Tobacco Documents Online

---

t ! I 1 : Robert ~. Harmon, M.D., M22L In January 1990, as this publication was about to go to press, Dr. Robert Harmon announced his resignation after accepting a post as Administrator of ~ federal Health Resources and Services Ad~ra~stration in Washington, D.C. Dr. Harmon had served as director of the Mixsouri Department of Health from January 1986 to January 1990,Among his many accomplishments, he improved the department's. relatfonships with city and county health departments, developed a model AIDS prevention program, helped to create an Offu:e of Minority Health, and launched an aggressive tobacco awareness campaign that improved clean indoor air policies statewide. The stories and articles that follow his me~age here reflect many of these actu'evements. Missoud Department of Health From the Director When I accepted' the position of Administrator Of the DHHSFUSPHS Health Resources and Services Administration, it was with mixed feel- ings. I was pleased to m~e on the challenge of nmning a large federal health agency, but sony to leave my friends and colleagues in DOH and " Missouri. It has been a tree pleas- ure to work with the Governor and his staff, DOH employees, local health officials, legisla- tors, and many other Missourians to promote the public health agenda in Missouri. It appears that real progress has occurred in launching the Department of Health, reducing tobacco use, addressing minority health issues, controlling AIDS, improving the state/local public health parmership, promoting mammal and child health, and fighting chronic diseases. It was a real te~n effort. Governor Ashcroft has pledged to continue this agenda, tie has ap- pointed Charlie Stokes, an outstanding individ- ual, to ~ Interim Director effective Feb. I. A high le~,el s~areh com- mitme will he interview- ing top candidates ~o select the next Director as soon as possible. I am confident that DOH will be in good hands. The challenges at.HRSA are immense. I will be working closely with Dr. Louis Sullivan, DI-IHS Secretary; Dr. James Mason, Asst. Secretary for Health; Dr. Antonia Novelle, Surgeon Gen- eral Designee; Dr. Bill Roper, CDC Director, and others on such national issues as infant mortality, minority health, AIDS/HIV care, the maldistribution of health professionals, homeless health care, and tl~ need to strengthen our federal/state/local public health system. Let's look at it this way. DOH isn't just losing a Direetor...it's gaining a friend in the federal government. With 57% of DOH funds being federal, that can be important. Thank you for all the support you have given me and my wife Ca~_l over the past four years. I especially appreciate the amazing volume of congratulations messages over the past few weeks. We will miss you. I hope to see many of you as I return over the next year to speak at several events. Keep up the good work! 3 :~ -.... ..~ .~ ;. I TI2506-0917

i I I B, iennia.l Rep or t Missouri Department of Health John Ashcroft • Governor Robert G. Harmon, M.D., M.P~-I. Director Charles Stokes, M.~I. Deputy Director MISSOURI DEPARTMENT OF P.O. Box 570. 1738 East E~m Jefferson City, MO 65102 ~14/751-6400 TI2506-0918

Missouri Department of Health Table of Contents From the Director ................................................. 3 Board of Heal .th ......................... : .......................... 8 Department Organization .... : ...... : ....................... 10 Financial Summary ~ ........................................... 11 Office of the Director ......................................... 12 Chronic Disease Prevention and Health Promotion .... .'. ............................... 14 Environmental Health and Epidemiology .......... 24 Health Resources ............................................... 34 Local Health and Institutional Services ............. 37 Maternal, Child and Family Health .................... 43 Legislative Update .............................................. 53 District and County Health Sercices Map .......... 62 Introduction Divisions Addenda TI2506-0919

Biennial Report, FY 1988/1989 3tate B oard of Health :Tames M. Whittico, Jr., M.D. Chairman August, 1987~March, 1989 A physician in private practice in St. Louis. Thomas C. Schnurr, M.19. A practicing physi~z'an with Sale Hospital, Inc. in Neosho. Thomas & Thomas Chairman March, 1989-:-present Corporaie Director of Governmemal Affairs for Christian Health Services in Columbia. Elias E. Zh'ul, D.O. A practicing physician witk the Hiland Medical Group, [nc. in Kansas City. Roger D. Nail, D.O.S. A practicing dentist in Je~'erson City. William J. Poe, R.P h. A pharmacist in St. Louis. W.C. (Chad) McCoy, D.D.S. July, 1987--Nov, 1987 A practicing dentist in Chillicothe. Marilyn If. Nelson, RJV. June, 1986--April, 1989 A RegL~tered Nurse Team Leader at Research Medical Center in Ka~tzs City. .'% TI2506-0920

. The State Board o.f Health con sists of seven members appointed by the governor, by and'with tim advice and consent of the Missouri Senate. Members oftbe Board of Health serve four-year terms, with the terms of two members ending each year. A member may serve no more than two terms. Missouri Ia,~ (section 191.400) specifies that t~e members of the Board of Health shall be physicians and surgeons licensed by the State Board of Registration for the Healing Arts of Mis- souri; one member shall be a dentist licensed by the Missouri Dental Board, and the other persons other than those licensed by the State Board of Registration. for the Healing Arts or the Missouri Dental Board and shall be representa- tive of those persons, professions and busi- nesses which are regu- lated and supervised by the Department of Health and the State Board of HealflL Duties and services of the : Advises the director of the Department of Health regarding the priorities, policies and programs of the pamnent. • Reviews all rules promulgated by the Missouri Department of Hcalth~. • Reviews the budget of the Department of Health. • Administers the State Hospital Subsidy Program, the Medical and Osteopathio Student Loan Program and Family Practice Residency Program. Board of Hcal~ include: The defeat of"'Premier" Patrick Reynolds, grandson of tobacco baron RJ. Reynolds, tes~fiez against Premier, a nicotine-delivery deWce, at the Board of Heahh hearing on Dec. 16,1988. The board unanimously passed a resolution to ask the FDA to declare Premier a drug, ask R,L Reynolds to stop test marketing Premier in Missouri; ask retailers to voluntarily return the product to distn'butors, and advise consumers not to use Premier until the FDA makes its deeL'~on. R JR withdrew Premier from the market on Feb. 28,1989. TI2506-0921

, DIVISIONS Missouri Department of 1 I i I ! TI2506-0922

FY 87 . FY 88 FY 89 Missouri Department of Health Financial ,Summary General Revenue $44,019,674 $ 45,509,577 $44,540,623 Federal 49;455,344 51,785,621 67,210,559 Other 19,414,482 19,562,680 19,999,864 Total $112,889~00 $116,857,878 $131,751,046 Department of Health $ 80,284,888 $ 85,471,744 $106,426,336 Ellis Fisehel State Cancer Center 9,114,129 12,164,029 9,407,489 Missouri Rehabilitation Center 11.,708,414 11,189,391 11,015,513 Total $101,107,431 $108,825,164 $126,848,338 Dcparmmnt of Health 641 725 818 Ellis Fischel State Cancer Center 283 283 281 Missouri Rehabilitation Center 456 450 448 Total 1,381 1,460 1,547 H. Douglas Adams, M.P A. Director Office of Admz~istration Appropriations Expenditures Employees 11 TI2506-0923

• Biennial Report, FY 1988/1989 DOH I adds Office of Minority Health 12 n Missouri and in most states, being born into the .minor- ity population means having a shorler life span, a lower chance of'seeing your first birthday, and a greater chance of con- tracting cancer, diabetes and other chronic dis- eases. In a~mpt re address rite disparity between the health status of black, hispanic, native Ameri- can, asian pacific and white Missourians, an Office of Minority Health has been estab- ]isbed by the General Assembly in the Depart- ment of Health (DOH). The new office will monitor h~alth programs and minority health status and report directly to DOI-I director Dr. Rober~ Harmon. "Minorities, espe~ialty blacks, have a higber rate of death due to cancer, cardiovascular disease and stroke, diabetes, homicide and accidents, chemical dependency, infant mortality and A]DS,"'said Ennis McClanahan, chief of the Bureau of High Risk Jcu~e Herren was named Chief of the new Office of Minority Health in October 1989. Intervention and acting coordinator of the DOH Minority Health Advi- sory Committee. Although the life expec- tancy of all Americans has increased to 75 years, the life expectancy of a black American is 69 years, McClanaban said. The Office of Minority Health will develop educational and cultural awareness programs, promote inter-agency cooperation, review programs and legislative proposals, and develop community resources, according to legislation creating the office. The state is in the process of hiring a cider, McCla- nahan said? "All state health pro- grams serve minorities, but due to the disparities in health status, we n~ed more programs targeted toward minorities to address these problems," Mc~lanmhan sal& According to DOH statistics, blacks died at a significantly higher rate~. The. "excess death~" reported reflect the difference between the number of blacks who died and the number who would have died if they had died at the same rate as the white population. , Hear~ disease-16 percent higher • Stroke-31 percent higher • Cancer-39 percent higher. Cancer, the second leading cause of death among Missourians, and AIDS arc me only major disease categories on the increase. • Homicide-slightly more than 10 times the rate. Homicide is the leading cause of death among black males between the ages of 15 and 34. • Diabetes-slightly more than twice the rate. Black women die of diabetes at a higher rate than men. TI2506-0924

i I. I Office el the Director • Liver Disease and cirrhosis- about twice • Infant mortality- 69 percent higher. Nation wide, infant mo~tality accounts for 80 p~rcent • of rite excess deaths of blacks and minori tics over whites, It i.~ the eighth leading cause of death among blacks in Missouri. Missouri's morality among blacks, is not significantly different than the national average, except in homicide, where the. Missouri rate is 41 percent greater. The followihg initiatives have been sponsored, by DOH to reduce infant mortality, and encourage smoking cessation and chronic disease risk reduction in the minority population across the state. The programs arc: Operation CldldSave, Chronic Disease Risk Reduction Project, CommuniLT Organization for Smoking Cessation Among Blac~ Ameri- cans, St. Louis Regional Cancer Controt-Coatition, Hypertension Screening Projects, and Smoking Cessation in Pregnancy Project. Also, DOH sponsors AIDS prevention pro- grams in the Kahsas City, St. Louis and Springfield metropolitan areas Which are designH to provide local health departmenls with input into the design and implementation of state and natiuonal long- range goals. Uacqudine Herren was hired as chief on October 2, 1989. 2Figures compared arc overall age-adjusted and age.specific mortality rat~s for black and white Missouri residents for 1975-1985 adjusted to the 1980 U.S. population. • Source: Missouri State Center for Health Statis- tics. '7nfant Mortalityis the eighth leading cause of death among blacks in Missouri." Director's Office - Overview As chief executive officer, the department director is responsible for the management of DOH and the administration of its programs and services. The deputy director assist~ the director in the management of the department and acts for the director in his absence. The department's general counsel and governmental affairs staff are assigned to the director's office. Four other offices report to the director and deputy director: the Office of Minority Health, Office of Personnel and Training, the Office of Public Information, and the Office of Information Systera~. Charles Stokes, M.Ed. Deputy Director 13 TI2506-0925

Biennial Report, FY" 1988/1989 FY.'89-A bnngs new division to DOH t the mm of the century, the most deadly diseases were infectious O~S, diseases llk~ pneumonia, in~tu~ and tuherculosis. But as the United States heads into the next century, most infectious diseases have been brought under control, thanks to improvements in hygiene, medicine and health care. Taking the place of infectious diseases are chronic diseases, those that develop over a longer period of time and last longer, such as cancer, heart disease and stroke. To lead and coordinate the state's effo~s to combat these killers, the Missotui Department of Health created the Division of Chronic Disease Prevention and Health Promotion. Ross Brownson, Ph.D., formerly chief of the deparurtent'~ Bureau of Cancer Epidemioingy and Control, was named director of the division in August of 1988. "'Public health has controlled many of the communicable diseases. Because people are living longer and personal risk Ross Brownson, Ph.D., was. named director of the new Divi~'on of Chronic Disease Prevention and Health Promotion factors am changing, public health officials are paying more attention to preventing chronic diseases," said Brown- son. "Many of the major causes of premature death, illness and disabil- ity ate related to lifestyle behaviors such as smok- ing, poor nutrition and a sedentary lifestyle." The new division coordi- nates programs designed to improve health habits and reduce the risk and disabling consequences of such diseases as hea~ disease, cancer, stroke, 'The division, located in Columbia in a building next to Ellis Fisch~ State Cancer Center, incorpe- 14 rated ~three existing department units. The division now includes the Bureau of High Risk " Intervention (replacing the Bureau of Chronic Diseases), the Bureau of Smoking; Tobacco, and Cancer (replacing the Bureau of Cancer Epi- dcmioingy and Control), and the Bureau of Health Promotion. Minorities and the economicaliy disadvan- taged are among the target populations addressed by the Bureau of High Risk Interven- tion, headed by Ennis McClanahan. The bureau develops and implements projects in hypertension and choles- terol control for rural, urban and high risk populations. Reducing tobacco use, cancer control and cancer surveillance are the primary goals of the Bureau. of Smoking, Tobacco and Cancer, headed by Jim Davis, M.S. This bureau includes the Missouri Cancer Registry, which collects, reviews and analyzes information on cancer in Missouri. TI2506-0926

In April, 198~, the bureau helped coordinate the Tobacco Consensus Conference, sponsored by the Missouri Coalition on Smoking and Health. The meeting of state and national health profes- sionals recommended such measu/es as raising excise taxes on tobacco and banning ~obacco sales to minors to reduce smoking among Mis- sourians. The Bureau of Hea~. th Promotion, headed by Nancy Miller, M.Ed., develops and directs projects to improve individual and commu- nity health status. Bureau activities include admini- stering a program to reduce smoking among pregnant women who us~ Division of Chroni~ Disease Prevention and Health Promotion public prenatal clinics, staffing the Coordinating Council for Health Education of Missouri's Children and Adoles- cents, helping state agencies and private business develop em- ployee.health promotion programs and conducting continuing education program~ for health professionals. "Reducing tobacco use, cancer control and cancer surveillance are the primary goals of the Bureau of Smoking, Tobacco and Cancer..." 15 TI2506-0927

Biennial Report, FY 1988/1989 The. ~. arlene Anderson, ~ ~ ~eanie Shane- • v beret and glssollrl circuit riders, but tI~ir Cancer The women, all Certified Registry to small Missouri hospi- tals to look at cancer records. They record information about a cancer patient's age, occupation, diagnosis and tmaUnent onto an abstract foral. Those abstracts, and others submitted by larger Missouri hospitals, we the core of the Missouri Cancer Regis. try. The cenual state registry now collects information on about 90 percent of all cancer diagnoses, in the state of Missom-i, but through circuit tiding, registry officials hope to push that proportion closer to I00 percent, Missouri has collected information on 191,000 cases of cancer since 1972, when the state began collecting data on a voluntary basis. Since August 1984, hospitals have been required by law to report all cases diagnosed, seen or treated for cancer in the state, said Dr. Jian Chang, the director. Most Missouri hospitals, especially large hospitals, maintain their owa cancer registries of demographic information on people who diagnosed with cancer, how they were treated, and how long they survived after diagnosis. Data from these registries is used in the state registry, which also collects information on an individual's gender, race, age, occupation, use of alcohol and tobacco and family hist6ry as welt as information on specific diagnoses and treatment. Information about individual people, hospitals and doctors is kept confidential and is not reIcased to research- crs without written consent of the parties involved. The Missouri Cancer- Registry is a rich source in the state's su'uggle to combat the disease. "In order to prevent or control cancer, wc have to know the true dimen- sions of the disease," Chang said. For cxamplc, many state residents were concerned th~ dioxin contamination in the state might cause • additional cases of cancer in residents. But without baseline statistics that show how many people would normally get cancer, it is difficult to assess the risk of such chemical sp'dls, Chang said. Registry informa- tion can help researchers determine the prevalence and incidence of cancer as well as provide clues to the role of environ- mentaI, occupational and lifestyle factors in causing cancer, Dr. Ross Brownson, director of the newly formed Division of Chronic Disease Preven- tion and Health Promo- tion, has used informa- tion in the registry to write many articles for such prestigious scien- tific and medical journals as the American Journal of Epidemiology, Ameri- can Journal of Public Health, and the Archives of Internal Medicine, "The registry is a gold mine of valuable data that hasn't been u~ed to its fuli potential," Brownson said. "Re- search adds to public 16 TI2506-0928

health collaboration with universities and e~b~nces our ability m get federal funding ~nd serve the- people of Missouri." Th~ statistics collected so far show that Missouri cancer rotes are very similar to national trends, Chang said. State offi- cials collected informa- tion on 23,431 cases of cancer diagnosed in the " state in 1986, the most recent year in which complete.statistics have been gathered. Those figures include some out- of-state residents treated in Missouri. The Ameri- can Cance~: Society estimated that there would be 23,500 new cancer cases in Missouri in 1989. Living cancer patients benefit£rom the regi~y because most 1 .arge Division o! Chronic Disease Prevention and Health Promotion hospi~s contact them to complete information for their recomls. "Reminding the cancer patient that they need annuat check-ups is one benefit of the survival tumor registry," Chang said. Follow-up care is impor- tant in long-term survival rates. The American Cancer Society estimated that five out of 10 patients who get cancer in 1989 will be alive by 1994. AboUt 30 pew.ent of all AmeriCans will eventually have cancer, according to American Cancer Society estimates. A~er the information is collected, the rcgistry's medical records profes- sionals review the data for accuracy, complete- ness and consistency. Information is entered into the rcgistry's com- puter, where further editing checks are performed to assure the quality of information in the da~ase. The information co]lecied can be incredibly complex; there arc arc more than 100 different types of cancer. Lung cancer is the most frequently diagn6sed and the most deadly type in Missouri, reflecting national trends. Breas~ cancer is the most frcqucntIy diagnosed ~ araong women. T~e registry, staffed by six full-time and three half-time wormers, also helps hospitals begin their own regis~cs and provides annual worM- shops and consulmtion for hospital-based ~egistrars. The state registry can also help hospitals evaluate their diagnostic and treatment practices and help in adminisWative planning. "The American Cancer Society estimated that there would be 23 ~00 new cancer cases in Missouri in 1989." 17 TI2506-0929

Biennial Report, FY 198~/1989 CancerI Control Missouri 18 n Missouri's battle.with cancer, the enemy is winning. Cancer is the second leading cause of death in Missouri and in the United States. In 1988, ~lmost 11,0C0 Missouri- ans died of caucer. Only heart disease claims more lives each year. "C~h'lccr rates are eotl- tinuing to rise in Mis- souri because the issue is not being dealt with effectively by the public at risk, local communi- ties, health care profes- sionals, or public health agencies," according to Missouri's Cancer Control Plan, released Feb. 15, 1989. The l~O-page document, in development since January 1987, is the Show-Me State's battle plan ag~ust cancer. The plan was developed by the Missouri Caucer Control Advisory Board, composed of 24 state expects in cancer control, health psycholoTy, community organization, health education, com- munications and legisla- tion. "The health care system has provided ~ew finan- cial or personal rewards for cancer ¢ontmI of- ions;' according to the plan. "Insurance often does not relmburs~ for preventive measures, patients are often reluc- tant to pay for them, and health care professionals have also been frustrated by the lack of patient response to their cancer control efforts.'" Gee. John Ashcroft, in ceremonies in the Capitol rotunda attended by national cancer experts, legislators and the public, hailed the plan as one of the first such comprehen- sive documents in the nation. '~be plan has been • designed to focus sources and expertise on areas that wilt be most effective in preventing deaths from cancer in state of Missouri," said Jim Davis, chief of the Bureau of Smoking, Tobacco and Cancer and staff coordinator of the group that wrote the plan. Reducing tobacco use, detecting cancer early, and teaching people how to avoid the disease are the main goals of the plar The state plans to direct speciaI cancer prevention activities at youth, minorities, women and the economically dis- advantaged, all groups at special risk of developing Au estimated 30 percent of all cancer deaths and morn than 80 porcent of alllung cancer deaths could be prevented by eliminating tobacco use, according to a U.S. Surgeon C-encrars report. Smokeless tobacco use by Missouri youths is a particularly serious problem. Research indicates.tha~ 14 percent of high schoot senior males use smokeless. tobacco ¢vc~y day, Smokctcss tobacco us~ is associated with a nearly fn~y-fold risk of oral cancer in long-term users. Early detection of cancer, especially breast and cervical cancer, has been shown to be crucial to survival. The use of mammography and physical, breast examina- tion to detect breast cancer in its early stages can achieve a survival rate of almost 90 percent. Missouri's minorities have a greater risk of contracting certain types of cancer than whims. Minority men have the highest cancer death rate TI2506-0930

t I I I i Division of Chronic Disease Prevention and Health Promotion (272 deaths per I00,000 population) of any population subgroup in Missouri, Largely du~ to ldgh rates oflung cancer associated with tobacco vse. Minority women have triple the death rate from cervical cancer and also have less access to medical services such as Pap tests. Among the action areas outlined in the Cancer Control Plan are: • Promotion- To work with professional and community organiza lions, such as medical associations and women's groups, to promote cancer control • programs. The plan makes speclfle recom mendations for cancer control aelion for 31 different provider groups, including health professionals, schools, community organiza tions and worksit~s. • Training - To train health professionals to implement the plan's recommendations, which include develop ing c.ouises on cancer epidemiology and control, tobacco use prevention and cessa tion and strategies to dete~ cancer early. • Coalitions - to form regional teams of people from medical centers, voluntary health organizations and commurdty organha tions ~o define local cancer control priorities and action plans. • Resource coordination The Missouri Cancer Control Resource Di rectory includes infor madon on what cancer control materials am available in the state and how to order them. The DOH Resource Center contains review copies of the materials. For more information or to obtain a copy of the plan and directory, contact the Missouri Department of Health's Bureau of Smoking, Tobacco, and Cancer at 314/875-2218. "An estimated 30 percent of all cancer deaths and 80 percent of all lung cancer deaths could be prevented by eliminating tobacco use..." 19 TI2506-0931

• Biennial Report, FY 198BI1989 Older L .now, but ",Growing Younger' An innovative program from the Bureau of Health Promotion offers older Missourian's an opportunity to learn new skills, improve their health and enhance ee and Flora Bittiker have • fountain of youth: it's called "Growing Younger." - No fancy creams or plastic surgeons give them the effects they seek. Instead, their secret is a Missouri Department of Health program spon- sored by the Bureau of Health Promotion. Nutrition, exercise, re- laxation and medical self- responsibility is what "Growing Younger" is all about. The name is appropriate becausv the program revolves a~ound the cenWal idea that a creativity Lee Bittiker, 69, gives his wife, Flora, 72, a back rub - a relaxation techm'que learned in the program. person's "health age" is not always the same as their chronological age. While we can't change 7 our birth date, we can slow the aging process with "more laughing, walking, relaxing and healthy eating." .] TI2506-0932

1 i I I I The Bittikers of Indue pendence, Me., have been doing all these things since they attended a four week session last summer. Lc~, 69, was recovering from triple by-pass heart surgery at the time. He was leery about living an active life again~ afraid of more health comp]ications. • Meanwhile, Flora, 72, started to attend the "Growing Younger'" sessions she heard about from a friend. She soon managed to convince Lee to sit-in on the sessions with her. By the time the first session was over, Lee was converted. He was doing exercises right. along ~;ith the re~t of group. He began to he faithfid to "Growing Division of Chronic Disease Prevention and Health Promotion Younger" ideologies. Drinking eight glasses of water a day, and watch- ing his cholesterol and salt intake, and exercis- ing helped him lose.the 20 pounds his doctor reconunended alter the surgery. L¢~ is now one of- "Growing Yotmger's" "It's an excellent pro- gram.. Janle, our instruc- tor, is great. It's well- worth the $10 1 spent to take the program." Flora agrees wbole heart- edly. 'q1~e Httle. %tretchies' they taught me for my bad back was worth the $t0 investment alone/' The couple makes a team effort to follow the program's guidelines. Because both of them are more health-conscious now, reading food lahels, cooking the fight foods and exercising daily has become a way of living for them. Flora says they am psy- chologically moro healthy too. '=Ilze sessions were really good for us," Flora recags. "'We had just been through Lee'.s heart- surgery. It was a time for us to relax and enjoy - a time to get both of us back on our feet.'" The couple says they arc busier now than before their retirement. Both work as volunteers cooking for their local church. After a long day of working in the kitchens, they like to sit in their backyard on the patio and "Nutrition, exercise, relaxation and medical self- responsibility is what "Growing Younger" is all. about" Older adults reached through "Growing Younger" and "Growing Wiser'* 1987 1988 1989 a mental wellness program for older adutts 21 T12506-0933

Biennial Report, FY 1988/1989 "Growing Younger" instructor Pat B[stllne demonstrates self-eye care to June Henning, 70. give each other back robs to unwind - a relaxation technique they learned from lanie at "Growing Younger." Meanwhile, across'the state, "Growing Younger" sessions am taking place in St. Louis CountT. Pat Bisttine, a registered nurse who specializes in gernntol- ogy, teaches older adults the same concepts that L~ and Flora lmve. incorporated, into their lives. "We can't cure chronic diseases, but we can make adaptations so we can live dch, fufilling lives," Pat says. "'Grow- ing Younger" helps us to make those changes by teaching.us to listen to our bodies and to practice simple self-care skills." The importance of "'self responsibility for health'" is one of the key concepts of the program. Skills, such as using thermome- ters and learning how to monitor heart ram, give the group a better under- standing of how the body works. Instructors also teach medication man- agement and common injury remedies. This approach helps partici- pants deal with health problems before major medicat attention is needed. Italso helps reduce health care costs. T12506-0934

In addition to self-care, the sessions teach reLaxa- tion skills, and flem%ility and toning exercises. Even nutrition is a skill, Pat says. Evaluating food choices and reading food habeas are recommended at "Growing Younger" to help people make the changes needed for the development of healthy eating habits., lune Henning, 70, and Celia Goldman, 77, say they decided tO give thO program a try becau~ they wanted a new approach to life. "I thoughti~ was a chanc~ to get out of the house and me~t people and learn something flew," June says. "Growing Younger" has succeeded where other programs have failed l~cause of the group support. In fact, ~at's the key ta the program's Cecila says, "I'm here to change my eating habits and to pick up mor~ in- formation than what I already know - I'm still capeble of learning things." DMsion of Chronic Disease Prevention and Health Promotion ffanie Wight,. the instruc- tor who got Leo and Fiom Bitter on the right track, cartainly captures "Growing Younger's" spirit. "Some people believe that you can't teach old dogs new tricks. They're wrong. Look at Grandma Moses and Georg~ Bums," lanie says. 'q'hey are proof that older adults can have positive expec- tati6ns about growing older. 'Growing Younger' helps them look forward, not back- ward at life." state's senior population. "Growing Younger" was the group's solution, says Carol Smith, health educator, who coordi- nated the progr~n. "Our goal is to incre~ functional independence and improve the quality of llfe for Missoud's older adults," she says. A program developed by Healthwise, Inc. in Boise, Idaho, "Growing Younger" is a commu- nity-based health promo- tion program primarily funded by the MAssouri Department of Health. "Group support is the key to the program's success" NOTE: In 1985 the issue of older adult health prempted the Missouri Coalition on Health Promotion for Older Adults to provide a special program for the " 28 TI2506-0935

Biennial Report, FY 1988/1989 dl).S I in Missouri Patients reported with AIDS virus • 19~ 1988 1989 Missomrians have died ~rom ilLr~sses such as cancer and ~e~ • ~e ~ ~m ~S. But ~e ~t~fi~ ~mad of ~ ~ ca~ed much morn ~de~g, ~o~on, ~ To prevent ~¢ spread of ~S, ~d ~¢ ac~mpa- n~g fe~ ~ ~s~or- ~p~ent of H¢~'s ~0~ Bur~u of~S Prev~fion h~ set up pm~ of ~ co~¢~g ~d tes~g, p~r no.ca- tion, educ~on, ~d ~ nation's flint ~-b~ed ~fiafiw m coord~a~ cam for ~mo~ ~ ~S. ~ pm~s ~ ~¢ gamu~ of pubic s~g ~d ~g of ~mo~ at ~ tes~g si~s; ~d pubfis~g s~eys of ~ecfion mt~ ~ong m~n~ng u~a~ ~d ac~m epid¢~olo~c~ statistic; dis~bu~g ~uca~on~ ma~fi~; s~g ~ ~ng m~ceted, commu- ~-b~ed pmvendon, educ~on, ~d fion pm~; ~d, helping people with AIDS and their families find support networks and negotiate a some- times daunting healthcaro system. Education is one of the best weapons in thefigh~ against the spread of HIV, but effoC~s to combat AIDS should not be limited 1~ a narrow scope .of intervention. 0nly a program that uses every tool at its disposal is addressing.the serious- ness of the prohiem. Testing programs can alert people who are infected with ~ AIDS virus and provide infer- marion and assistance which may improve long- term survival rates through medication, therapy, and lifestyle modifications. People are given the opportunity to modify their ~ehavior when they know their infection status or at least are told that their lifestyle is placing them at risk for exposure w HIV. The director of the Department of Health, Robert G. Harmon, M.D., has recently stated, "Medical advances emphasize how critical it is that people at risk for HIV infection be tested and seek prompt medical care. Medications and specific medical care are now available for persons infected with HIV, even before they show any symptoms of HIV." The state funds 38 HIV- testing sites which had tested about 34,512 people by mid-October of 1989, according to Anne Payne, assistant bureau chief. She said several more sites were planned for the near future. "Testing and partner notification is an excel- lent way to do one-on- one education," Payne said. "Anyone who is tested receives pre- and post-test eounseli~, g on risk reduction behaviors." D0H also has developed programs to assist in the care of persons infected with I-IP¢. The department's HIV Care Coordination program provides multi-discipli- nary teams responsible for locating, coordinating and monitoring .services for HIV-infected persons in Missouri. These teams can assist people with HIV in locating services, regardless of their ability to pay. A Medicaid waiver program also TI2506-0936

I i ! Division of Environmental Health and Ep~demiology provides cost-cffcc6ve home and community- based s~rvices in lien of hospital care for p~opI¢ Since October 1987, the state has required" all Missouri physicians and ]aboratories.to mpor~ the names of people testing posirlve for antibodies to the AIDS virus. To safe- guard the confidentiality~ the state also has made it unlaw~ to disclose this information. Access to this information is strictly limit~ and continuousiy guarded. More people arc choos- hug to bc tested. The state laboratory, which ' rims blood tests for both public testing sites and and private physicians, expects to ran about 60,000 blo0d tests in 1989,. up from 39,203 in 1988, and 14,508 in 1987. Ongoing efforts are underway to a¢ourately assess the.rate of ttIV infection among the general population in Missouri. Initial survey results of selccmd population segments indicate that the infection rate in Missouri is below national average. Clients ~f Sexually Transmitted Disease (STD) cl~. "cs in Kansas City and the city of St. Louis have an infection rate of 1.3 percent and percent. Tests of morn than ~4,000 women [ tenuincd from neonatal testing] giving birth in Missouri from November 1988 through Iune 1989 showed only 12 positive for HIV, a rate of 0=035 percent. Other HIV-infection surveys,, are being con- ducted in drug treatment clinics and tuberculosis clinics in St. Louis and Kansas City and in women's health clinics in St. Louis. The surveys are "blinded," which means that personal information, including names and addresses, is removed prior to testing. These surveys will be r~peated in 1989-90 to allow tracking of trends in infection and the as- scssment and targeting of prevention efforts. In June 1988, one of the nation's first comprehen- sive packngcs of AIDS legislation was e.nactcd by tim Missouri legisla- tare. The focus of this legishtion was the protection of confidenti- ality of people with AIDS or who are infected Other Sections of this law gave DOtt the power to regulate laborutories doing mY-antibody testing, the authority to shut down establishments promo~ng unsafe sexual practices, and provided p~naltics for people who knowingiy infect others with tl~ AIDS virus. The law also gave the .Departments of Mental " Health and Corrections the authority to test prisoners and patients. The law initially con° rained a sunset provision, meaning it would expire at the end of 1989~ but that provision has been relmled. "Ongoing efforts are underway to accurately assess the rate of H1V infection among the general population in Missouri." 25 TI2506-0937

Biennial Report, FY 198811989 The F Dioxin Study orherjob, Kathy Allen n~ds to be part detective, part class reunion organizer. Allen, a biologist,'tries to keep t~ck of the comings and goings of 3,000 Missourians. To find some people, AHen has consuked driver's license files, written to postmas- ters, called reladves, and looked at state death certificates. But the group that. • absorbs AHen's interests is not bound by school ties. All have been exposed to a suspected carcinogen, dioxin, or have answered the Dioxin Health Effects questionnaire. Although dioxin was first sprayed in 1971, it was not until 1974 that it was identified as the agent of concern. The discovery 6f dioxin contamination in Missouri generated • .'ntensc publicity and public panic. Nearly two decades aRer the inci- dent, Missouri health officials are still monitor- ing tl~ health of people believed exposed to the chemical through its Missouri Dioxin Special Investigations Project. "We keep track of them, make sure we know their addresses, because there's a possiblity that studies will be done in the furore," said Allen, an environmental specialist and coordinator of the dioxin program. Thos6 included on the DOH list of l~oplo ex- posed to dioxin will be kept abreast of research news on the health effects of dioxin and may be asked to participate in research programs. The Dioxin Update, an annual newsletter including information on current research on dioxin, will be sent to all participants on the central listing. Since 1983, researchers from the DOI-I's Division of Environmental Health and Epidemiology have collaborated with the federal Centers for Disease Control in seven A cleanup crew from the Environmental Protection Agency removes dioxin contaminated ~oil using plastic sheeting to prevent contamination from spreading to previously cleaned or uncontaminated areas. TI2506-0938

studies of dioxin's effects in Missouri. Their research has been. pub- ]ished in such. scientific publications as the Journal of the America~ Medical Association, Archives of Environ- mental Contarra'nation and Toxicology, the Archives of Environ- mental Health, the American Journal of Industrial Medicine, and. the American Journal of Epidemiology. • Dioxin is the layman's word for a substance known to chemists as TCDD, or 2,3,7,8- dioxin. It was an un- wanted contaminant of the anfispectic hexachlor- phene that was manufac- tured by a Verona, Me, plant. In 1971, a L0uisi- ana waste facility sub- contracted with a Mis- souri waste oil dealer to dispose of the dioxin, but the dealer mixed, the chemical wi.th oil and then sprayed the oil on horse arenas, stables, dirt road and commercial track terminals for dust control In the days and weeks • following the spraying, dead birds, mice, cats and dogs were found around the horse arenas and stables. More than 50 horses died in the n~xt three years and the sprayed suil was exca- vated and sold. Urffortu- na~ciy, it was used as fill for s~veral nearby homes. To date,45 sites have ~n ~d~nfified as having dioxin contamination. Those sites have more than I part per billion (ppb) contamination. One ppb is equivalent to one second in 32 yeats. Most people have been e~posed to low levels of dioxin from using hexachlotophen% some hethicides and incinera= posed" pcmon lias about I to 20 p.arts per triilion of dioxin in their bodies. Division of Environmental Health and Epidemiology '~Iumans carry body burdens of many chemi- cals including dioxin, pesticides, and various metals. Metals occur namratly and am un- avoidable and cause harm only in large doses. Although dioxin is not a 'naturally occurring' chemical, of it, the same is true. Unfommately, we don't know what dose is Not much is known about " the long-term health effect~ of such small levels of dioxin, but DOH researchers in conjunction with the federal Centers for Disease Control are studying the problem. Daryi W. Roberm, M~I., chief, Bureau of Environ- mental Epldemiology, Wahine Schramm, M.A., chief, Bureau of Data Analysis, and Brace Gibson, a research analyst with the same office, collaborat&i with other researchers on the flint study to evaluate the health status of people with ~ direct measure of "Most people have been exposed to low levels of dioxin from using hexachlorophane, some herbicides and incineration.'" TI2506-0939

Biennial Report, FY 1988/1989 "Some early studies of the health effects Of long-term dioxin exposure indicated that people exposed to dioxin had signs of lessened immune system response." dioxin in their bodies. The results of that study ar~ to be published soon. l:ligtt doses of dioxin in humanshave been . associated with: The only human health effect clearly produced by exposure to dioxin is ckloracne, a skin condi- tion rescmbling.acne. Them is suggestive evid~.nee that in humans the liver, immune system and nervous system may also be affected. Tile human evidence regard- ing eareinogenicity is conflicting. ' Dioxin has been associ- ated with cancer in laboratory rats and mice and reproduction prob- lems, such a~ spontane- ous abortion and malfor- mation, in laboratory animals. DOH researchers, in conjunction with the federal Centers for Disease Control, helped develop a blood test to accurately measure body levels ofdioxin. Previ- ously, tests had to be done on fat tissue that could be collected only through surgery, such as taking a sample of fat cells from a person's abdomen. Health officials collected fat tissue samples from 50 Missouri residents in 1985 and 1986. The dioxin level in their fat tissue was compared to the level of the elmmical in their blood. Some early studies of the health effects of long- term dioxin exposure indicated that people exposed to dioxin had signs oflesselmd immune system response. How- ever, researchers couldn't duplicate these findings when they conducted follow-up studies. TI2506-0940

DMslon of Environmental Health and Epidemiology It's coted ,¢ss, odorless and danger ous. Radon, a namrally occurring mdioamiv¢ gas, can seep into basements and accu- mulate in closed spaces. The Environmental Protection Agency calls radon the second leading cause of lung cancer in the U.S., attributing up to 20,000 lung cancer deaths a year to exposu~ In outdoor air, radon is diluted to such low concentrations that it is usually harmless. Indoor levels depend both on the concentration of radon in tbe underlying soil and the building's construe,- lion. As part ofan ongoing, nationwide, program, the lVKssouri Department of Health (DOH) and the U.S. EPA collaborated in to test radon lweis in nearly 2,000 Missouri homes. The testing program w,as designed co determine the distribution of radon in Missouri and to identify areas in the stare that might have the potential for significantly elcvamd concentrations o~ indoor radon. "Missouri is about in the middle r'~g~ of the states tha~ have been tested so far," said Ken Miller, chief, Bureau of Radio~ logical Health. "What we have found is that the distribution of radon is pretty much the same statewide. Them arc individual berets that arc high, but them is no ar~a. where the whole area is higl~" released in April 1988, showed that about 18 percent of the 1,947 homes tested-- or nearly one in five -- showed radon concentrations greater than the "action lever' of 4 picocuries per liter (pCi/l) set by the EPA. The lfighest level measured in Missouri was 51.8 pCi/I, and the average was 23 pCi/L In the seven-state EPA study nearly one in three homes had screening levels above 4 pCi/L A picocurie is a measure- ment of alpha-particle radiation and derives its name fiom "pico" for a trillionth and "curie," a unit of radioactivity named after Nobel-prize winning scientist Marie Curie. In the fn~ phase of the study, begun in Novem- ber of 1987, charcoal cannisters were placed in the basements of 1,947 homes. Since basements tend to have higi~r goncentrations of radon and there is less air circulation in homes in winter, this cannister placement should detect household radon levels at their highest, Miller said. The cannisters were collected after 48 hours and analyzed in a iabora- tory. An additional 10 percent of the homes tested were given another radon- detection device called an alpha Wack detector, or "ATD. ATD's measure alpha particles produced by radioactive decay and record them as lirde etches on plastic film. These devices are placed in Hying areas rather than basements and remain in a home for up to a year. ATD's provide a more accurate picture of average radon levels than charcoal cannisters, which.must bc removed and analyzed within a few d.ays. "Data indicate that the average concentration of radon may be sl~gl~ly Radon'. A New Alert Prompts Study 29 T12506-0941

Biennial'Report, FY 198811989 "The Environmental Protection Agency calls radon'the second leading cause of lung cancer in the U.S., attributing up to 20,000 lung cancer deaths a year to exposure to the gas." higher in il~ northwest- em part of the state than in tt~ state as a w~.le, al~ou~ the highest measured concentration there was less tha~ 30 pCi/l;' said state health director Dr. Robert Hazmon. To monitor radon levels, ATD's were placed in 234 randomly selected Missouri homes for a year and the devices were sent to the EPA in March 1989. Results am pending. State officials offered to send ATD's to 77 Missouri homes identi- fied in tim in/tial survey as having radon concen- trations greater than 10 p.Ci/l. Of those, 48 homeowners accepted and received ArI'D'S to plaec in their homes for a year. Eleven of tlm 48 homes had radon concen- trations great¢~ than 20 pCi/L, and were given additional ATD's for three-month measure- ments. Results of these additional surveys are pending. Cumulative State/EPA.Indoor Radon Survey Results by Department of Health Region Including 10 highest Radon Measurements in Missouri." TI2506-0942

Division of Environmental Health and Epidemiology DOH recommends additional testing in homes where radon levels exceed the action level and risk reduction measures when levels consistently are over th/s mark. "Radon is a national health problem," said Harmon, "and while levels in the state gener- ally appear robe within the n6rmal range, the department is neverthe- less encouraging Mis- sourians to test for . elevated levels in their • own homes." Testing kits are available commercially for less • than $25, and the depart- . ment will provide a list. prepared by the ]SPA of laboratories that special- ize in radon analysis. Because radon levels can vary greatly from season to season, 88 well as from room to room, a screen- ing measurement sexves • only to indicate the potential .for a radon problem. "If radon levels are shown to be eomistently above 4 pCi/l," said Harmon, "remedia[ measures can be taken to reduce eoneentratious in your home. Any risk from exposure depends upon the amount of radon "entering the structure ahd the length of time it remains in living areas." A Citizen's Guide To Radon, published by,the EPA, lists several quick, inexpensive steps that can be taken to help lower a person's risk from radon exposure: • StOP smoking and discourage smoking in ygur home. By doing so,. you should reduce your family's overall chance of developing lung cancer as well as reducing your family's risk from radon expo- 811_re. -Spend less.time in areas with laigher concentra- tions of radon, such as the basement. • Whenever practical, open doors andwin dows and turn on fans to increase the air flow into and through the house. This is espe- .cially important in the basement. • If your home has a crawl space beneath, keep the crawl-space vents on all sides of the house fully open all year. Harmon cautioned that while these actions will help reduce th~ risk ~rom radon, they generally do not offer a long-term solution. You eau find more information about permanent, cost-effective solutions to lowering radon levels in the EPA publication, Radon Reduction Methods: A Homeowner's Guide. A copy of this booklet as well as the Citizen's Guide and the more detailed Radon Reduction Techniques for Detached Houses, can be obtained from the department's Bureau of Radiologieal Health. For more information about radon testing or to obtain names and ad- dresses of Iabomtories that provide testing devices, write DOH's Bureau of Radiologiea[ Health, or call the depart- ment's Radon hotline, which began operation in October 1988. The number is 1-800-669- 7236. "Radon is a national health problem," said Harmon, "and ...the department is encouraging... Missourians to test for elevated levels in their own homes." 31 TI2506-0943

Biennial Report, FY 1988/1989 Measles I School ~n ~e middle in of December of 1988. Measles ~cHy ~ad Missouri Ct~ ~b~b~ school • ~e=. By ~e fo~ow- woNe~ had reentered mom,~ ~d fo~ ~at a~ut 4~ were co~ed me~les e~. It w~ ~'s wo~t ombm~ of m~es ~ a decade. dep~em woNe~ b~ded mge~er a~smr ~ost 42,~ dos~ of ~ Mea~es, ~ps ~d Rumba vac~me, or of seNor~gb schoo~ smde~, s~d Ste~e Weems, a mp~enta~ve in B~u of l~- acre. ~ outbm~ sima~om, ~e O.S. Dep~ent of Ne~ ~d Sewi~' ~zaaon Co~i~o (AC~ ~co~o~ed ~u- ~g: • Students and tl~r sisters and brothers whose most recent measles vaccination was before 1980, and • Students and their bmthem and sisters vaccinated earlier than 15 months of age. Research indicates the Vacb"inO was more effective in children who • received it when they were at least 15 months old, when it no longer affected mammal anti- bodies, Weems said. The recommended age- for routine vaccination was changed from 12 to 15 men .ths in 1976. Also, a new stabilizer was added to the MMR vaccin~ in 1979 to lengthen its potency. The revaccina- tion schedule was recommended by the Centers for Disease Control to fight measles outbreaks. Jackson County commu- nities were hardest hit by the outbreak. The outbreak included 256 cases at 50 schools in the Kansas City metropolitan area, including Blue Springs, Independence and Lee's Summit. Several schools in St. Louis County and the Springfield area also experienced outbreaks. Fommately, measles was not a problem among students at Missouri's colleges or universities as it was in other.communi- ties around the nation. Measles, or rubeola, is also called hard measles or red measles and is usually associated with fever, coughing and a red, blotchy rash that lasts four to seven days. This is a common childhood disease tl~t ~s more severe in infants and adults. Complica- tions include ear infec- tion, pneumonia and" encephalitis. Two children in every 10,000 who contract measles wilt die from it, al~ough no Missourians died in the most recent outbreak. Rubella is also called German measles or 3-day measles because of the length of the illness. Its symptoms resemble measles, but half of cases occur without evidence of a rash. Children with the disease may show few or no symptoms wNle adults may experi- l TI2506-0944

Division of Environmental Health and Epidemiology enc~ one to five days of fever, coughing and headache. Pregnant women who contract this. disease early in their pm~mmcies, have a high risk ofmiscardag~ or beating babies who are crippled, blind or have other serious defects. Mumps occurs less regularly than otter common cldldhood diseases and is character- ized by swelling .and tenderness of salivary . Between 97 and 98 percent of school-age children in Missouri arc considered adequately vaccinated against measles, Weems said. Careful handling of the vaccine occupied much of health care workers time during the epidemic, Weems said. "We were taking up the vaccine early in the morning in time for clinics at 7 a.m. The vaccine ha~ to be handled under cold temperatmes, and we had to pack it jus~ fight," Weems said. , Health workers also monitored some 800 rash cases and determined that only 400 were actual measles. Fifty-three state employ- ees spent 3,310 hours working to control the outbreak by administer- ing the vaccine, helping run clinics, and coordi- nating outbreak proce- dures, Weems said, but that was small compared to the hours put in by workers in Iocal and couiaty health depart- ments, especially Jackson County. The state spent $54,384 on wages, travel, meals and lodging, and nearly $500,0~0 to purchase the vaccine, Weems said. At $16.I8 per dose, the MMR vaccine is the most expensive vaccine John R. Bagby, Jr., Ph.D. Director Iiilda ChasM, M.P.H. Acting Director 12121188--12125189 Division of Environmental Health and gpiaemiology - Overview The director for EnviromnenialHealth and Epidemiology supervises the sections of Disease Prevention, Laboratory Services, the bureaus of Radiological Health, Community Sanitation, Environmental Epidemiology, Veterinary Public Health, and AIDS Prevention. The inter- related services of these health programs focus on disease prevention a/d control. Included are responsibilities related to communicable diseases, immunizations, zoonoses, nosocomial (hospital acquired) infections, sexually transmitted diseases, community.sanitation, environment-related health hazards, occupational health, hazardous substance control and public health laboratory services. The division provides a coor&'nated approach to solving public health problems that involve community sanitation and risk assessments of hazardous substances and radioactive instruments and materials. TI2506-0945

Biennial Report, FY 1988/1989 .A fight against fraud D r. J~nes Ennis is a con-artist's has a sharp eye for drag abusers and dealem who, ~ he c~ it, "~ l~k- ~g for a ~e l~c~'" l~es have fo~d out • at ff~ey come Dr. E~s' way, ~c~"~g harem" mm into b~m~on c~tem ~d The catch? TweIve yems of professional experi- ence and a firm knowl- edge of con-artistry provided by the Missouri Department of Health's Bureau of Narcotics and Dangerous Drugs (~NDD). Take for example "Mr. Merchant Marine,'" better known as 1ohn Sawyer. He knows what it feels like to have a seam back- fire. He fell into Dr. Ennis' web on January 18, in Holts Summit, Missouri. Dr. James Ennis, right, and BNDD chief grnie ~joblom, discass the "Scum of the Month." Sawyer was on his fourth seam of the day when he went to Dr. Ermis' clinic. The trickster had already conned three.doctors out of prescdpti6ns for laudid, a sister drag to heroine, that same day. Sawyer was addicted to the drug after receiving treatment in C~llfomia and Illinois for kidney stones and intestinal complications. He then moved to Missouri to perform "acts" across the state to support his habit. TI2506-0946

Division of Health Resources Sawyer thought Dr. Eunis' clinic looked • vulnerable. Holts Summit is a tiny ~illage with a smag clinic aral not many patients were waiting to see the doctor; H¢ got right in. Sawyer= Showed Dr. ~nuis a com- plete medical history file and explained he was a merchant marine who was going to sea for • scveralmonfl~ and needed a large quantity of Dilaudid. Suspicious, Dr. P~nis the room and oared Hmest Sjoblom, chief of the Bureau of Narcotics and Dangerous Drugs in ~efferson City. Sjoblom said ~ero was a warrant, out for Sttwyer's arrest, He was wanted for obtaining controlled substances by fraud. At Sjoblom's suggestion, Ennis decided to "con con." Dr. Emais hung up the phone and returned to Sawyer. Ennis said hc could prescribe the medication, but he needed time to verify Sawyer's medical file. He mid Sawyer to come back Iater and he would • have the prescription ready for him. In the meantime, the Callaway County Sheriff's office entered the picture. When Sawyer'returned for the Dilaudid prescription, they arrested him. In March, 1989, Sawyer was convicted and sen- tenced to 10 years in prison. Although the saga of :Iohn Sawyer is complete, the tales of con-artistry proliferate through other jtinldes who arc hitting up doctors and pharma- cists across the nation for hard core medications. Dr. Ennis says one of the biggest reasons the trick- st~rs are suc~eding is thai "doctors have a tendency to want to believe what they hear. They are giving people the benefit of the doubt," he says. "What they need to do ~s follow through with their index of suspi- cion." To secure tl~ir indexes of suspicion, many doctors and pharmacists in Missouri am getting advice from BNDD. In 1982, the bureau • formed the Missouri Task Force on Misuse, Abuse and Diversion of Prescip- tion Drags. The force provides health-care professionals and lawo enforcement officials with phone counseling, lectures and a varietN of .publications about currer~ cons being used aud tips on how to circumvent the aims of drug abusers. One publication that has received national atten- tion is BNDD's Seam of the Month Ini~iatDe. The booklet is distributed to professionals throughout Investigations Conducted 1987 1988 1989 Routine Inspectkms 1987 1988 1989 TT2506-0947

Biennial Report, FY 1988/1989 Individuals Registered 1987 1988 1989 Garland Land, Director the star~. Sections of it have appeared in national publicatioim such ~ American Medical News and Medical Times. The goal Of Seam of the Month Initiative is to act as a clearinghouse for health professionals to share tclated cases experienced with "pro- fessional patients.." Emie Sjoblom says booklet was a driving force behind the health- professional n~two~ that is emerging. He says he has sccna cooperative effort made nationwide among health profession- als to stop prescription fi:aud. Missouri's BNDD phone counseling serv- ices, too, have increased dramatically since the booklet was first pub- lished in 1984. Dr. Ennis says the program helps deter drag abuse because it is geared toward prevention. "You can't catch these con-artists on down the line. $~tistics show that one out of every 14 patients is a drug abuser," Ennis says. "It's much easier to block it off at the source. Scare of the Month Initiative is certainly a .step in the right direction.'" Division.of Health Resources- Overview The dlrector.for the Division of Health Resources oversees the statistical support and health care as~arances activities of the Department of Healdt Based on the analysis of health statistics, ttu's officer advises the director of the Deparlment of Health regarding the general health status of Missourians. Other health stotistics responsibilities include monitoring the labor pool of selected health professionals in the state and monitoring the number, staffing, and utilization of haspitai~ and other health facilities. The direc, tor of the Division of Health Resources also supervises state hospital Iicensure activities, state emergency medical services, the registr~tian of Missouri handlers of controlled substances, and state health planning and development activities. Statistical services of the Department of Health primarily are assigned to the State Center for Health Statistics. The units that comprise this section collect, analyze and distribute health-related info .rlnation which promotes the better understanding of health problems and needs in Mis- souri, us well a~ spotiigh~ing improvements and progress achieved in the general health status of Missourians. Data generated by the center aid and guide the planning, develop- merit, and evaluation of programs and services of the Department of Health as well as the health.related activities of other agencies, institutions and organizations. General services of the center include: • Besides the specific statistiealpublicationsproduced by its program units, the State Center for Health Statistics (SCH$) staff prepares, edits, and publishes other reports for the Department of Health. Issues news releases to report wends in births, deaths, marriages, marriage dissolutions, abortions, family and lifestyle patterns, etc. • Provides Missouri data on vital statistics, to the National Center for Health Statistics (NCHS). TI2506-0948

Division of Local Health & Institutional Services In the remote areas of northeast Missouri where hospitals are sparse, lay midwi#es still deliver newborns. There, physicians are considered a luxury. Such is th~ story of Beverly Horst. The third child of a Men- nonite family, Beverly was delivered by a midwife. That's nothing unusual considering that • almost half the bin~ in the area occur outside of hospi~ls. But Beverly was an ex- ception, not bceause of her bixthplace, but because she Was. born with a nonfuncfioning thyroid gland, a condition that causes mental retar- dation and delayed physical growth and development if not diag- nosed and treated prop- erly. The chances for a baby to bc born with this condi- tion are only one in 5,000. Beverly's situ- ation, howe~er, is cvcn rarer tha~ the rarest, says Iim Baumgmlner, chemical chemist for the state health department's laboratory. '~It is unique in the fact that 19 of 20 babies each year are born with this condition in hospitals under the regnlar supervi- sion of a physician in Missouri. Little 'Baby Horst' didn't have either. That's where the local health departments pick up the slack and provide the services these pcop!e need;' he added. Services such as the Northeast Missouri Area Prenatal. Program and the Child Health Confer- ences help mothers like W'flma Horst handle her • -every day medical COncerlls. ,' Expectant mothers and children up to age five receive free examinations from the health department's nurses and doctors, as well as labo- ratory worl vitamins and educational literature at clinics distributed throughout the state. Recipients must bc finan- dally eligible. Consider- ing that the average family income is $14,200 in the region, which is $4,500 below the state's average .l~overty level of $18,700, the majority of the pop~ation is eligiNc. Because the Ho~t fandly was eligible, Wilma go~ to know nurse Beverly Oliver, wh5 monitored her progress while preg- nant with her second child, Amy. Ms. Oliver counseled the expecting mother about nutrition and prenatal care. She also got Wilma enthused about taking the Horst family's first child, Sheila, to the Child Health Conferences where children are regularly examined as they grow .mid develop. The two young women struck up a close relation- sh/p. During Wilma's third pregnancy, she decided to name her child after this nurse whose care enriched her family's life. After the midwife delivered the infant, Ms. Oliver stopped by the Horst home to see her little namesake. She was amazed at what she saw. Wilma~ too, was lighted with the newborn. "Little.Beverly had a • head full of th/ck, black hair," W'flma recalls. "She had as much hair as I had ever seen on a Local health centers: the front line in rural Missouri 37 TI2506-0949

Biennial Report, FY 1988/1989 "We thank the health nurses and doctors for their concern and excellent care." m Wilma Horst, mother Nurse Beverly Oliver hold, her namesake, Beverly Horst, while the infant's mather looks on. newborn, which made quite a contrast to our other two girls who were blond.'" A week later nurse Susan Ridgway made a d.sit to. the ttorst home to conduct newborn screen- ing tests to ensure the baby was healthy. Susan had to draw blood from little Beverly's heel, which was then sent to the Department of Health's laboratories in Jefferson ~2ity. When Jim Baumgartner conducted the tests he got a positive reading. Con- cemcdi he called Dr. Coleen Kivlahan in the Division of Maternal, Child and Family Health. She immediately called specialism at the Univer- sity of Missouri-Colum- bia and arranged for little Beverly to have a diag- nostic test, which con- firmed that she was a hy- pothyroid baby. "'We thank the health nurses and doctors for their concern and excel- lent care," Wilma says. I'm relieved the health professionals discovered and treated Beverly's thyroid disease so quickly." Now almost four months old, the little infant takes an inexpensive synthetic thyroid hormone to com- pensate for the imbalance in her body. "We thank God," says W'tlma, "our darling has this chance to be normal.'" TI2506-0950

Doctors told Tonya ~ Orrell she would never walk again. They were wrong. Tonya, ahead injured patient, treks thd grounds of the Missouri Reha-. bilitafion .Center in Mr. Vernon on fool With the help of a physical thera- pist, Tonya was able to discard her wheelchair and crutches and can now walk the 30-acre grounds without any assistance. "Without the physical therapi~ I doubt she would be this far along- At home she wouldn't have had such a struc~ . • tu~ed program," says Marylu Campbellt case manager and speech pathologist for Tonya. T0nya agrees. "It was the only way I could make Her injuries came from a car wreck on a dark • autumn evening in 1985. Tonya was driving on a highway ~nroute to Bolivar, Me., when her car went out of control. Tonya spem the next 7 1/2 months in a hospital and rehabilitation pro- g~.min Springfield, Me. Tonya entered the Missouri Rehabilitation Center the summer of 1987. Marylu remembers those first days when she came to know Tonya. 'q'onyi was an u~appy girl sitting in a wheel- chair not knowing where she was or what hap- pcned," Marylu says. "SI~ would get angry • when people couldn't understand her silent whispers. Her memory was damaged so badly that she would forget who I was, after I spent hours working with her." But after a few months, the wounds of mental anguish were cleansed through rehabilitation. As exemplified by Tonya's team of profes- sionals, the staff at Mr. Vcmon slrives to im- prove the conm~uctive activities of patients through therapy - to restore beth mental and physical health impaired Division of Local Health & lnstlutional Services f~om accidents or ill- nerve damage. of o~upational and physicaltherapists, for th speech pathologists, e head special educators, nurses, doctors, as well as voea- injured specialists help patients accept traumatic events that force them to reshape their lives. The program is just four years old. In 19115 the Missouri Department of Health's Division of Local Health and Institu- tional Services expanded the hospitals' services beyond its original mission of treating respiratory problems to include 10rig-term Head Injury Patients 1987 1988 198! TI2506-0951

Biennial Report, FY 198811989 Tonya Orrell, who was told she would never walk again, strolls the rehabilitation center's ground~ with her cage manager, Marylu Campbell. rehaWtlitation. As part of this new mission, head injury treatment became a highlighted area that has gained national The.program is at its maximum- 30 patients, wh/ch is one-~rd of the people who receive treatment at the c~nt~r. "Head injury rehabilita- tion is an awakening field. People used to not know Wharto do with these victims- they were put in institutions for the mentally retarded or rest homes or sent to live with family members who TI2506-0952

Division of Local Health & Institutional Services could watch at~r them," M.arylu says. "Now p~ople am fmd~ out ~¢m's holy ~¢n pafi~ leave M~ Vemo~ ~ey. ~ acq~ overly ~g ~ m ~ve mo~ ~den~y. '~ey Ie~ new w~ys of do~g ~gs, orle~ how m do eve~g ag~" M~lu Tony~ ~or ~ ~d m mle~ m~y s~ ~r her ac~de~ Some of her co.five ~ m~ss~ to ~c ~t ~de l~et. Bu~ ~ou~ a ~ci~ educator, she s~d m- le~g her ma~ Me~- w~le, a @ech pa~ol~ • ~er ~s~abt¢ able l~ag¢, ~d ~ physic~ ~d occupa- fio~ ~erapis= he]~ her w~ ~d ~. Tonya s~ ~co~s her visi~ m her s~ ~ a "memo~ ~ok." ~e ~ok c~ her pm~ss ~d ~ves Tonya ~¢ s~c~d, d~y routine ~e n~s. Cindy Hill, occupalio.nal therapist, says 'Tonya does her schedul~ clock work. She needs to do it over and over again and make it par~ of her life. One thing I teach her is l~w to prepare a meaJ, all the way fi'om the grocery .list to the kitchen table." Tonya's morale has boosted since she entered the kitchen. She never dreamed she would be cooking sloppy joes and peanut butter cookies again, not when she wasn't even able to feed herself less that two years ago. Ted Haamid, a friend receiving treatment, remembers. "She's come a long, long way. I used to feed her when we were both patients at St. lolm's Rehabilitation Center in Springfield. She was in a wheel chair the last time saw her." Tonya's sister, Marilyrm, 17, remembers Tonya's wheelchair days, too. '~he doctors mid her she would not walk gain. Therapists at Mt. Vernon didn't los~ hope and neither did Tonya. They started her out with leg braces and now she can walk on her own," Madly~. says. '~ronya works hard for every inch of progress she makes." Her determination has helped her reach the last stage of rehabilitation known as "txausitional living.'? Tonya plays softball, attends summer camps with other young adults her age, and now lives by herself in a • supervised dorm-style at- mosphere. She has her own ~oom and shares a bathroom, living morn and kitchen with up to 12 other residents undergo- ing this final phase at the rehabilitation center. Here, Tonya sets her long-term goals: She wants to live inde~nd- ently - her own.job, home and boyfriend. Inpatients Served 1987 1988 1989 Outpatients Served 1987 1988 1989 41 TI2506-0953

Biennial Report, FY 198811989 Lorna Wilson, R.N., MI.P.H. Director Occupational therapist Cindy Hills teaches Tonya everyday living skills in the kitchen so she can have a more independent life. I II I Although Tonya still has memory problems and trouble following.direc- tions at times, her progress makes her go~tls look obtainable, Matylu says. -'~I'onya is one determined girl. Her motivation and cooperation have made our job at ltae rehabilita- tion center easier," Marylu says. Divldon of Local Health and Institutional Services- Overview This Division of Local Health and Institutional Services plans, directs and evaluates the programs and operation~ of the Sectioa of Local Health Services, Bureatt of Community Health Nursing, Bureau of Primary Care, and the Missouri Rehabilitation Center located at Mr. Vernon, Missouri. The services amt programs offered by the division are coordinated through the central office and provided by district and local offices. Services include consultation to local health agencies and .evaluation of services provided by local agencies under contract with the Department of Health. TI2506-0954

Ren~ Shoge knows wt~t a nutfifionat crisis can do to a f~y. ~r ~ baby, ~, ~ca~ ~¢ was h~. ~r ~g ~, ~a wo~d c~ ag~ spi~g b~k up ~ baby fo~ she had just cain. ~s~, Re~e w~nt ~c de.or. S~ w~ wld to s~d~d baby festa md a sub~mw - o~ended. Re~, 27, ~'t affo~ ~ sub- ~m~. Sho n~ed heip but ~'t ~ow whe~ to ~m. Rm~ ~g~ Sp~ Supplem~ Food Pro~am for Womm, ~f~ C~en, ~o~ ~C. A feder~ a~te~ state he~ depa~en~ ~C h~ hei~d m~om of mo~v~ ~u~out ~ nation s~ce Con~s enacted the program into lawin 1972. Thepro- gram is designed to provide nuUitious foods to supplemem the regular diets of pregnant women, new mothers, Lufants, and children under age five who meet financial. gnidelines and are "nutri- tionally at risk" based on health and diet assess- ment. Renee found immediate relfet The Springfield WIC program provided an alternative formula Kendra could digest. A clerk issued a food voucher, which is a coupon for free supple- menus recommended by WIC, for Kendra's baby formula and for nutri- tional products such as juices and cereal. Renee has been on the WIC program for three years now. She has three children; they recoivc WIC benefits. A health assessment is made every six months by registered nurses who carefully monitor the children's iron levels to ensure they are getting the nutrients needed for Division of Maternal, Child & Family Health proper growth and development. At dfis time, the uio's weight, height, and teeth are also checked to .rf, cerdfy their need for WIC aid. Then the nutdtionist does a '~24-hour recall" with Renee to assess the childrea'S eating habits. A~er the examination, food vouchers a~ issued to supplement their dieL In the following months a nutfitionist counsels R~nee on how her family can eat healthier and more economically. Tips on how to feed picky eaters, plus ways to enforce good earing WIC mas: s a lifetime of" diffe :ence Women, infants and children provided WIC services 1987 1988 1989 TI2506-0955

Blenn|al Report, FY 198811989 "Dick Blount" s study shows the government is actually saving m6ney through its appropriations for WIC." pamphlets and through consultation. Rene.esays she gives her family meals ~ snacks high in nutrition. For example, she carries small boxes of raisins in her bag for her toddler andpre-schooler. A firm believer in the benefits of juice, Renee expelled atthCiciaUy- sweetened drinks from her refrigerator. "Some parents give their children KooI.Aid and soft drinks, but on the WIC program children drink july," Rencc says. • "My children actually prefex it. They've been healthy being on the program." Tana Lovan, nutrition educator at Springfield's WIC, says "WIC helps parents realize how im- portant nutrition is. We want parents to realize that the responsibility for nutrition lies with the parent, not the child. Our goal is for improved growth and dcvclopment, physically and mentally. We want to make our participants healthier." The need to cat right has become a community cffo~ says Mary Nau, coordinator of the Springfield Greene County WIC of:rico. '~l'he local grocery stores will t~lp mothers with food vouchers select WIC approved products. They have been very Renee Shoge watches as WIC nurse, Kathy Hayter, weighs her daughter, Kendra, 2, to ~ee if she is growing at a.healthy rate. TI2506-0956

receptive m the program. It means a lot to have everyone concerned about the health of these families." WIC's mission is tO improve the health of moflmm and c.Hldnm through food supple- ments, bt~t k is in educa-. fio~ that the program has • i~s roo~s. Ifmothem knew tha~ malnu~tion is a major cause of bLrth defects and Hgh mortal- ity rotes, fewer babies . would be born mentally • or physically retarded, says Di.ck Blount, head of the Section of Food and Nu~tion for the Missouri Department of Health and former director of " Missouri's WIC program. OATMEAL As director of the Mis- souri WIC program, Dic~ commissioned two state- wide program s~udies that documcnW.A both WIC's success in improving infant andmatemal health care and the cost- effectiveness of admini- stering the program. Based on the Missomi WIC Study, the U.S. General Accounting Office said, "We estimate that WIC decreases the proportion.of low birth- weights for infants bern to women eligible for WlCby 16 to 20 percent. WIC's effect on mean bil~a weights also Division of Maternal, Child & Family Health appears to be positive. WIC mothem appear to experience greater b~rmfit the longer they participate," Tim program also showed that the government was actually saving money through its appropriations for WlC. 'q'he.cost breaks down to tm $547 per year for each clicm, which may s~ean like a loL But hospital intensive care forjus~ one day costs more than $1,000," Dick says. • Tamara Spidle gives her 8112 month daughter, Rebekah, iron-fortified infant formulas, juices, and cereals from WIC. TI2506-0957

Biennial Report, P-'Y 1988/1989 WIC agencies statewide providing sen/ices 1987 1988 1989 Federal Grant Dollars for Missouri WIC Program ( in rail~ions of do//ars) 1987 1988 1989 "That's where alot of babies end" up when they aren't wen-nourished" during pregnancy - It's the l~St we can do. It saves the country" so much in terms of long- .term health cam." These findings helped pave the way for the expansion of WIC flLmugh morn funds and more agency sites r_hxoughout the state - a totat of $16,84:2 was allocated to the Missouri program in 1974 com- pared to mugldy $34.9 million this year. Within this 14-year period, WIC has grown from two locations in 1974 to 108 centers that serve the state today. Missouri's 12-year experience with WIC has been an innovative one. Dick Blount was a key player in the develop- ment of contracmat agreements between WIC and baby formula manu- facturers. Dick says the increasing cost of formula was absorbing WIC funds. Because the national WIC program buys 30 percent of the counwy's formula, Dick was able to cr~a~ a rebate agreement with Ross Laboratories and Mead ~ohnson Laboratories this year. WIC gets $1.09 back on every can bought - that will be a $8.3 million savings for Missouri in the firs~ year alone. Formula is an important supplement that WIC provid~ because it is an iron-fortified concentra- tion that babies need ~ ensure a wholesome diet. Tamara Spidle, a mother of two littl~ gifts, says WIC provided the for- mula when she n~Ied it. If WIC hadn't been there, she says she doesn't know if her children would have been as healthy. "I find the program very informative. I.have learned a lot about the benefits of food, and it has h~lped us out finan- cially," Tamam says. Rencc Shog¢ says she, too, is better able to fe.~d her children through WIC benefits. "It's a good thing I am on WIC so I can help feed my chil- dren fight and be able to " work around their aller- gies." Dick says that the benefits will live on in the children. "I fccl the WICpmgram has be~n a great setwic~ to the people. Infants get a good start in life when -the mother gets the nutrients she needs during pregnancy. It makes a lifetime of difference." i TI2506-0958

For 18 years, Ieremi Kroos was tmpl~l inside a voiceless body. ~s cc~b~ p~sy, a music ~n~l ~Mcr, kcp~ ~ ~ a world ap~ ~m f~y ~d ~ends. He "w~d to say some~ng, buthc co~'L EXcept for o~ or two ge~s ~d t~ious hob.taping lyac~ ~ a ~w~r ~ a head w~, ~c~ w~ mu~. Fms~at~, he • sat~ ~ wh~lch~ ~ s~nce. He wonde~d ff • c day wo~d ~mc when he co~d ~- ca~ ~y. That day arrived in October 1987 with the help of the Children with Special Health Care Need~ (CSHCN) pro- gram (at that time known asthe Missomi Crippled ~'s Service). CSHCN bought Jeremi a communication board that allows him to talk to the outside world. - A communication board is an electronic device that utilizes computer technology to enable the user to store information of his choice and recall it at will. Messages are Division of Matemal, Child & Family Health recalled, when the key- board is activated by touch, a light sensor, or a control switch. The recalled message is then translated into synthe- sized speech. JeremJ's communication board is activated by a light sensor slmppcd to his head. His board is programmed to "say" phrases and sentences. In addition, Yeremi can spell out words which are not already programmed. • "It s~vms like it's really Jeremi talking and not a computer. It's a part of him," says ffackie Eifer~ fferemi's teacher's aide at Lincoln High Scbool in Lincoln, Missouri. "He's a very colorful pcrmn with it." In his own words Case manager Sara Thelin, watches dererai, 18, operate his communication board. TI2506-0959

Biennial Report, FY 1988/1989 Medical services provided for children with handicapping conditions Jerernl smiles when asked what difference tim board has made.in his life. He told his mother. "You don't know what it's like m be able m talk after 18 years! Oh, it's so wonderfull" With the help of CHSCN, similar communication boards hecame the "voices" of I~ other chiL dren throughout the stare of Missouri last year. Communication boards are orm of the latest tech- nological breakthroughs in the field of communi- cation disorders. Last year, CSHCN invested $38,000 in communica- tion boards, says Jane Stephens, CSHCN chief of speech and hearing. For morn than half a century, CSHCN has helped families who could not afford medical care and services for their disabled childrem Throughout these 51 years of service, CSHCN has strived to keep pace with modem technology .and provide its clients with quality care. Com- munication boards have broadened horizons for children like Jcmmi. "Individuals who cannot communicate are often perceived as being mentally retarded," says Jane Stephens. "Com- munication boards have changed this perception for many individuals. Instead of only being able to respond to qtmstions from others, nons~aking individuals can now initiam conver- sation and make requests via their communication boards." 1eremi was referred to CSHCN when he was ~ years old. Over the past 15 years several CSHCN case managers have assisted the Kroos family. CSHCN has sup- plemented the Kroos' private imurance to help 1eremi receive medical care, equipment purchase and medications. When ' CSHCN began purchas- ing communication beaixis, Nancy Lyscn, medical social wo~er for CSHCN, ~uided the family through the ~valuation process and equipment purchase. One of leremi's closest friends and classmate, Rodney Fisher, 15, says the board has made an impact on their friendship and their ability to com- municate. "I used to ask him only 'yes' or 'no' questions,'" Rpdney says. "Now I push him around in his wheelchair and we talk a 1eL He's got a good sense of hamor and he goes over well with the other kids." His ~pecial education teacher, Peggy Evans, says "He's like a young person learning how to talk. I've seen a lot of growth in him this your." During the past school year, Jeremi was main- streamed into a history course in the standard high school curriculum. "He really liked being with the other kids," Evans says. "He can interact with his class- ma~es since he got the TI2506-0960

Division of Maternal, Child & Family Realth A new young man has emerged, said his mother, Norma, who has helped fferemi-program the board with slang phrases appropdat~ for a teen- ager. "You're driving crazy!" or "Hey, let's bust out of this place," added with a sarcastic, "Who said that?" am a few of Ieremi's favorite phrases. He now takes on the role. of comedian. He pokes fun a~ his sister, Sbelbi~ 14, li~ any other age b~.y. Sbelbi says b.efore ~eremi got the beard~ thefamily urdn- tcntionaliy excluded Jercmi from tl~ir conver- sations, It was jus~too hard and took too long for ~eremi to relay his message. But now it's only a matter of scanning the board with.his 1mad pointer. TI~ brother- and-sister team works almost daily on a com- puter at the Kroos' farmhouse.. Together . they play games, type . papers for class and write letters to friends and relatives. ,Tc~cmi's equipment has opened up new doors for.him that wero p~viously closed. ffe~cmi is becoming so efficient with his board chat he might be able to pumue higher education and a career, says Sam Tbvlin, speech and hearing pathologist for CCS. With the board his potential is greater. Jeremi knows what kind of work lm wants to do. "Someday I want to have a restaurant for kids;' leremi says, his bluc eyes twinkaing. With his dctcn~ination, he can probably outdo Ronald McDonald. Outpatient Services 1987 1988 1989 T12506-0961

Biennial Report, FY 198811989 III Project T First Steps he arrival of Mai~uel and Efleen Muelier's first clKld was marked by heartache for the Inde- pendence, Mo., couple. Nicole was l~orn two months premature, weighed just 4 pounds, 2 ounces, and was b]Md in one eye. Her disability and low birth weigh~ were cansed by mxoplas- mosis, a. disease often transmi~d by contami- nated cat feces or under- cooked meat. The baby's illness kept her in St. Luke's Hospi- tal's intensive cam unit for two months and strained the family's resources. Although Mucller has a job at United Parcel Service worker and health insurance, it did not cover nearly $I,000 in expenses from their baby's hospital stay. As the hospital prepared to discharge Nicole, the Muellem' got a call from Satinder Khalsa, a social worker with the Depart- ment ofHcalth. Khalsa has worked with the Muellers to reduce some medical bills associated with rented equipment, "She really tries to help," said Mrs. Mueller, who is still working with Khalsa to arrange physical therapy and day care for the baby. 'qlaey just don't say they want to help, they do help." Khalsa works with tim Muellers and other families through a program called Proje6t FLrst Steps, run through the DOH's Bureau of Special Health Care Needs in cooperation wi~ the departments of Elementary and Secon- dary Education, Mental Health and Social Services. The federally funded pilot program is designed to help Missouri families care for infants and toddlers bom with low bivzh weights or with developmental delays that may include or lead to mental retardation. "When families have a baby that has such serious problems they olten get thrown for a loop," said Khalsa. Khalsa fi~st visited the Mueller home to deter- mine what resources were available for the child." She then worked to help identify public programs that could help the baby and helped the family to better under- stand their baby's condition. Project First Steps director Mary Iolmson says the program is espe- cially helpfttt to working families like the Muellers who might not qualify for other types of public as- sistance. There are no income limitations on the program. "'A lot of families didn't get services because they were lower middle class and they didn't meet ~mancial eligibility limits," said Johnson. TI2506-0962

"While we can't help thos~ people with hous- ing assistance, wc can h~lp ~ break through th~ system,'" Eligible for the program are babies who ar~ born weighing less than 1500 grams, that's about three and a hnlf poul~ds, and are considered to be at risk for developmental disabilities. Also eligible are babies with hypoxic ischemic encephalopathy,. a condition in which the brain is damaged by diminished blood and oxygen supplies, sus- pected genetic abnor- malities such as Down's Syndrome, and other developmental disabili- ties such as spina bifida, epilepsy, blindness, deafness, congenital hem disease, cerebral palsy,. fetal alcohol syndrome, and other viral and drug- associated difficulties. Families of infants enrolled in the project are assigned a ease manager, either a nurse, soeiaI worker or speech pa- thologist, to help them find developmental, health, social and mental health services. Case managers visit families before an infant is discharged from the l!ospital to discuss the program. Families work with case managers to identify the serviees and resources they need to care for theirnew baby. "Families are telling us what they need and we're listening," said Johnson. Case managers help in obtaining such services as speech therapy, occupational therapy, physical therapy, parent edueatiort, health serv- ices, nutrition counseling, psychological services, developmental stimula- tion and developmental pre-school. Division of Maternal, Child & F~mily Health The project helps to eliminate duplication of services and waste by assigning a single case manager.who can work with different agencies to coordinate cam for the baby, said Johnson. Many families with at- risk babies might be served by several public programs, such as Medicaid, Department of Mental Health or the Division of Family Services. Between August 1, 1988 and June 8, 1989, the program has identified 565 babies eligible for the program at 12 hospi- tals in St. Louis, Kansas City, Columbia and Springfield. Of those "Eligible for the program are babies who are born weighing less than 1500 grams, that's about three and a half pounds, and are condisered to be at risk for developmental disabilities." 51 .-.:. -,~ .'..~ "#.. :.4 T12506-0963

Biennial Report, FY 198811989 "...Project First. Steps spreads responsibility for infants and toddlers among several agencies." Deanna Severance, R.N. Director babies, approximately 300 have been discharged and helped.by the pro- gram through individu- ally designed care plans. The rest will be scived by the program when they. leave the hospital, $ohoson said. But she estimated that as many as 2,100 babies are born in Missouri.each year who could benefit from the program. "Early intervention wodcs;' said Jotmsom Money spent on early intervention reduces the amount of services required for a child entering school, she said. "ChiT~n's lives will be more productive, more enriched because of this program," Johnson said. "It will make kids' lives The program is a "last. dollar" effort, meaning. that all other payment means - i.e. insurarlce, Medicaid, etc. - must be explored and exhausted before th/s program kicks in, says Johnson. While the Department of Elementary and Secon- dary Education is primar- ily responsible for special education for school age children, Project First St~ps spreads responsi- bility for infant and toddlers among severat agencies. Iolmson says DESE is working to find ways to help children between the ages of three and five, the interim between children serv~,d by the Project First Steps program and the schoot system. Legislation to extend the program did not pass in 1989, but Johnson hopes it will be reintroduced in 1990. By 1991, the statewide program of early inter- vention must be in place to continue receiving federal sappoxt, Johnson said. Division of Maternal, Child and Family Health - Overview This division assists the director of health in the planning, policy development, evaluation and direction of statewide maternal and child health programs. Those programs are administered through the following bureaus in the division: perinatal health care, child and adolescent health care, children with special health care needs, food an4 nutrition services, and dental health. T12506-0964

"Legislative Update • "Pne Office of Governmental Affairs assists in the development of key public heaith legislative concepts w~th Department of Health personnel, advocacy groups, and legislators. As a result, the department keeps involved and informed on state and • federal public health issues in a coordinatexl approach. The Missouri General Assembly passed the following successful legislation during fiscal years 1988 and 1989. FiscalYear 19.88. Hospfial Subsidy; Dispropo~'tionate Share (SCS HB 1134) allows more 1V~souri hospitals to provide care to low income patients. The legislation calls for $4.2 million in general revenue funds to be used to generate $6.2 million in federal matching funds for a total of $10A million. This additional funding will allow the state to pay higher rates for Medj'caid services to more hospitals that serve large numbers of low income patients. The legislation allows hospitals whose patients include a dispropo~onate share of indigent Mis- sourians to choose between remaining in the state's existing Hospital Subsidy Program or entering this new program. Other sections of the bill address related issues, including: • Hospital Inspections; Licensure Fee Increase - The Department of Health shatl have sole authority to inspect hospitals and shall make inspections at least annually. The depamnent may disclose the final inspection reports. Beginning July 1,1989, any application for license f-rom a medical treatment facility shall also include an armual license fee of $250 plus $3 per bed for the first 400 beds and $2 per bed thereafter. • Epidemiology Confidentiality - The department may receive information from patient medical records for the purpose of conducting epidemiol- ogieal studies. Such information shall be confi- dential except that a statistical aggregate may be released. No person or organization shall be liable for providing information to the depart- ment. Any person who releases information which violates this section shall be guilty of a class A misdemeanor. AIDS (SCS HCS HBs 1151 & 1044) Laboratory testing for HIV or its antibodies will be done only by physicians, hospitals, or those authorized by the Deparanent of Health. Except as othenvise pro- vided by the bill, physicians, hospitals, and other persons taking blood samples for ttlV testing will report the identity of those with confirmed HIV infee.tion to the Deparunent of Health. • Confidentiality- Disclosure of the identity of infected persons is described, as is immunity from liability for disclosure to various persons, so long as it is not done in bad faith or with conscious disregard. Negligent violation of confidentiality provisions will incur civil liability for actual damages, court costs, and legal fees; willful violation will incur further lia- bility for exemplary damages. Those who in good faith report the identity of a person tea- TI2506-0965

Biennial Report, FY 1988/1989 I II I III II I sonably behoved to have HIV inf~tion to the Department of Health or assist in an investiga- tion of or judicial proceeding against such a person will also be immune from civil liability. Conununication between the person tested and the physician, hospital, or o~her person drawing the blood sample will b¢ privileged communica: tiom A person found to have HIV infection must di.sclose the fact to a health cam profes- sional prior to receiving care from him or her. Anonymous Testing- The Department of Health will establish throe testing sites where anonymous testing for HIV is available. The sites will be in Kansas City, St. Louis, and Springfield. Prisoner Testing - Inmates entering or leaving state prisons will be tested for I-HV infection without right of refusal. The Department of Mental Health may require testing of clients in its custody or in methadone treatment programs if there am reasonable grounds to suspect infection and clear and convincing evidence of a health threat to others if infected. Insurance - HIV testing by insurers, beatth maintenance organizadous, and health services corporations which test solely to determine eligibility for coverage will be governed by regulationof the Division of Insurance. Such firms are otherwise exempt from the big, except as regards discrimination in employment. How- ever, they will only disclose HIV test results as authorized by the applicant and to the applicant's physician or, if none is designated, to the Depamnent of Health. Improper disclosure is a violation of laws governing unfair trade practices of insurers, but existing legal remedies will also be available. Laboratories for insur- ance testing which meet certain standards may conduct HIV tes ~t~g. In renewing a policy of medical insurance, an insurer, health services corporation, or health maintenance organization may not deny or utter covexag¢ solely because of a diagnosed HIV infection and may not exclude coverage for its tmannent. • Blood Donation- A person who knows that he or she is HIV-infected may not donate blood, sperm, or organs, except for medicaI research, and may not deliberately risk exlx)sing another to the virus through sexual or other contact. Violation is a class D felony. • Discrimination- Laws governing the Commis- sion on Human Rights and discrimination protection wiR apply to those with HIV infec- tion, AIDS, or related disorders, except for infected individuals who, because of their infection or condition, pose a direct health threat to othezs or are unable to complste their employ- meat duties. • Closing Establishments - The Department of Health may seek court orders to close certain establishments used for sexual or other activities through which HIV is transmissible. • Premarital Testing- DOH may also issue rules providing for mandatory premarital HIV testing if the Centers for Disease Control support doing SO. • Reports to the Legislature - DOH will prepare reports to legislative commRtees concerning HIV infection control programs and the number of infected individuals. " • Education- The Department of Elementary and Secondary Education will prepare education programs about HIV infection and its prevention for use in public schools, to be available for use at the schools' discretion at grade six and above. • tIealth Providers- A hospital, ambulatory surgical center, or nursing home will notify firefighters, poIice officers, emergency medical care pr6viders, and mortuary personnel who transport or treat a patient later diagnosed as having a reportable infectious disease as defined by the Department of HeaItlL Notification will protect the identity of the patient and exposed TI2506-0966

• School I~li~ics - I~ a Sr, hool h~ ~op~d ~Ucics on ~ ~c~on ~i~ ~ ~ ~p~en~ ofHe~ ~d ~e ~d's ~ d~os~ ~ ~ c~d'sidenfiW w ~e su~nd~t of i~ pubic school ~ct or ~c c~ ~~r ofi~ p~a~ school. ~e id~fi~ may ~ d~closed ~ ~ose dete~ng ~ fim~s to ~d ~ool ~d ~ose who h~ve a ~onable ne~ m ~ow to p~de h~ c~ se~i~s. ~e b~ h~ ~ eme~ cla~ ~d ~ e~fion da~ of ~m~r 3L Me~ Student ~ Pmgr~ ~ 1380)~ conce~ Io~ fortress p~s for ph~ci~ agr~g W p~ce ~ ~ ~. A ~t pm~ for m~c~ ~den~ ~ ~ a~ste~ by ~e ~p~ent of He~ ~er ~ ~e S~ Boa~ of pm~ ~ i~m~ medic~, ~i~cs, ~d obs~cs ~d ~e~lo~ w~ ~ ~i~ble for defe~ of ~pa~enL ~o~ b~a~ng pro~ ,con~ ~ ~ ~n~d ~ce ~e s~ of ~e p~p~ ~d accm~ ~e b~ ~ ~mbHsbes a p~ in w~ch ~e s~te ~pays Io~ for medic~ education ~d liv~g ~es ~ ~ch~ge for a ~fiod of se~i~ ~ ~ of ~e Io~ ~pa~t w~ have pfiofiW for physici~ plummet. ~e p~p~ w~ ~ fou~-ye~ medic~ ~n~ o~,H~ed physici~. Pre-Sch~l Imm~fion (CCS HCS SCS for SB ~ ~9~ pm~bi~ a ~d ~om ~g ~ or a~en~ng ~y day ~, p~ool, or nu~e~ sch~l of I0 or mo~ ~d~ ~out evid~ of i~za~on ~ ~v~ble ~I~o~ dis~. veSt.on of ~e ~ ~d ~ of racoon ~m a ~ysi~ or o~er ~ f~ or ~o~el ~~o~ ~ ~ ~b~ by ~e ~p~- mcnt ofHe~. A ~d ~t ~y ~~ may Legislation FY 1988 and 1989 continue to a~end ff fl~e immunization process has begun and proceeds according to departmental schedules. Repeal of the Seat Belt Law Sunset Clause (SCS HCS HB ]512) repeals provisions in curare Iaw stating tha~ the mandatory seat belt usage law will expire if the U.S. S~cremry of Transportation determines no later than April 1,1989, that two- thirds of the U.S. population are not subject to mandatory sea~ belt usage laws which meet federal regulatory standards. This makes mandatory seat belt usage p~rmauent in Missouri law. The bill further provides tlmt cour~ costs will not be ~ssessed for violation of ~e seat belt usage law. Cur~nt law prohibits ~e assessment of such court ~osts only in instances in which they have be~n levied on anot~r charge in fl~ same occurrence. Medicaid Expansion; Transitional Living, MRC (SCS HB 1139) makes various changes concerning • Medicaid eligibility standards and covered services, including: 1) T~e bill authorizes Medicaid coverage of medically necessary W~nspormtion to scheduled noneIective ~aunents prescribed by a phYsi- ciau. Coverage will begin on Janaury 1,1990. 2) The bill also authorizes Medicaid reimbursement for certain mental health services, including various outpatient and clinic services and rehabilitative or sub~anc~ abuse care provided by a mental healfl~ or subsmnc~ abuse profes- sional in a¢cvrdanc~ wi~ a treaunent plan. 3) Medicaid coverage will include comprehensive day r~habilitation s~rvi~s for those with dis- abHng impairments. Coverage parameters will be defined by adminisu~tive rule and services will be provided in accordance wi~ a ~reaunent plan. 4) TI~ bill also authorizes Medicaid reimbursmnent for hospice care. Hospice care is a program of medical treatment and counseling services for TI2506-0963

Biennial Repod, FY 198811989 mrminally ill patients and their families. Eli- gible hospice.s must meet federal Medicare re- quirements. 5) Currant law provides for Medicaid reimbttrse- .ment of nursing homo costs for up to four days of authorized ovexnight loaves of absence by certain nursing home patients during a six- month i~riod. This bill ingreases the limit to 12 days of leave during asix-month period. 6) If federal law ~rmiis the Division of Family Services to exclude the income arid resources of the parents of a child under age 18 in assessing his or her eligibility for Medicaid coverage of the ix~rmanently and totally disabled and to limit the exclusion to such parents, the division may do so by administrative role and Medicaid coverage of those eligible for benefits for the permanently and totaily disabled and will not b~ limited by age.. 7) The Division of Medical Services may establish a separam benefit classification for nursing home cam of patients under age 21. 8) The Division of Medical Services may admini- - ster funds appropriated for medical cam of children in the Mgal custody of the D~pamnent of Social Services. Once of Minority Health (HB I~65) establishes an Office of Minority l-lcaith within the D~pamnent of Health. It wRl monitor health programs and minor- ity health status. Various duties are assigned to the office, including the development of educational and cultural awareness programs, promoting interagency, cooperation, reviewing programs and legislative proposals, and deveaoping community resources. The bill also directs the department to include information on minority health and mortal° ity in certain reports. [~fectious Waste (CCR I-IS SCS SB 535) requires generators of hazardous waste to use the best demonstrated available technology for treatment or destruction of a hazardous waste be26rc placing it in a hazardous wasm disposal facility. I l I l Infectious wasm transferred from the premises of the gen~mtor shall be taken to a l~rmittod infectious waste processing facility or hospital for treatment, except that persons generating 100 Idlograms or less ofinfectinus waste may 1~ exempt from the treat- ment provisions. However, such persons shall certify to the transporter or landfill Ol~mtor that such exempted waste may be legally placed in a sanitary landfall. The Department of Health sh .a~l promulgate rules governing the handling and treatment of infectious waste by hospitals and such rules shall be consistent with the rules of the Department of Natural sources. Waste transported offsit¢ shall tm pack- aged and transported according to rule, except that small.quantity generators and hospitals may trans- port infectious waste to a hospital or infectious waste processing facility for treatment, or to a central collection point using their own employees and vehicles. The D~partment of Health shall provide for a registration process for hospitals treating or han- dling infectious waste. Facilities permitted to treat infectious waste shall adhere to a I:~partment of Natural Resources approved operation plan for handling and treatment. The Department of Health shall approve a similar plan for hospitals. Trans- porters or generators, except small quantity genera- tors and hospitals, shall pay a fee of $2 for each ton of infectious waste delivered to an infectious waste facility. The foe is to be deposited in the hazardous waste remedial fund. Waste transported in excess of 300 miles to a hazardous waste facility shall require an additional charge equal to 10 percent of the gross charge to deposited in the general rcvcnu~ fund. Hospitals may treat waste gencrated on the premises or the waste of other hospitals and small quantity genera- mrs pursuant to Departmcm of Health rules. Single site research facilities am exempt from inf-cctious waste processing facility pemlits. I ! T12506-0968

Any ~acility whi~ received a clean air pem~it in 1987 and which Operated tim. fa~'ty for the treat- ment of infectious waste by incineration without receiving a solid waste or hazardous waste permit shall not be issued an infectious waste facility permit. County and city ordinances may exceed solid waste provisions, provided that such ordi- names am not in conflict with th~ same. The hill contains penalty provisions and an emer- gency clause for a certain section. Regulation of All-Terrain Vehi.cles (CCP, #2 HCS lib 990) provides that all-terrain vehicles (ATVs) shall not be operated on state highways with the exception of ATVs owrmd and operated by a gov- ernmental entity for official use or ATVs operated for agricultural purposes between sumiso and sunset. When ATVs are operated on the highways, the operator must: have a valid operator's or chauffeur's liCense but is not required to have passed an examination for the operation of a motorcycIe;.operates at speeds less than 30 mph; mad have a bicycle safety flag attacl~d to the rear of the vehlcle extending at least ~vcn feet above the ground. Tim governing body of cities and counties may issue speciat permits to licensed drivers for special use of ATVs on city streets or county roads. Off-mad vehicles cannot be operated in any stream or river, except where a river or stream flows • through land owned by the.off-road operator or land he has permission to. be on. Effective lanuary 1, 1989, all ATVs in Missouri must be registered, with a fee of $10. Registration is for a three-year period. Interim Study on Nursing Shortage (HCR 09) creates a joint committee of tim Missouri C-~nerat As~mbly to make a study of the degree, if any, of tim current and furore shortage of nursing personnel in Missouri, the reasons and potentiat solutions. Legislation FY 1988 and 1989 Community Right-to-Know Law (SCS SB 765) combines the Missouri Community Right-to-Know Law with the federal Superfund Amendments and Reauthorization Act of 1985 (SARA), Title HI, emergency planning and Community Right-to- Know. Removes the Community Right-to-Know Program from th6 Depamnent of Health and places ' th~ program in the Department of Natural Re- sources. The law retains provisions requiring the reporting of stored chemicals and banned pesticides. It also mandates state and local agencies to abide by the provisions of the law. Patient Access to Medical Records (I-]B 925) estab- lishes the statutory right of a patient to reques~ and receive a copy of ttmir medical records from a provider. Allows the provider to charge a reason- able fee for duplication of the records. The provider does not have any Hability for consequences which result from the release of these records. .Certificate of Need (lib 1368) limits the use of beds allocated, for Medicaid patients in a statement for Certificate of Need. Fetal Organ and Tissue for Transplants Prohibited CrIB 1479) prohibits use of fetal organs and tissue resulting from an abortion for medical transplanta- tion if the abortion is procured for the purpose of utilizing organs or tissue for transplantation. Medical Malpractice Law (liB 1701) changes Medical Malpractice Law to clarify that post- judgment interest is allowable in a medical malprac- tice action. TI2506-0969

Biennial Report, FY 1988/'1989 FiscalYear 1989 Repeal of Sunset of AIDS Law (SB 19) Current law provides that the statutes governing AIDS testing, control education, and discrimination, which were enacted in 1988 byHCS I-]Bs 1151 & 1044 will expire on December 31, 1989. This bill repeals that expiration date,making Missoud's model AIDS legislation permanent. Local Health Departments Given Additional Authority ~SB 58) permits certain county authori- ties to establishreasonable fees tq. pay for the cost incurred in enhancing thepublic health and prevent-. ing the spread of infections,contagious, communi- cable or dangerous diseases into such county. The bill prohibits the dmdal of seffn'ce to individu- als who cannot pay the fees. The bill prohibils the fees generated for these health-related activities from being used for any other purpose. Water Testing & Resources, County Health Fees (HCS $CS SBs 112, 65,114,185, 223) concerns testing for contaminants in public water systems, water resources planning and county health fees. It directs the Department of Naun~ Resources to test for contaminants as ~equired by federal drinking water law and regulations. Community water systems will be tested annually, unless the depart- ment determines that less ~requent testing will provide equivalent health protection. Testing for lead and other contaminants in private plumbing will include "first draw" samples collected from the tap, but sampling on private property other than the water system itself will require the owner's permis- sion. Also, the department will publish an annual census which wilt list the results of the most recent test for each contaminant in each public water system. It will also issue an annual press release to local newspapers and radio stations in each commu- nity water system concerning the system's water quality test results and tw.nds. The bill adds refer- ences to the Department of Naturol Resources in statutes governing water tesfiug. The bill also permits a county commission or county hemlth center board to establish fees to cover the cost of implementing its public health ordi- nances or regulations, However, such fees will not act to hinder communicable disease control pro- grams or deny services to those unable to pay tl~m Fees will be deposited~ in the county treasury and used to support the public health activities which generated.them. Revision of Rape Payment Statute, Crime Victim's Medical Exam (HCS SB 138) Current law directs the Depamnent of Social ServiCes to pay hospitals and physicians for the otherwise uninsured costs of medical examinations o£ those who may be victims of rape. The examination is used to gather evidence for criminal proceedings. This bill allows such payments to be made for examinations involving alleged violations of chapter 566, which governs sexual offenses, and certain crimes defined in chapter 558, such as incest, endangering the welfare of or abuse of a child, child pornography offenses, or trafficking in children. The victim's guardian may give written consent to the examination. The Attorney General's forms and procedures for such forensic examinations will be developed with the advice of the Department of Health. The bill also updates current law to reflect the 1985 creation of the Department of Health. The bill also requires that minors in juvenile court who are charged with state or municipal violations other than nonfolonious municipal traffic offenses will be assessed five dollars in court costs. Proceeds will be used to supportforensic laboratories and compensation of crime victims. The Deparunent of Health will pay for laboratory tests for HIV, the vires implicated in causing AIDS, for victims of rape, sodomy, and incest if the person convicted of the crime is found to be infected with HIV when tested upon incarceration in the state prison system as directed by current law. Payments TI2506-0970

for such tests will be limited to not more than two ELISA tests per year and will cease five years after the crime was committed. Such .HIV testing win be .performed by the State PublM Health Labgora~ry. Volunteer Immunity (SB 208)provides th~ any volunteer of a nonprofit org~ization or governmen- tal entity shall be immune from personal liability for any act or omission r~ulting in damage or injury to any person intended to receive.ben~it from such volunteer's service, if he acted in good faith and within the scope of his official functions • and duties with the organization or entity and the damage or injury was not caused by the intentional or malicious conduct or by the negligence of such volunteer. Controlled Substances (CC$ HC$ $CSSBs 215, 55). codifies and expands criminal provisions dealing with controlled substances. It establishes new offenses, increases penalties, and contains provi- sion~ regarding application of the death penalty to drug-related crimes. It contains new provisions relating to precursors and registration of those who manufacture, sell: disuibute or transfer those chemicals. The bin has an effective date of July 1,1990, for those provisions relating to regulation of precursors by the Depaxlmcnt of Health. Health Care Professionals (CCS HS SB 217) allows nongovernmental agencies.or associations which grant professional recognition tO applicants for professional status as occupational therapists, physician's:assistants or respiratory care practitio- ners to register their certification program with the Department of Economic Development. A fee is charged to cover the cost of program certification. The bin also provides that persons who advertise or present themselves as registered occupational therapists, physician's assistants or respiratory care practitioners must possess certification by the department. Violators ~1 be guilty of an infraction and may be required to pay a fine of up to one thousand dolla~. Legislation FY 1988 and 1969 Child Care Development Program (HCS SB 241) establishes the '~issouri Child Care Development Program" within the Department of Social Services. The department is charged with developing a comprehensive state child cam plan and with administering a development fund created to receive money from general revenue and other sources. TI~ depamnen~ is required to have licensing enforce- ' ment policies and practices in effect witi~in two years of the effective d~e of the bill. The depart- ment is also required to establish a storewide • resource and refewal service which shall gather, update, and provide information concerning child care sexvice. The bill also authorizes the establishment of the "Child Ca~ Advisory Committee" to review the currant status of child care across the state. The bill does not apply to those day care centers exempted from licensure. Licensing of Physicians (SB 283) allows the Board of Healing Ar~s to issue a conditional, temporary license to a graduate of an accredited medical school who is a first time candidate for a medical license in this state. The license is limited and expires af~ex one hundred twenty days and cannot be renewed. The bill also extends the length of the temporary license given to a physician for teaching purposes from 30 days to 12 months. Emergency Medical Technicians (SCS SB 337) defines an emergency medical technician (EMT) as one who has completed an approved training course and is certified by the Department of Health. The various emergency me~iical procedures which an EMT may perform are listed. The bili also allows an EMT to perform cardiac defibrillation, a process of re~oring the heartbeat's normal rhythm through the use of external ~ecu-ic shock. An F_2dT may perform defibrillation as approved by the ambu- lance service's local physician medical advisor or advisory committee when voice contact by radio or telephone is main .t~dned with a physician or a TI2506-0971

Biennial Report, FY 1988/1989 registered nurse authorized by a physician. In an • emergency, the EMT may peifonn deiibrRladon prior to contacting the physician or registered nurse according to written protocols established by the • local physician medical advisor or advisoty, com- mitt~ and the Department of Health. The employer of an ]~MT will have the same physician medical advisor or advisory committee as the local ambu- lanc~ service. , County Coroners (SB 389) estabIJsbes who shall pay for the 6mbalming of a deceased body. It also provi~les which county coroner or medical examiner is responsible for p~paring the death certificate and investigating the cause and manner of death when a l~son is being transferred for medical [reannent from one county to another, Thebill also provides for the compensation of deputy county coroners. Cur~nt law does not provide for Their compensation. Board of Health (SB 390) allows members appointed to the State Board of Health to bc employed in a consulting status relevant to the, member's profes-, sion. Children's Services Commission (HCS HBs 22, 390) renames the Children's Service Commission the "Missouri Children's Service Commission" and replaces the mem~r of the Commission from the Division of Family Services and the Division of Youth Services with a member from the Depart- ment of Social Services. It changes the meeting requirements flora a monfi'dy meeting to a hie monthly meeting and allows the Commission to meet any place in the State of Missouri rather than in ~efferson City only. It gives tlc Commission authority to him an executive dixcctor. The bill also allows the Commission to invite individuals repre- senting oth~r agencies 0r the general public to serve as ex officio members of the Commission. It adds to the Commission's du~y that of developing a plan to improve the quality of child day care programs storewide. . Community Right to Know; Underground Storage Tanks; and Asbestos Abatement (CCS SCS HCS HB 77 & HCS HB 78 & HCS HB 356) addresses three areas relating to environmental control: (1) Community Right-to-Know; (2) underground storage tanks; and (3) asbestos abatement. " The Community Right-to-I~ow provisions addxcss the location and marking of hazardous substances and create the Missouri Rmergency Response Commission. The underground storage tanks provisions requkc owners of underg~und storage tanks ~sed to store or dispense certain hazardous substances and petroleum products to notify the, Department of ~atural Resources. The bill also creates the Underground Storage Tank Insurance Fund. All owners or operators of under- ground storage tanks shall pay a $100 fee per tank to the fund. Participation in the fund is optional. The asbestos abatement provisions anthodze ~e Department of NaRaalResouroes to promulgate ruies and regulations pertainng to asbestos abate- ment and accreditation of persons involved in such an activity. Persons engaged in asbestos abatemen~ shall obtain certification before conducting such an activity, Certification will be granted [o those persons that have successfully completed an EPA approved maining course and have passed an exam on Missouri or local asbestos statutes. Mining Waste (HB 321) authorizes the director of tho Deparl,rnent of Hatural Resources to coordinate environmental programs gor the processing of metallic minerals waste management permits. Operators or persons seeking to operate a metallic minerals waste management area under a National Pollution Discharge Elimination System pert'nit or dam safety permit shall apply for a metallic miner- als wast~ management permit. " State Procurement and Plastics (HCS HBs g38, 440, 96, 97) directs the Office of Administration m make efforts to purchas~ certain pmdac~s that utiliz~ TI2506-0972

recovered materials, to reduce and ~liminat¢ pur- chase of chlorofluomcarben (CFC) produced pclystyren~ foam pmductsand tq purchase certain products that are manufactured using recovered materials. Also, state agencie~ are required to institute recycling.programs for waste paper and aluminum containers. Food or beverage containers made of CFC produced polystymn~ foam arc prohibited in this state. Other CFC produced foam products shalt comply by 1992.. • Plastic six-pack yokes that am not degradable am prohibited in this state: Plastic c0ntainvrs shall be coded to facilitate separation for ~ecycling. Earthquake Emergency Compact (HB 561) provides for the ratification of an interstate earthquake emergency compact by the General Assembly on behalf of Missouri.-The purpose of the compac~ is • Legislation FY 1988 and 1989 to provide mutual aid among the memI~rs of the " compact in the ~vent of earthquakes or oth¢r seismic disturbances. Child Health Insurance Reform (HB 795) cquires that health iusuranc~ policies which extend cover- age to family members offer coverage for"child health supervision services," which are periodic reviews of a ctdld's physical and emotional status made by a physician or pursuant to a physician's supervision. The bill states the approximate inter- vals at which such reviews should be made. Such coverage would be subject to the same limits, deductibles and copayments as other coverages • under the policy. The offer of such benefits would have to be in writing and could be rejected by the individual policyholder or by the contract holder. TI2506-0973

Missouri Department of District and County Health Services O District Offices (6) "~" Area Offices (8) • City Health Departments (7) I Td-County Haal~ Department (1) U No Locally Organized Health Units (6) [] Heallh Units-County Commissions [] Health Depadments- County Boan:l of or Charter Counties (24) TrusteesAdministration (81) St.Joseph Independence KansasCity Raytown (816) 353-9902. Jo~in (417) 625.3195 Northwestern District Mary LouAndsrson, RN, Admir~lstrator 219 N. Chestnut, I~x 230 Cameron, MO 64429 (816)632-21D7 |- Springfield Southwestern District Richard McDowell, Administrator 1150 E. Latoka, P.O. Box 777 Springfield, MO 65801 " (417) 837-6855 Northeastern D|sWiot. Kenneth Freeman, Administrator 250 P~tton, P.O. Box 309 Macon, MO 63552 (816) 385.3125 Hannibal West Plains (417} 2568126 Rolla (314) 364-3888 Southeastern Disl~ict Ron Cares, Administrator 2875 James Boulevard Poplar Bluff, MO 63901 (314) 785-9634 Columbia (314) 882-9861 Central District LeRoy VanLoo, Administrator 907 Mlssoud Bird, Jefferson City, MO 65101 (314) 751-4216 St. Louis City Eastern District Paul Saunders, Admin. 2 Campbell Plaza 59th & Arsenal St. Louis, MO 63139 {314) 781-7825 Jackson (314) 889-5880. 8189 • T12506-0974

---