 2010, from http://www.dshs.state.tx.us/CHS/hprc/MUAlist.shtm.

26_{Texas Department of State Health Services, Texas Primary Care Office. (n.d.). Primary Care HPSA Designations. Retrieved}

November 2008, from http://www.dshs.state.tx.us/CHS/hprc/PChpsaWC.shtm.

27_{Centers for Medicare and Medicaid. Medicare Learning Network. Health Professional Shortage Area Fact Sheet. March 2010}

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Figure 7: Medically Underserved Areas in Texas as of November 1, 2010

Source: Health Resources and Services Administration, Shortage Designation Branch, May 8, 2008

Figure 8: Health Professional Shortage Areas in Texas as of November 1, 2010

Source: HRSA Geospatial Data Warehouse Retrieved November 1, 2010 from http://datawarehouse.hrsa.gov/DWOnlineMap

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SOLUTIONS:

 Develop a distance learning Master of Public Health program in Texas that makes it possible for public health practitioners in rural areas to get properly trained in their field,

 Provide senior public health staff with management training so they can guide their departments to meet national voluntary accreditation standards of local health departments,

 Provide basic public health training to government workers and others who enter the field without formal public health education,

 Encourage minorities to enter the public health field, so that the workforce reflects the community they serve,

 Adopt the national public health professional competencies as standards in all levels of public health,

 Monitor the changes in the public health workforce supply, and

 Require medical students to take public health coursework and practice in public health agencies during their training.

HEALTH DISPARITIES

Out of Texas’ estimated total population in 2010 of 25.2 million, approximately 17.7 million (70.4 percent) were White, 3.0 million (11.8 percent) were African‐American, 9.4 million (37.6 percent) were Hispanic and 2.6 million (10.5 percent) were Other. By 2015, Texas is expected to have an estimated total population of 27.6 million, with 11.4 million (41.5 percent) White; 3.0 million (10.7 percent) African‐American, 11.8 million (42.7 percent) Hispanic, and 1.4 million (5.1 percent) Other.28

Since research indicates minority and ethnic populations have a disproportionately higher rate of disease incidence, prevalence, and death than the population as a whole, these changing demographics will result in adversely affecting the overall health of the Texas.

Death rates from diabetes, kidney disease and septicemia (blood poisoning) for African‐Americans and Hispanics exceed White death rates. Additionally, higher death rates were reported among African Americans from heart disease (the leading cause of death in 2005), cancer (second leading cause of death in 2005), stroke (third leading cause of death in 2005), and influenza and

pneumonia.29_{A higher percentage of African Americans and Hispanics are overweight or obese.}30

HIV infection rates were higher among African Americans and Hispanic populations.31

Higher rates of obesity, smoking, lack of prenatal care, lower immunization rates, and the lack of physical activity result in poorer health outcomes for Texans who are racial/ethnic minorities, many of whom are also poor, live in urban settings, live in the most rural areas, and on the border. Poverty, geography, and lack of health insurance are social determinants of health disparities. Texas’ overall poverty rate in 2011 was 17.8 percent. Broken down by race and ethnicity, 12 percent of Whites, 31 percent of African‐Americans, 34 percent of Hispanics, and 18 percent of Others had an income below poverty. Over 25.0 percent of Texans aged 0-18 lived in poverty.32_In

28

Projections of the Population of Texas and Counties in Texas by Age, Sex, Race/Ethnicity for 2000‐2040, Based on 2000‐2004 Migration Scenario, Population Estimates and Projections Program, Texas State Data Center, October 2006.

29

DSHS Center for Health Statistics 2005 final death data and Centers for Disease Control and Prevention, National Center for Health Statistics.

http://www.cdc.gov/nchs/data/nvsr/nvsr56/nvsr56_10.pdf

30

BRFSS, Behavioral Risk Factor Surveillance System Surveys.

31

BRFSS, Behavioral Risk Factor Surveillance System Surveys.

32

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2011, Texas’ uninsured rate was 23.4 percent. Broken down by race and ethnicity, 21.9 percent of Whites, 21.1 percent of African‐Americans, 36.2 percent of Hispanics, and 42.7 percent of Others were without health insurance33

SOLUTIONS:

 Identify activities in Texas that reduce health disparities and disseminate the other communities,

 Coordinate health disparities activities between all agencies under the Texas Health and Human Services Commission,

 Support community collaboratives to design, implement, and evaluate community-driven strategies to eliminate health disparities,

 Expand the use of community health workers in addressing physical and behavioral health improvement at the individual level and promoting healthy lifestyle choices, and

 Support community efforts to build healthier environments in areas of lower socio-economic status.

ACCESS TO CARE

Texas has the largest percentage of uninsured citizens among the 50 states. This directly impacts the state’s capacity to achieve basic public health objectives such as immunization coverage and prevention and control of major infectious diseases. Without significant changes to state and federal policies by 2040, almost 1 in 3 Texans may be uninsured.34

Improved access to medical care is needed especially in rural and medically underserved areas.

SOLUTIONS:

 Support re‐design of the Texas Medicaid eligibility systems to incorporate a new income eligibility determination methodology and do so in a way that will interface with the new health insurance exchanges,

 Encourage policymakers to establish a state health insurance exchange to accelerate health coverage expansion,

 Combine technology, people, and outreach by using tools such as The Benefit Bank, a web-based counselor supported system to increase enrollment in state federally-funded benefits, especially CHIP and Medicaid,

 Explore new grant opportunities and demonstration programs to test new payment and delivery system methodologies,

 Research and implement new long term care options and incentives intended to increase the availability of home and community‐based care options,

 Support and improve outreach efforts to eliminate barriers to integration of primary care, behavioral health, and public health,

 Restore funding for the Medically Needy Program for counties,  Encourage expansion of community health centers and clinics, and

 Expand funding to support rural public health activities involving outreach, education and prevention, nutrition access, health delivery systems, and emergency preparedness.

33

U.S. Census Bureau. U.S. Census Bureau, Table HI05 Health Insurance Coverage Status and Type of Coverage by State and Age for All People, 2007.

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PUBLIC HEALTH INFORMATION TECHNOLOGY

While progress is being made in healthcare information technology, the public health field is facing and will continue to face issues with changing technology unless new policies and priorities are adopted. Public health departments rely on the secondary use of personal health information; therefore it is essential that public health agencies have adequate updated technology so that disease surveillance can take place in a secure, safe and timely fashion.

SOLUTIONS:

 Invest in health information technology and training for public health workers,  Promote interoperability between medical care and public health sector IT systems,  Develop model language for agreements that enable health information exchange and

analysis across different jurisdictional boundaries so that public health department can respond to multi-jurisdictional emergencies, and

 Create funding opportunities and incentives for public health departments to adopt health information technology practices.

In 2010, the Texas Health and Human Services Commission was awarded $28.8 million through the State Health Information Exchange Cooperative Agreement Program. All the areas mentioned above should be addressed during the three year grant period.

OBESITY

Obesity continues to be one of the most important health challenges facing Texans. Without significant intervention, the state health care system is estimated to spend approximately $40 billion in health care costs by 2040 because of obesity. Texas has the 10th highest percentage of obese adults and 20th highest percent of obese and overweight children in the U.S.35

One in four Texas children lives in a food insecure home; one in five (20.4%) is medically obese.36

And according to Trust for America’s Health’s ‘F as in Fat’ report, in 2011, nearly 66% of Texas adults were overweight or obese and almost one-third (32%) of Texas high school students were overweight or obese37_{. According to National Council of La Raza (NCLR), Texas is #1 in Latino child}

obesity38_{. Being overweight increases the risk of serious illness, including heart disease, stroke,}

type-2 diabetes, certain cancers, and other serious medical conditions. According to Texas Food Policy Roundtable, Texas is the #2 hungriest state in the nation with the hunger rate exceeding the poverty rate (15.80 vs. 16.30%) and #2 in child hunger.39

35_{Trust for America’s Health. F as in Fat: How Obesity Threatens America’s Future, 2012.} 36_{Feeding America: Hunger 101 http://feedingamerica.org/faces-of-hunger/hunger-101.aspx} 37_{Trust for America’s Health. F as in Fat: How Obesity Threatens America’s Future, 2012.} 38

Salud America, 2010

3939

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SOLUTIONS:

These are the policy priorities of the Partnership for a Healthy Texas, a statewide coalition focused on developing and promoting policies that prevent obesity in Texas.

School and Community Environment

Fiscal Priorities:



Preserve funding for the School Health Network within the DSHS Budget



Support the DSHS Chronic Disease Prevention exceptional item related to obesity

prevention



Support expanded funding for the Texans Feeding Texans program, a Texas

Department of Agriculture grant that helps farmers donate surplus produce to local

food banks.

Policy Priorities:



Improve the health of schoolchildren by restoring a half credit of physical education

in high school as well as health as requirements for graduation



Support efforts to ensure advertising on school district property is nutritionally

appropriate



Support Complete Streets and Safe Routes to School



Utilize local school health advisory councils to make policy recommendations to

school district concerning the types and quantity of sugary drinks sold in school

sited vending machines and a la carte offerings.

Early Childhood



Improve nutrition and physical activity in early childhood programs by

strengthening the Texas Education Agency’s Pre-K health standards.



Encourage innovative approaches to engaging parents and child care facilities by

earmarking a specified percent of the Texas Department of Agriculture's health and

nutrition grants for programs serving young children.



Support recommendations outlined in the Early Childhood Health and Nutrition

Interagency Council report released in the fall of 2012.

Food Systems and Access



Support policies that address food insecurity and obesity as they relate to a lack of

access to affordable and healthy foods. Improve access to healthy foods by

supporting policies that allow the use of vacant state land for community gardens

and incentivize private landowners to offer a portion of their land for the same

purpose.



Promote guidelines that establish nutritional content standards and that set local

food procurement targets for foods offered via vending machines and food service

programs located in state facilities and agencies.

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IMMUNIZATIONS

Childhood vaccinations have been shown to control the development and spread of diseases within populations. Texas ranks 37th nationally for childhood immunization rates. Additionally, the state law requiring immunizations for public school attendance contains an exemption for parents and guardians to opt children out of receiving immunizations for religious purposes. While this protects religious freedoms, a concurrent health education effort should ensure parents make informed decisions.40_{For example, there is currently a great need to educate persons on the fact}

that vaccinations do not cause autism.

Improving influenza vaccination rates and meeting vaccine demand remains a significant health concern. Each year in the United States it is estimated that there are 36,000 deaths, 226,000 hospitalizations, and approximately 5 to 20 percent of the population experiencing illness because of influenza. With the current Texas population, it is expected that approximately 1.2 million people annually may become sick with influenza.41

SOLUTIONS:

 Expand Texas’ existing immunization registry so that it captures immunization records for both children and adults,

 Improve childhood immunization rates by implementing education and outreach programs,  Expand flu vaccinations, especially for high priority populations, and

 Provide incentives for businesses to offer vaccinations for their employees to prevent infectious diseases such as influenza and H1N1.

40_{United Health Foundation. (2011) Texas’ Health Rankings, Immunization Coverage. Accessed via:}

http://www.americashealthrankings.org/TX/Immunize/2011

41

Texas Immunization Stakeholder Working Group (TISWG), (2008) Meeting minutes, February 21, 2008. Retrieved October 22, 2009, from http://www.dshs.state.tx.us/immunize/partners/minutes_022108.pdf

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MATERNAL AND CHILD HEALTH

New technologies, longer life-spans, and other scientific developments in maternal and child health have created opportunities for improved quality of life for many Texans. Texas can become a leader in defining how to accept and appropriately implement expansions of maternal and child health programs.

Texas has already faced enormous pressure to resolve a lawsuit about the storage of dried blood spot specimens after the initial newborn screening was conducted. Storage of the dried blood spots began in 2002 and did not require parental consent. Once stored, these dried blood spots could be used for de-identified scientific research to improve the quality of screening tests and to serve as quality controls for the state newborn screening laboratory. In 2009, a lawsuit was filed against the Texas Department of State Health Services and Texas A&M University, who provided the storage facility, stating that the storage of the dried blood spots was unconstitutional. As a result, Texas has destroyed all dried blood spots that were stored prior to May 27, 2009 and now parents have the opportunity to opt-out of having their child’s blood spot stored.

SOLUTIONS:

 Explore and define the ethical, legal, and social issues related to new technologies, improvements in scientific research, and patient privacy. Texas should look to national advisory bodies such as the Secretary’s Advisory Committee on Heritable Disorders in Newborns and Children, staffed by the Health Resources and Services Administration, for recommendations.

 Support improved transition from pediatric into adult services, especially for those young adults with complicated special needs. Young adults already bear the burden of

transitioning out of their parent’s house into independent living. This transition is particularly difficult for those young adults with critical, life threatening diseases. They must also find adult providers that understand and are comfortable treating their disease. They have to negotiate with insurance companies that only sometimes provide coverage for their health needs. All young adults should have a community support system that assists with transitioning from pediatric into adult services.

 Promote the development of lifelong health homes (medical homes) for all Texans.

EMERGENCY PREPAREDNESS

Preparing for health and medical emergencies, both natural and man-made, is a continuous challenge for Texas given its proximity to “hurricane alley”, and the number of critical infrastructure and commercial interests targets located inland and along the Gulf Coast.

SOLUTIONS:

 Invest in a highly skilled professional public health workforce, including dedicated preparedness staff,

 Establish stronger partnerships with the private sector through organizations like “Voluntary Organizations Active in Disaster” (VOAD), and

 Use nationally established performance measures to assess Texas’ communities’ ability to respond to disasters and to make them attractive for Federal competitive grants

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CONCLUSION

Public health protects and improves the health of communities through education, promotion of healthy lifestyles, and research for disease and injury prevention. Public health professionals analyze the effect on health of genetics, lifestyles and the environment in order to develop programs that protect the health of everyone. Texas faces many challenges in protecting and improving the public’s health, including anticipated workforce shortages, an uncertain economy, needed improvements in immunization rates, rural access to care, public health information technology infrastructure, rapid increases in the prevalence of chronic diseases, and other significant health concerns.

Texas can respond to these challenges by: increasing funding for public health infrastructure, improving workforce development, facilitating voluntary accreditation of all local and regional health departments, expanding public health involvement in health information technology development, and developing community collaboratives, public-private partnerships at the local level to address public health issues.

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Appendix A

APPENDIX A: HISTORIC PUBLIC HEALTH ACHIEVEMENTS

Public health advances have largely been responsible for increasing the lifespan of populations. From 1900 to 2006, life expectancy at birth increased from 47.3 years to 77.7 years for males and females of all races.42 The U.S. Centers for Disease Control and Prevention created the Ten Great Public Health Achievements – United States, 1900-1999 to demonstrate how far public health and the people of the United States have progressed in just 100 years.43 These accomplishments are:

1. Vaccinations:

Vaccinations keep individuals healthy by eliminating the spread of disease within a population. Inherent in successful vaccination programs is a high immunization rate, which provides for a very little risk of contracting an infectious disease. Population-wide vaccinations have resulted in the eradication of smallpox, elimination of polio in the Americas, and the control of measles, rubella, tetanus, diphtheria, Haemophilus influenzae Type B, and other infectious diseases in the United States and other parts of the world. Today all 50 states have mandated vaccinations for students before entering public schools.

2. Motor-vehicle safety:

Improvements in motor-vehicle safety have contributed to large reductions in motor-vehicle-related deaths and policies have successfully changed personal behavior (e.g., increased use of safety belts, child safety seats, and motorcycle helmets, improved vehicle safety standards, and decreased incidence of drinking and driving).

3. Safer workplaces:

Work-related health problems, such as coal workers’ pneumoconiosis (black lung), and silicosis, common at the beginning of the 20th century, have been significantly reduced by improving workplace safety standards and implementing environmental controls. Severe injuries and deaths related to mining, manufacturing, construction, and transportation also have decreased. Since 1980, safer workplaces have resulted in a reduction of approximately 40 percent in the rate of fatal occupational injuries.44

4. Control of infectious diseases:

Clean water and better sanitation have resulted in control of infectious diseases such as typhoid and cholera.

42

Centers for Disease Control and Prevention. (2008). Health, United States. Retrieved October 21, 2009, from http://www.cdc.gov/nchs/data/hus/hus08.pdf#026.

43_{Centers for Disease Control and Prevention. (1999). Ten great public health achievements}_{– United States, 1900-1999. Retrieved}

October 21, 2009, from http://www.cdc.gov/about/history/tengpha.htm.

44

Achievements in public health, 1900-1999: improvements in workplace safety -- United States, 1900-1999. (1999). Morbidity and

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5. Decline in deaths from coronary heart disease and stroke:

Risk-factor modification such as smoking cessation, blood pressure control and improved access to early detection and better medical treatment have led to a decline in deaths from coronary heart disease and stroke.

6. Safer and healthier foods:

Since 1900, safer and healthier foods have almost eliminated major nutritional deficiency diseases in the U.S. such as rickets, goiter, pellagra.

7. Healthier mothers and babies:

Since 1900, infant mortality has decreased by 90 percent, and maternal mortality has decreased by 99 percent. Healthier mothers and babies are a result of better hygiene and nutrition,

availability of antibiotics, greater access to healthcare and technologic advances in maternal and neonatal medicine.

8. Family planning:

Family planning has provided health benefits such as longer intervals between the birth of children; increased opportunities for preconception counseling and screening; fewer infant, child, and maternal deaths; and the prevention and control of sexually transmitted diseases in both men and women.

9. Fluoridation of drinking water:

Fluoridation of drinking water began in 1945, and in 1999 reached an estimated 144 million persons in the United States. Fluoridation is a safe and inexpensive strategy to tooth decay in children and adults, regardless of socioeconomic status or access to dental care. Fluoridation has played an important role in the reductions in tooth decay (40%-70% in children) and of tooth loss in adults (40%-60%).

10. Recognition of tobacco use as a health hazard:

In 1964, tobacco use was recognized as a health hazard. This resulted in increased promotion of smoking cessation and lead to a reduction of exposure to environmental tobacco smoke.

O P P O R T U N I T I E S F O R A D V A N C E M E N T

PUBLIC HEALTH IN TEXAS: