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WHATCOM COUNTY COUNCIL
Special Council Meeting
BOARD OF HEALTH
May 11, 1999
The meeting was called to order at 12:30 p.m. by Council Chair Marlene
Dawson in the Council Chambers, 311 Grand Avenue, Bellingham, Washington.
Also Present: Absent:
Kathy Sutter None
L. Ward Nelson
Connie Hoag
Tom Brown
Barbara Brenner
Robert Imhof
PUBLIC HEALTH ADVISORY BOARD COMPOSITION
Chuck Benjamin, Health and Human Services Director, introduced the
members of the Public Health Advisory Board and the Health and Human Services
Department (HHSD) staff.
Benjamin stated that the purpose of the Board is to advise and recommend
policies and issues to the Board of Health.
Susan Trimingham, Public Health Advisory Board Chair, thanked Nelson for
being an active member of the Board. The Board has worked on the agenda items.
They are asking for approval of the ordinance to establish the Public Health
Advisory Board and its bylaws.
Benjamin gave a history. It is the Advisory Board subcommittee and Health
Board subcommittee that established today's recommendation. He gave a history
of the Health Department. There have been many changes since 1989. The Board
of Health's responsibilities include enforcing State health regulations, supervising all
measures necessary to protect public health, and acting and enforcing local rules
and regulations necessary to preserve, promote and improve the public health.
Other responsibilities are to control and prevent dangerous or contagious infectious
disease, abate nuisances to public health, make reports to the State, and establish
fees. The Board of Health told the Advisory Board to form a subcommittee
regarding the necessary composition of the Public Health Advisory Board. The final
recommendation is that they forward amendments to Ordinance 91 -040 and WCC
24.01 and approve bylaws. He listed the proposed composition recommendation.
A name change is also recommended because the previous language stated that
the old advisory board gives advice to all issues within the agency. This name
change reflects that they advise for public health programs, and no longer advise
for substance abuse, developmental disabilities, or mental health. The composition
Board of Health, 5/11/99, Page 1
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also mandates certain expertise on the board. A transition plan allows the current
members to remain there until their terms would expire.
Brenner questioned whether the three members who are to represent
administrative /fiscal, nursing, and hospitals are going to be a cross - section of those
groups. Trimingham stated that they looked at the programs the HHSD offers and
made suggestions accordingly.
Brenner suggested that the three positions be separated into specific
expertise representation. Trimingham stated that many people serve dual
purposes.
Brenner suggested wording that the two areas are definitely included in the
composition. Benjamin stated that they didn't want to earmark every position for
expertise so that they could have flexibility of membership representation in other
areas.
Imhof stated that the purpose of giving them the direction was to give them
the flexibility. The members go to the Council for approval, who can ensure that
the representation is present.
Hoag questioned the wording regarding consumers and professionals. Most
of the representatives look like professional positions. She questioned the
difference between the current Board and the change. She questioned whether
they are losing consumers. Benjamin stated that they are to provide services
throughout the community. Page 11 of the packet outlines the changes. They
currently do not have a natural science representative from higher education. The
Business /Industry will be reduced to one position.
Hoag stated that, on page 7 of the substitute packet, the bylaws call for the
Public Health Advisory Board to broadly represent the demographic character of the
County and consist of persons who are representative of consumers and
professionals in the various programs under the public health. She requested
clarification on the term "public health." The sentence doesn't make sense the way
it is proposed, and needs to be fixed.
Nelson stated that he would change it to, "...various programs under t#e
public health."
Hoag suggested, "...various programs � �trt- deF ttrhie relating to public health."
The Board concurred.
Hoag questioned why section 24.01.090 was stricken. Benjamin stated that
it has been 10 years since there was a Health District. The Health Department
doesn't have any consensual contracts.
Hoag asked why there was a non - consensual section. Benjamin stated that
there are contracts longer than 10 years that continue.
Board of Health, 5/11/99, Page 2
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Hoag asked about unexcused absences, in section 1.9. Benjamin stated that
the Advisory Board felt there shouldn't be any excused absences, because a
member is making a commitment to serve the community. The language change is
still flexible. It is at the discretion of the Advisory Board. It would not be an
administrative call.
Hoag stated that if they remove " unexcused," and don't apply the bylaw
consistently, then it would create an awkward situation. Benjamin stated that is
when he would consult with the members regarding their actions.
Nelson questioned who decides what an excused or unexcused absence is.
Making that determination would create a burden for either Benjamin or the chair of
the Advisory Board. Also, they have to make sure there is always a quorum. This
is a tool for a committee to have a quorum to do business. It takes the burden
from whoever would have to assume that responsibility. It would still have to go
through the Board of Health for approval.
Brenner stated that an absence is excused if the board is made aware ahead
of time. She would prefer that " unexcused" be left in the language. Because it
isn't harsh. She suggested wording that would allow for removal if there is a
pattern of missed meetings.
Dawson stated that she wanted to leave it up to the Board.
Sutter stated that she was more concerned with the period of time. She
suggested three absences in one year instead of every four years. Benjamin
concurred. Regarding leaving " unexcused" in, if someone calls in every month and
gives an excuse, then they still can be on the Board. They need to have a measure
of what is okay and not okay.
Imhof questioned whether they could make amendments. He moved to
amend section 1.9 "Three absences per year may be grounds for recommended
removal..."
Hoag asked how often they meet. Trimingham stated that there are 12
monthly meetings and one or two special meetings regarding the budget.
Sutter suggested a friendly amendment to allow for three absences in any
one -year period.
Imhof accepted the friendly amendment.
Motion carried unanimously.
Brown was concerned that everyone has to have an expertise in a field to be
on the Board. There needs to be a citizen representation that does not have any
expertise, in addition to the tribal representative. Trimingham stated that she was
not appointed because she was a nurse, but because of her community activities.
Board of Health, 5/11/99, Page 3
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The Board has moved toward creating ad hoc task force subcommittees that bring
in other community members.
Nelson stated that all people are citizens. One concern is that elected
officials don't always have expertise and rely a lot on the Advisory Board. This is
an area in which he wants the experts so that he can get information from the
people that deal with the issues on a regular basis. A general citizen is not
necessarily excluded.
Dawson asked what expertise the tribal position brings. Benjamin stated
that they have to indicate in the application process why they are interested and
what they do in the field. The recommendation would be forwarded by the
Executive and confirmed by Council.
Hoag stated that under the new structure, Trimingham wouldn't be allowed
unless she indicated that she was a nurse. They need to include the people that
are affected by the decisions. Many people that are not in the field have health
knowledge.
Hoag suggested 11 members to include one citizen and an additional
business /industry representative.
Brenner agreed, but there doesn't need to be an additional business
representative. She suggested one slot be for a consumer.
Hoag stated that there are many people in the County that have knowledge
but are not a professional. They are consumers. She moved to add two more
members, one specifically for citizen and one for at- large.
Dawson asked if the tribal member is considered a consumer. Benjamin
stated that they do partnerships with the tribes.
Nelson stated that special interests come before the Council on a regular
basis. The Council will be utilizing task forces. Many times there are complex
issues, such as bloodborne pathogens. The task force format would be more
effective in including citizens and consumers that have knowledge on a specific
issue. The Board would have general knowledge on public health issues.
Brenner stated that all the advisory boards on which she serves have a
consumer component. Having someone who has dealt with the programs provides
feedback on how the programs are working.
Brenner suggested a friendly amendment to make one of the two positions a
consumer position.
Hoag accepted the friendly amendment, so that there would be one position
for a citizen and one position for a consumer. On almost any issue that comes
forward that is general in nature, citizen's can provide a point of view.
Board of Health, 5/11/99, Page 4
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Sutter questioned whether the Board's meetings are open public meetings.
Benjamin stated that they are.
Sutter asked if there is time for public input. Trimingham stated that if it is
appropriate and scheduled on the agenda, then they accept public input. In
practice, they allow someone to speak on an item on the agenda.
Hoag stated that she attended a Board meeting where someone who
attended felt like she was not listened to and was very frustrated. Trimingham
stated that was a meeting where the Public Health Advisory Board and the
Substance Abuse Advisory Board were invited to hear a presentation regarding
bloodborne pathogens.
Sutter stated that having a citizen or consumer on the Board will not
guarantee that people will not have those types of complaints.
Motion failed 3 -4 with Hoag, Brenner, and Brown in favor.
Brenner questioned section 1.10, and whether expenses cover conferences.
(Clerk's Note: End of Tape 1, side A.)
Benjamin stated that there is only one conference in which the Health
Department pays for two Board members to attend. There is some money
available to help send someone to a conference. No one is currently submitting
claims for reimbursement, but they may pay for someone's transportation to get to
and from a meeting.
Hoag called a point of order that the person to make a motion is the last
person to speak to the motion so that discussion does not go on continuously.
Sutter stated that the demographic contribution of the current Board, minus
Nelson and the Natural Science position, is an overbalance of people from the City
of Bellingham. There should be included people from other parts of the County.
Nelson moved to recommend approval of the bylaws, as amended. (Nelson
stated the motion twice, for clarification)
Motion carried unanimously.
1998 PUBLIC HEALTH ADVISORY BOARD REPORT
Benjamin stated that this is the first formal report given as an annual report
from the Public Health Advisory Board (PHAB). In prior years, they used the three -
year plan during the budget process as the report. He didn't consider that a report
from the board, it is more of an agency report.
Board of Health, 5/11/99, Page 5
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Trimingham stated that this the 1998 report. She credited the Health and
Human Services Department (HHSD) staff for help. The report is an accountability
report to the Council and community. The focus is on results for a healthier
County. They are committed to community input. There are a lot of references to
process in addition to product. They are always trying to find a balance between
the two.
Benjamin stated the mission statement of the Board and the agency. The
format of the report is around the Public Health Improvement Plan of Washington
State, centering on assessment of public health issues. Assessment takes a lot of
time. They involve as many people as they can. From that, they do policy
development, such as litter control and on -site sewer (OSS) enforcement. Then
they put together assurances to ensure the policies are working. If needed, they
then recommend more changes.
Accomplishments of the Board in 1998 include the three -year plan, the 1999
Budget, bloodborne infection policies #1 through #3, the litter control ordinance,
an increase in water program staff, and the formation of community task forces
regarding bloodborne pathogens and medical waste. Remaining issues include the
Bloodborne Infection Protection policy, needle exchange, medical waste regulation,
groundwater contamination, the leukemia cluster, and communicable diseases.
He acknowledged that this report is more appropriate than the previous
formats in the three -year plan. He also recognized valuable contributors.
Hoag questioned what a seroconversion rate is, as referenced on page 20 of
the packet. Benjamin stated that it is the increase in the HIV infection rate. The
rate has come down to what it used to be in the past. There are questions and
concerns about the spike that occurred.
Nelson stated that it is the conversion to the active virus.
Brenner asked about bio- solids on page 19. She questioned why they don't
need additional staff. Benjamin stated that the workload required would not be
beyond the existing resources. They are formally doing the activity now, instead of
the State.
Brenner asked about the bloodborne infection section and why the PHAB only
voted 4 -2 to approve policy #2 on page 21. Trimingham stated that policy two is
not the same as component two, regarding counseling and testing.
Brenner asked if the County does assessment for human mad cow disease.
Benjamin asked Brenner to defer her question to Dr. Stern.
Hoag asked about bio- solids. Benjamin was supposed to provide information
on a law that required this to be applied rather than landfilled. Benjamin stated
that he received a report, which he wanted to summarize because of its volume.
Board of Health, 5/11/99, Page 6
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Brenner asked about arrow three on page 24 regarding the health
assessment. She questioned the meaning of "at least." She questioned whether it
meant more than one public supply well.
Nelson stated that it is confusing.
Brenner asked for clarification. Trimingham stated that there was one well
that tested above the maximum contaminant level.
Hoag stated that it is fine with "at least" because it indicates that they tested
and found one, and there may be more.
Regina Delahunt, Health and Human Services Environmental Services
Manager, stated that it can be clarified. "At least" should be removed. All of the
public water supplies in the north County area have been tested, including the small
group B systems.
Brenner suggested "all public water supplies in the north County area."
Delahunt stated that they will clarify that sentence.
Brenner stated that recommendations don't work on page 26, such as bath
temperature, use of windows in the winter, and the lack of available exhaust fans.
She suggested putting filters on all faucets in the house. Benjamin stated that the
State Department of Ecology (DOE) has hired a consultant to find a more
permanent solution. The different options may include a filter for each system.
That consultant is in the process of determining the options. Until that time, this is
the best recommendation that they could make.
Brenner stated that there should be filters on all faucets. Delahunt stated
that if anyone's water is above the MCL, then DOE will install filters on showers and
supply drinking water.
Brenner stated that some people don't have showers.
Delahunt stated that the study should be done by the end of June.
Brenner stated that bullet three of the policy development regarding the
manure ordinance should say Board of Health. Benjamin stated that it refers to the
Conservation Board.
Brenner questioned where the County stands regarding enforcement and
violation of litter control. Delahunt stated that they have additional staff and have
become more proactive addressing the complaints. They will put together a
summary of activities.
Dawson stated that it was mentioned during one of the meetings that the
Sheriff can have cameras and videos in problems areas. However, the Sheriff
stated that he didn't have any.
Board of Health, 5/11/99, Page 7
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Nelson stated that the Drug Task Force has the equipment. They probably
would not loan out the equipment.
Brown stated that Fish & Wildlife use 35 -mm cameras.
MEDICAL WASTE TASK FORCE UPDATE
Trimingham stated that the Public Health Advisory Board established a
community -based task force. Joanne Linville is the representative from the Board,
Dr. Stern from HHSD serves also, and Council Member Barbara Brenner represents
the County Council.
Delahunt stated that there is a summary of the task force activities on packet
page 28. They have met twice per month since December. Many meetings through
February were educational and background informational meetings. The task force
then began going through a matrix to evaluate policy decisions. The major
question is whether there is a basis for regulating medical waste differently from
solid waste. If so, which the task force agreed that it is so, then the question
becomes what different areas of medical waste should be controlled in regards to
transportation, generation, and /or handling. The task force will discuss regional
treatment facilities. Also, they will discuss whether there should be restrictions on
medical waste disposal. There is a list of the decisions that have been made. So
far, the task force has been unanimous on all decisions. She read the five major
decisions made so far.
Nelson asked for clarification on the difference between sharps and sharps
containers. Delahunt stated that sharps need to be properly disposed of.
Brown asked if the waste haulers are picking up bio- solids and used diabetic
needles. Delahunt stated that they put them in the bottles or other containers in
the regular trash.
Brenner stated that the concern is putting them in plastic instead of glass
containers. Inexpensive containers should be available for residences. There is a
distinction between a regional facility and on -site, small -scale facilities. By right,
the County cannot regulate where any kinds of waste can come from or go to.
They need to make it clear that is not what she brought up. They are talking about
the amounts of waste.
Delahunt stated that they also discussed the need for safe transportation of
medical waste and inspection of the transport vehicles. The task force hopes to
have a recommendation by June 30.
Hoag asked if the task force will disband once the recommendations are
made. Delahunt stated that this was a short -term committee to bring forth
recommendations and then disband.
Board of Health, 5/11/99, Page 8
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Hoag asked about the medical waste generators. They should be regulated.
She asked if the task force is looking at different levels of risk. Delahunt stated
that there is a definition of medical waste.
Regarding the Center for Disease Control's (CDC) levels for pathogens,
Delahunt stated that medical waste includes the higher level CDC pathogens. If a
facility meets the definition of medical waste and is commercial, then they must
meet the regulations.
Hoag stated that a concern is that pathogens that are extremely virulent
should be treated differently than something of a lower risk or hazard. Delahunt
stated that she would make the recommendation if it is not on the matrix.
Nelson was concerned about sharps containers. They used to be separated
from the general waste stream. Usually they were separate from the household
waste stream. Delahunt stated that she would look into it. The intent was to make
it easy and affordable for the residents.
Brenner stated that she wanted to see the use of retractable needles. She's
hoping the cost will drop with increased use.
Nelson stated that diabetics don't like them because they can only be used
once. Many diabetics use a needle two or three times.
Brenner stated that, regarding the CDC levels, hospitals don't separate their
higher -level pathogen medical waste. She would like to discuss with the task force
the letter that the Health Department sent to the State regarding the bills that the
County supported. They could be enacted locally.
Hoag stated that the different hazard levels should not be separated out.
Her intent was to regulate higher -level hospitals from those that don't need that
higher level regulation.
Trimingham stated the PHAB held a retreat recently to clarify their roles and
responsibilities, look at the communication patterns among themselves, with the
Department, and with the Board of Health. They sometimes don't know what the
Council's concerns are, as a Board. The question is how to communicate and work
towards the best policies for Whatcom County.
Benjamin stated that the retreat focused on what the Board of Health wanted
the HHSD to look at. He suggested another retreat to look at issues and prioritize
them.
Nelson stated that their retreat only took four hours with a facilitator. He
commended the advisory board.
(Clerk's Note: End of tape one, side B.)
Board of Health, 5/11/99, Page 9
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PUBLIC SESSION
No one spoke.
(Clerk's Note: Meeting was recessed from 2 :05 p.m. to 2 :30 p.m.)
PUBLIC HEARING — COMMUNITY PLAN FOR REDUCING BLOODBORNE
INFECTION
The meeting was reconvened by Council Member Brown.
Benjamin laid out the format of the presentation, prior to the public hearing.
Trimingham presented a community plan for reducing the risk of bloodborne
infections in Whatcom County. The plan has evolved through a community -based
process. The origins were from the Citizens' Advisory Board, adopting policies on
bloodborne pathogens. There were also recommendations from the Substance
Abuse Advisory Board. The Board of Health approved the comprehensive policies in
1998. To implement, the plan needs community commitment and they recognized
that they also needed a task force. As the task force met, other issues emerged.
The plan has several components and focuses on making Whatcom County a
healthier place. She introduced Dr. Stern.
Dr. Greg Stern, Whatcom County Health Officer, discussed the three
components of the plan, its legal basis, information on bloodborne infections,
studies regarding effectiveness and adverse outcomes of needle exchange
programs, and value issues. Three components include risk reduction education
and outreach, counseling and testing, and a needle exchange program that includes
referral for substance abuse treatment. The first component outcomes include
increased awareness, reduction of behaviors that place individuals at risk for
bloodborne infections, and decreased incidents. Each component includes an
evaluation. Evaluation for outreach and education looks at services provided, pre -
and post- testing, client survey, and monitoring incidences of bloodborne infection.
All components are attempts to implement policy the Board of Health approved last
year regarding bloodborne infections. Education and outreach are the topic of
policy #2, and the goal is to inform, educate, and empower individuals, which
lessen their risk of obtaining a bloodborne infection.
Brenner asked if that is in the activity portion. Stern stated that this is on
the original policy on bloodborne infections. The activities are detailed in the
packet.
Stern stated that a component #2 goal is early identification. The purpose is
to provide referral, reduce risk, and do partner notification. The outcome for
component #2 to increase the number of high -risk individuals who have been
counseled and tested, reduce secondary infections of their partners, and refer them
to treatment services. Evaluation will monitor the number of referrals and number
Board of Health, 5/11/99, Page 10
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of conversations with partners who are counseled. This is related to policy #3, task
#1.
The component three goal is to reduce the spread of bloodborne infection. It
is a program to reach high -risk individuals, provide education, and pomote behavior
modification. The purpose of needle- exchange (syringe needles) is to reduce the
spread of bloodborne infection, and to remove contaminated drug paraphernalia
from circulation, reduce sharing contaminated needles, referral to services, and to
prevent transmission of bloodborne infections. Activities for component three
include and exchange of one needle for one needle, refer program participates to
substance abuse treatment, educate about risk reduction, provide information on
health care services, and counsel and test for bloodborne infections. The model
proposed is for a fixed site at the Health Department using counseling and testing
staff at current facilities. They will look for a community partner for another site.
The outcome of needle exchange is to reduce the number of discarded syringes at
public areas. The program will increase proportion of injection drug users who do
not share contaminated drug paraphernalia, decrease circulation of contaminated
syringes among those who share syringes, and increase the number of individuals
seeking substance abuse treatment. Evaluation would follow baseline data,
monitor, track educational contacts and referrals, and monitor complaints of
syringes found.
There have been questions about the legality of distributing drug
paraphernalia. The Revised Code of Washington (RCW) 70.05.060 and 70.05.070
give health officers the responsibility for prevention and containment of any
dangerous or contagious infectious diseases within their jurisdiction. The State
Supreme Court decided that the Board of Health has authority to initiate a program.
The CDC estimates that there is .5% of users in the national population (800 in
Whatcom County). The number of unduplicated admissions of injection drug users
to local substance abuse programs in the County is around 400 - 500. They don't
collect data on HIV incidents, such as acute infections. Whatcom County is 4th in
the State for AIDS rates in 1997, at 11.5 people per 100,000. AIDS is an end -
stage disease of the HIV infection. The Statewide incidents of AIDS are 11.2 people
per 100,000. Of the 1997 cases, 89% were male. Other risk factors were
calculated for women and men.
Brenner asked about female to male infection. Stern stated that would be
much lower. He focused on the drug users. Half of all new HIV infections are due
to injection drug use.
Hoag asked if the 1997 statistics were for new cases or existing cases. Stern
stated that it was for the new cases.
Stern stated that Hepatitis B is the one vaccine - preventable disease. Rates
are dropping due to the availability of the vaccine. State rates are between 2.0 to
4.7 people per 100,000.
Brenner asked if someone without a chronic infection, but a history of
Hepatitis B, can still spread it through needle- sharing. Stern stated that it is linked
Board of Health, 5/11/99, Page 11
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to the chronic infection. With an acute infection, one has the virus in his or her
blood and they can spread it. 90% of those are clear and there isn't any more virus
in the blood.
Stern stated that chronic cases of Hepatitis C are not reportable. It has
changed its risk factors. A major past risk factor was transfusions and use of
approved blood - clotting products. There has been a historical change in the blood
screening and tissue screening. There was not a test for Hepatitis C until 1990. By
then, the risk of getting Hepatitis C was 2 in 10,000. Currently, the rate of
infection is 1 in 100,000. The CDC reports that 60% of new infections are related
to injection drug use. Also, 90% of injection drug users are infected after five years
of use. Prevalent studies show between 72% and 86% rates of infection. Another
risk factor is sexual activity. The more lifetime partners, the higher the risk of
infection.
Stern stated that there are studies showing that needle exchange programs
both work or don't work. There are many factors in the infection rates. Design of
program, group comparisons, and other factors are included in the programs.
Studies should be reviewed and compared. The programs seem to be reducing the
HIV rates. Studies on the reduction of Hepatitis B and Hepatitis C are not as clear.
They need to look at the prevalence of disease in the community currently. One
sharing episode has a high chance of passing along infection. These programs are
more effective when the infection rate is lower. They are designed to keep the rate
low.
Brenner questioned whether the CDC differentiates between the studies.
Stern stated that they look at the components and effectiveness of the studies.
The more exchanges that occur, the more effective that the program will be.
Concerns about the needle exchange program are about encouraging drug
use. Literature shows that this is not true. The program includes referral and
treatment, support, and education.
(Clerk's Note: End of tape two, side A.)
Dawson asked about self- destructive behaviors. Stern stated that there are
risky sports that people engage in. The community takes on responsibility through
pooled health insurance or by the public safety folks. If they are going to be
consistent, then the question is whether they should exclude people from the
community that do anything that is risky. Addiction is a disease. A lot of people
would like to quit.
Benjamin stated that Don Pierce, Bellingham Police Chief would speak next.
Pierce stated that this has been a long process. The program is
controversial. There is not a nexus between the program and encouraging or
condoning drug use. They have to believe the science. Increased drug use is a
concern, but has not been realized. People who use drugs will take the responsible
action and exchange the needles. Through this program, the community will gain
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added protection. The police department would support this program because that
is what the community wants. Police officers are more at risk of putting their life
on the line by contracting an infectious disease than being shot. He urged support
of the program.
Dawson asked how the officers happen to get stuck by a needle. Pierce
stated that they can get stuck searching a person who has been arrested or
grappling with someone that has loose needles.
Hoag asked how the exchange program would change the risk. Pierce stated
that the needles become more valuable and are carried more safely. Fewer needles
are discarded in public areas. Individuals involved in the program care for the
needles in a different way.
Benjamin stated that the participants in the program are more careful of how
they can be handled and are more educated.
Kay Guirl, Health and Human Services Personal Heath Services Manager,
stated that they have not developed the specifics of the program yet. If it is
passed, then they need to look at procedures of current programs in other
jurisdictions.
Brown asked Pierce about his experience with the needle exchange program.
Pierce stated that they don't know a lot of people involved in Skagit County. His
experience came from reading the literature and talking with other jurisdictions. It
may not make sense, but the users do take better care of the needles.
Benjamin invited Mr. Reitz, St. Joeseph Hospital Director of Behavioral
Health, who stated that he looked at incidents of Hepatitis C among drug users.
Another convincing factor is that 30% of admissions being active IV heroin users.
Over half were women, some with children, or had a psychiatric dual- diagnosis.
The ages ranged from 16 to over 50 years old. The hospital is asked why there
isn't a program. Some folks go to Skagit County. The hospital is already doing
some of the three components. What is missing is that they only get the people
that come to them for detoxification and treatment. They are not successful at
reaching out to the active addict. This is a way to reach the active addict who is
not ready to go through detoxification or treatment.
Brenner asked about the percentage of needle users with a psychiatric
diagnosis. Reitz said that it is about one - third.
Hoag questioned what a bona fide psychiatric diagnosis entailed. Reitz
stated that it would be a diagnosis that a professional person would have come up
with, after an assessment. The diagnosis would be listed in the diagnosis and
statistical manual used for psychiatric illness. Drug addiction and dependence is a
diagnostic category in mental health.
Benjamin introduced Dac Jamison, Bellingham Police Department Lieutenant
and Substance Abuse Advisory Board Member.
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Jamison stated that three of the appointed bodies have looked at the
program and developed an extensive program. This program goes a long way to
addressing a problem. From a law enforcement program, giving the needle a value
will solve the problem of discarding needles in public places. It also educates the
users. One shooting gallery was carefully handling the needles for exchange. Now,
only someone at rock bottom is ready for treatment. With the program, they might
be able to interdict with people that are not at rock bottom. The crime rates are
related to number of drug users. From the law enforcement perspective, being able
to reach out with the education and information, in addition to the needle exchange
program, would be a good thing for the County.
Nelson asked if there is a positive impact for other emergency management
personnel, such as volunteer firemen. Jamison stated that is true for paramedics
who treat overdose situations. Park workers are exposed because they pick up the
needles. Children are exposed because the needles are discarded in public places.
Hoag stated that the incidents of leaving needles in public places are only in
hot spots. Jamison stated that in the summer, it will increase. Many times, parks
staff handle it themselves.
Hoag stated that there is already a value to needles because they have to be
replaced. She questioned what is going to make a drug user less afraid of being
arrested, if they are carrying a needle to an exchange program. Jamison stated
that they take care of the needles that they don't have to share. They would store
it somewhere it would be safe. They carry needles around now because they are
hard to get. One reason that they are share is because there isn't an abundant
supply. They take care of the needles because they want the clean needle.
Nelson stated that it is illegal to gain needles. The State does not investigate
reports regarding purchasing needles at the pharmacy. It is difficult to be assured
that they are not using it for drug use. People get needles for a variety of reasons.
Users won't purchase them in large quantities.
Benjamin recommended that the Board of Health approve the three
components. He discussed the costs. Needle exchange would cost about $12,000
per year. If there is a community partner, then only the administrative oversight
would be the cost. HHSD would be the lead agency. Not included are additional
costs from a community partner. There are six letters received from the public.
One was in opposition. The Lummi Tribe supports the program. Many in the health
field also support the program.
Dawson opened the public hearing.
Mary Kelleher, 501 - 12th Street, reported her experiences of having a child
with heroin addiction and was at -risk for HIV and Hepatitis C. She received
recovery after moving to Seattle and using their needle exchange program. Every
addict is someone's child. She supported the program, especially the needle
exchange program.
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John Thibault, 1263 Roy Road, spoke as a County resident, a mental health
professional, and as a father of a 17 -year old daughter. He supported the program
as outlined.
Katie Kellogg, 2985 Ferry Ave., works as a volunteer with HHSD, and stated
that she has researched this issue. Seattle and Tacoma have lower infection rates
because of their exchange programs. Federal studies on needle exchange
programs show that they impact the communities by not increasing drug use, not
increasing dirty syringes being left in public areas, drops in Hepatitis B and
Hepatitis C infection, more users joining treatment programs, and decreasing rates
of HIV. Despite all of these factors, science and public policy are going in opposite
directions. Individuals are concerned that they can't get clean needles safely. The
programs are safe and effective in protecting public health.
Randy Budd, 2201 C Street, Representative and a Member of the Board of
the Hepatitis Education Project, stated that he supported the program. The attitude
expressed about the value of the needle is a reality.
Arnie Cleveland 7373 Birch Bay Drive, Blaine, stated that he is a Member of
the Substance Abuse Board. He addressed the Board as a personal citizen, and
discussed personal experiences. Robbers mainly break into homes to steal things
that they can sell for drugs. This program will encourage users to get into
treatment. Also, the money for the program is much less than the cost of putting
people into the health care system. Lastly, everyone is subject to exposure.
Reducing the exposure reduces the risk to the general public.
David Moody, 2831 Lyle Street, Chairman of the Whatcom County Alcohol
and Substance Abuse Board and Task Force Member, stated that he is a past drug
user. They have investigated this issue for over two years. They reviewed many
different programs. A free needle will not entice someone into using drugs. An
addict will protect its disease by protecting the needle. It will not be left in the
bushes or forgotten somewhere. There must be a recovery component with the
needle exchange. It is important to get dirty needles off the street. This program
has been proven to do that. Also, there is not much of an interface between the
intravenous community and the drug recovery community. This is the interface
that works the best. It is important to have a recovery component. It is important
the entire program is coordinated to encourage the people to get into recovery.
Citizen, 1400 Moore, Bellingham, spoke.
(Clerk's Note: End of tape two, side B.)
Citizen continued to state that she supported the program. The population is
aware of the dangers they are facing, but they are in disease behavior. Outreach
volunteers hear requests for referrals and drug counseling and testing. The
combination of education and outreach, counseling and testing, and needle
exchange are crucial to risk reduction in the community.
Board of Health, 5/11/99, Page 15
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Lorenda Perez stated that the community needs the program to decrease the
number of cases of bloodborne infections. Heroin use is increasing among the
young adults. She sees real -life mental and emotional statistics daily. Availability
is the key to success and freedom. They need education for those with drug
addictions. Other programs are experiencing success.
Dawson closed the public hearing.
Nelson stated that two years ago, he began this issue with Dr. James, the
health officer at that time. He tried to work within the community. Recently, the
pharmaceutical association endorsed needle exchange programs, with counseling
for treatment, in reducing the cost and health impacts of drug usage. Everyone
from the community has come forward to speak in support of the program. He
wanted this to move forward.
Nelson moved to recommend the approval of the proposal.
Brenner supported the motion. One letter against the program was from a
person whom she called on the telephone. He now understands more about the
program and has a different attitude than what was stated in the letter. Most
people that are substance abusers also have problems beyond the substance abuse.
The Drug Abuse Resistance Education (DARE) program is not effective. This
program is a reality. The County needs to deal with people in the same way. If
this program prevents any instance of disease or gives a user time to fix their life
without contracting a disease, then it is worthwhile. People in the throws of drug
addiction are not responsible. Society has a responsibility to help people in pain.
They shouldn't make moral judgements of how people became users.
Dawson stated that she is fearful of people making moral judgements. A lot
of this is a mental health situation. This program allows people to fix their lives.
Brown stated that he had supervisory access of some of the biggest drug
using areas in the state, the interstate rest areas. The programs didn't reduce the
rate of dropped needles. He can't justify supporting drug shops to rent the needles
out. He can't see the conclusive evidence that the people have testified to. He
attended meetings regarding this. As the user population increases, there is a rise
in the people who seek treatment. The program sends the wrong message. It is
condoning the use.
Hoag stated that she shared Brown's concerns. People should look at what
they are trying to accomplish and how it is to be accomplished. Everyone is
concerned about bloodborne pathogen. That was the purpose of the task force, to
reduce the bloodborne infection being spread in Whatcom County. Some of the
proposals are wishful thinking. Also, it is not the needle exchange program that is
making the difference, it is the education. Sharing the needle is the point of
contact, regarding reducing bloodborne infection. The one - for -one needle program
doesn't affect the sharing, which is the cause for infecting bloodborne infections.
On page 20 of the packet, it says that a regional epidemiologist study had flaws.
One of the bullet items said that disease rates are low and there is likely not be a
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decrease in disease rates, but it may slow the rate of increased disease. It is the
education, not the needle- exchange program that makes the difference. In areas
with a needle exchange program, but no education, it doesn't make a difference.
In component #3, item #2, said that they would reduce the sharing of
contaminated drug paraphernalia. The sharing has nothing to do with exchanging
one for one. It has to with someone sitting next to the drug user, wanting the
needles. The measures of accomplishments measures the number of syringes that
were exchanged, the number of educational contacts, the number of drug
treatment referrals, the number of syringe complaints, and tracking individuals
referred to other agencies. There is nothing about monitoring whether or not the
instances of bloodborne infections have gone down. The education is the goal of
the needle exchange program.
Nelson stated that one measure is to collect baseline and longitudinal data on
incidents of bloodborne infections.
Hoag stated that she didn't notice that section. If they look at the different
studies that were presented, then they will see some show that, in some areas with
needle exchange programs, the incidents of bloodborne infections went up. There
were a number of them. It depends on the type of needle exchange program that
is being used. How the program is administered makes a difference. Education will
reduce bloodborne infections. The argument was made that, without the point of
contact, they will not be able to educate and refer. However, statistics given at the
beginning of the presentation show that there are 400 to 500 unduplicated
admissions to the drug treatment. If comparing the CDC numbers of drug users for
Whatcom County with the anticipated number of HIV and AIDS, Whatcom County is
far lower than the national average. If they are far lower on HIV and AIDS, then it
stands to reason they are also lower on drug users. She believed that the 400 -
500 statistic indicates that they are reaching the drug users. She supported
contact and education, but not giving a free needle to a drug addict.
Dawson asked how she would propose contacting the users.
Hoag stated that referrals are outlined in the other components.
Sutter stated that she supported the program. There is misconception of the
nature of drug use and addicts. Many functional people are addicts. She would
rather a value be placed on the needle so a user will exchange it rather than it be
picked up by a child. She had some questions regarding the wording of some of
the components. Under component #2 the purpose statement was changed from
testing to notification of partners. Guirl stated that it was changed due to a
meeting with some of the HIV /AIDS regional individuals. Partner notification is a
very specific component of counseling and testing. They wanted to change the
language to be more specific to say partner notification.
Sutter asked why they can't do notification, provide information, and do
voluntary testing. Guirl stated that is added in the activity section. It should state
counseling and testing.
Board of Health, 5/11/99, Page 17
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Sutter stated that the new version did not specify testing, and it should be
added.
Sutter questioned outcome #1 regarding increased numbers of individuals
obtaining counseling and testing. In order to have an increased number, there will
have to be an increased number of individuals who are drug users. It should be an
increase proportional to the number of users.
Sutter moved, on page 36 at the second bullet point under "Activities", to
add "...counseling and testing to partners of infected individuals."
Brenner suggested also adding testing above, regarding Hepatitis B and
Hepatitis C.
Sutter stated that her motion is for infected individuals of any infection.
Benjamin requested that they add the language separately.
Stern stated that word- smithing went on regarding testing and counseling
and availability of funds. Providing testing for Hepatitis B and Hepatitis C will be
another funding issue.
Brenner asked how much. Stern stated that it was left out because there is
only funding for HIV.
Sutter stated that they may not be effective in reducing bloodborne
infections if they are not offering testing to partners. Stern stated that the testing
is available, it depends on who funds it. The County does HIV testing and testing
for specific outbreaks.
Sutter stated that, until there is funding for Hepatitis B and Hepatitis C, they
need to specify the testing is for HIV. She clarified her motion, "...to partners and
individuals infected with HIV."
Hoag asked how many partners they usually deal with in the County.
Faye Jenson, Health and Human Services Public Health Nurse Supervisor,
stated that not all partners of Hepatitis B or Hepatitis C are infected. That is part of
the disease investigation. For HIV individuals, the partners are contacted.
Hoag asked how many infected partners would be covered for Hepatitis B
and Hepatitis C infections. Stern stated that chronic Hepatitis B and Hepatitis C are
not reportable, so there is not much information. Applying the 2% prevalence rate,
there would be 4,000 people with Hepatitis C in the County.
Nelson stated that is a low estimate.
Brenner stated that they need to explore that issue.
Board of Health, 5/11/99, Page 18
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The Board concurred.
Benjamin stated that they are looking into that issue. He would not want
this held up for that issue.
Stern stated that the response to Hepatitis C is more than just by the Health
Department. There is interaction with the medical community. They need to
decide about testing and the capacity for referral treatment. It is complicated.
Sutter withdrew her motion
Sutter moved a new bullet point to "provide testing to partners of HIV
infected individuals."
Hoag stated that she preferred the previous motion. Hepatitis C can be fatal
and it shouldn't be taken lightly. If providing testing for AIDS, then they should
provide for Hepatitis C.
Benjamin stated that a guideline of the State Public Health Improvement Plan
contains a provision to look at what is provided already in the community. If it is
the decision of the Board that the HHSD is the last resort, then they will come
forward with a funding proposal.
Hoag stated that they are already dealing with infected people. The majority
of the population has not been tested, so the number of people that have it is
unknown. Stern stated that the estimate is not pulled out of the air.
Brenner stated that if it is just partners of those they already know are
infected, then it won't be too much.
that.
Sutter asked to give them direction for a proposal for funding something like
The Board concurred.
Motion to add a new bullet point carried unanimously.
Sutter moved that the Outcome be amended to increase the proportion of
high -risk individuals getting counseling, instead of the actual number.
Nelson stated that his concern is whether there is an adequate baseline.
Benjamin stated that establishing the baseline is the whole concept behind
the entire bloodborne infection plan, so that they can measure the effectiveness of
it.
Brown questioned whether the County is providing the testing for free.
Benjamin stated that it is free to the persons that they are testing, but it is funded
Board of Health, 5/11/99, Page 19
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by the federal government. He didn't believe that there was income eligibility
criterion.
Motion carried unanimously.
(Clerk's Note: End of tape three, side A.)
Sutter questioned to what "proportion" is referring to, in the first bullet point
under Outcomes in Component #3. Guirl stated that was an error on her part.
Proportion should actually be under the second bullet. Bullet #1 should be "Reduce
the number..." and Bullet #2 should be "Increase the proportion..."
Sutter stated that her last concern was about an outcome regarding
decreasing circulation of contaminated syringes among those who share syringes.
That outcome was not in the amendment. Stern stated that it was not added after
their discussion, but it should be added. The other item refers to the proportion of
those who are not sharing. The purpose of the needle exchange program is to
reduce the circulation among those that do share. There needs to be an outcome
relating to the circulation of contaminated needles.
Sutter moved that the bullet be added, "Decrease circulation of contaminated
needles among injection drug users who share needles."
Nelson questioned whether they are already measuring the amount of
needles that are not contaminated. Stern stated that is an outcome of having a
needle exchange program. Under the evaluations, they will be measuring that
indirectly. The outcome of an exchange program, besides the behavioral changes,
is specifically the proportion of needles.
Nelson questioned how they would establish the baseline for the number of
contaminated needles. Benjamin stated that they will probably not establish a
baseline for that item, but will monitor the number of complaints that law
enforcement, emergency services, or the health and human services agency
receives. They would have to monitor for at least one year, to establish a baseline
for that year.
Stern stated they need to keep in mind that this isn't a research project.
They are not proposing an epidemiological study of Whatcom County, with pre -
intervention and post- intervention. They have to make some estimates based on
the information they have from the State, based on the fact that these diseases are
not reportable. They are relying on State and local data. The idea is that they are
going to do the best they can with estimates and direct measurements when they
can, to establish baseline data. Part of the program is designing mechanisms for
evaluation and monitoring over time. They also need to keep in mind that this
program may or may not impact all of the factors involved in the infection. When
they say they can't guarantee that rates will go down, they can say that the
interventions make sense in terms of reducing the rates that it could have been, if
they didn't intervene. The data they have to work with includescurrent figures,
historic figures, and estimates.
Board of Health, 5/11/99, Page 20
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Nelson stated that they could monitor how many people have successfully
been through treatment, compared to last year.
Brenner stated that they need to know the proportion. Stern stated that
they will get both numbers.
Sutter stated that the two bullet points that need to switch the words
"proportion" and "number" are scrivener's error and don't need a vote.
The Board concurred.
Sutter stated that she had a motion on the floor regarding the decrease in
circulation of contaminated needles.
Motion carried unanimously.
Sutter moved to amend the third bullet item, "Increase the nungbe
proportion of individuals seeking substance abuse treatment."
Dawson stated that was a scrivener's error.
The Board concurred.
Hoag asked about the meaning of the term "conversion" in the Evaluation
section on page 36, regarding the conversion of partners counseled. Stern stated
that refers to positive test results after previous negative test results.
Guirl stated that is the seroconversion rate, the number of partners who
acquire the active HIV infection.
Hoag stated that she appreciated the education and counseling section,
however she was concerned that they are not doing enough testing. She wanted
more screening available to the public for these types of diseases. This may catch
people who do not realize that they have a problem, particularly those that are not
high -risk.
Dawson stated that this was already discussed.
Hoag stated that she wanted to see more testing. Stern stated that this is
broad enough to include appropriate testing and public outreach. The issue of
universal testing, or screening the general population, is frequently debated in the
public health field. They look at issues of how many cases they may detect and the
number of negative tests that they will find. They may find themselves spending
$400,000 or $800,000 to detect one case in the low -risk population. Those kinds of
valuations are important in deciding when to target screening, based on risk
groups. There are clear ways of analyzing the cost effectiveness of that activity.
The program being proposed has room to develop that as the data comes in. They
should address issues of universal testing.
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Hoag suggested a stronger emphasis on educating people on the risks of
Hepatitis C. People don't know that one can get Hepatitis C from Rhogam (sp ? ? ?)
If the statistics aren't there to support universal testing, then they should at least
educate people to let them know that they're at risk. Benjamin stated that the
education component for Hepatitis C is there. What isn't there is the testing, which
he would like to process through the Public Health Advisory Board.
Brenner questioned component one, the third bullet under Activities,
regarding networking with community groups. She suggested the language,
"Network with community groups servicing potentially affected populations,
including people of color and local tribal nations." There are other groups, such as
mental health organizations and counseling groups, who would deal with affected
populations. Churches could also be included. This should be broadened.
Dawson stated that they are dealing with a limited amount of funding, and
are focusing on the high -risk groups.
Brenner stated that people of color and the local tribal nations are not the
only high -risk groups. It needs to be more inclusive. Networking with other
community groups will not be very costly.
Dawson stated that it will take much more funding.
Brenner questioned whether her suggestion would require much more
funding. Stern stated that the question excludes networking with other groups.
Nelson suggested that they just say, "Network with community groups that
service people." Stern stated that there are higher rates of Hepatitis C among the
black and Hispanic populations.
Nelson stated that his suggestion would still leave that open.
Sutter suggested, "Network and community groups servicing high -risk
populations."
Benjamin stated that they would agree with that.
Brenner moved to amend the language, "Network with community groups
servicing high -risk populations."
The motion carried unanimously.
Brenner questioned bullet item #8 under Activities, regarding distribution of
risk - reduction materials. She questioned to whom would they distribute the
materials. Guirl stated that reflects their street outreach, in which they distribute
risk - reduction kits to teens, IV drug users, and various individuals.
Brenner suggested, "...through our community outreach."
Board of Health, 5/11/99, Page 22
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The Board concurred.
Hoag stated that education to the general public is not in the plan. It only
talks about high -risk populations. She moved to add a bullet point under Activity in
component #1: "Educate the general public as to risks they may have been
exposed to." Guirl responded that works with Purpose #1, which doesn't have an
activity to go with it.
Brenner stated that it also dove -tails with the at -risk populations.
Brenner suggested that they educate the general population on bloodborne
infection, not on risks.
Hoag stated that her point is that there is a group that has been overlooked.
They are not engaging in risky behavior, not in any high -risk groups, and are not
going to be addressed by the risk - reduction education. They just need to know that
they may have been exposed in the past. Benjamin stated that would be covered
under "risk" as long as they don't add the words "high- risk."
Hoag stated that she wanted education to the general public.
Brenner stated that specifying risks of bloodborne infections would cover
Hoag's concerns.
Hoag stated that it isn't the same thing. She wanted the public to know
about past risks that they may have encountered that they may not be aware of.
Stern stated that those are risks. As a part of this, they are coordinating with the
CDC, the Look -Back Program, which does public announcements and educates
people.
Hoag stated it is important that they be proactive, instead of hiding their
heads in the sand until it becomes a huge problem.
Hoag restated her motion to add a bullet point to component #1, "Educate
the general public to risks of exposure to bloodborne infection."
Motion carried unanimously.
Brown questioned why they are distributing educational materials to the
employees of businesses involved in drug -free workplaces, and they are not putting
them in workplaces that don't have a drug -free program. Guirl stated that it is
another connection to an activity already going on in business to help reduce risks
and substance abuse.
Brown stated that a drug -free program in a workplace is pretty self -
explanatory. There should be a bullet point that addresses locations that aren't
involved in the program.
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Stern stated that, to not specify that they are doing it to support the drug -
free program, would mean that they are going to every workplace in the County
distributing literature, whether they want it or not.
Hoag requested that they vote on each component separately.
Dawson stated that it is one program. They will not divide it.
Hoag moved to drop component #3 from the program.
Brown stated that drug use is increasing. It is because of the tolerance that
is being shown. He didn't see how they can target one group of people and give
them free needles to continue an illegal habit, while they make someone on a low -
income pay for their diabetic needles. They are giving to the illegal person and are
making the legal person pay. This program doesn't mandate an exchange of
education.
Hoag stated that it is the sharing of the needles that causes the spread of
infection, not the single user with his needle. This does not address the sharing.
They are elected to represent their constituents and spend the taxpayers' money
wisely. The taxpayers that have contacted her are very much opposed to this.
There are studies that show these types of plans cause an increase in infections.
The data isn't there to support it, which has been acknowledged. Contaminated
needles are a risk. They are disagreeing on how that problem should be solved.
The solution is not a solution.
Motion failed 2 -4 with Hoag in favor and Imhof absent.
Brenner stated that she was moved by the person who testified about the
costs. The costs of taking care of people in emergency treatment are a lot more
expensive when they have these diseases. Many of them become a burden on the
taxpayers after they become infected. They all agree that this isn't good behavior.
The issue is whether this will help to reduce the incidences. She believed that it
will.
Hoag stated that, in terms of fiscal conservatism, everyone would agree that
prevention is easier. The question is whether or not this would prevent more
incidences.
Nelson thanked everyone for their effort. Contrary to Hoag's comments, he
spent over two years researching the data. The preponderance of evidence
opposes everything she argued. The County is ranked fourth in AIDS cases, behind
counties with needle exchange programs. He deals with the frustration that people
feel regarding drugs and drug addicts on a day -to -day basis, even with legal drugs.
He looks at the issue as a health problem that requires a support network to be
solved. That is what this program is about, getting people into treatment. If they
are able to get people into treatment, they have more than compensated those that
they haven't. A fiscal conservative needs to look at this as a mechanism to get
people into treatment, get them off of drugs, and get people to become responsible
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citizens in this community through a support mechanism in a health - related
fashion. He urged the support of his fellow Council members.
Motion to adopt the plan, as amended, carried 4 -2 with Brown and Hoag
opposed and Imhof absent.
Benjamin thanked the Board for their hard work.
ADJOURN
The meeting was adjourned at 5:30 p.m.
Jill Nixon, Recording Secretary
These minutes were approved by Council on August 10 , 1999.
ATTEST:
Dana Brown - Davis, Council Clerk
WHATCOM COUNTY COUNCIL
WHATCOM COUNTY, WASHINGTON
Marlene Dawson, Council Chair
Board of Health, 5/11/99, Page 25