CHAIR'S REPORT
Human Services & Public Safety Committee
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The 63rd Annual Meeting of the Southern Legislative Conference

August 15-19, 2009

TO: Members of the Human Services and Public Safety Committee
FR: Representative John Arnold, Jr., Kentucky
Chair, Human Services and Public Safety Committee
RE: Report of Activities of the Human Services and Public Safety Committee at the 63rd Annual Meeting of the Southern Legislative Conference in Winston-Salem, North Carolina, August 15-19, 2009

The Human Services & Public Safety Committee convened on Sunday, August 16, for a business session, Monday, August 17, for a program session, and Tuesday, August 18, for a technical tour, during the 63rd Annual Meeting.  The following is a summary of the speaker presentations and Committee activities during this event.

Business Session, August 16
I.          Vocational Rehabilitation and Supported Employment
Toni King, Unit Manager, North Carolina Division of Vocational Rehabilitation Services

Background

For more than 80 years, North Carolina’s Division of Vocational Rehabilitation Services has assisted citizens with various disabilities in achieving independence and gaining employment.  During these dire economic times, states more than ever are relying on such programs for workforce development.

Ms. King’s Presentation

Ms. King began her presentation by stating that the mission of the Division of Vocational Rehabilitation is to promote employment and independence for people with disabilities through customer partnership and community leadership.  The goal of the organization is to help North Carolinians with disabilities live and work in the communities of their choice with economic and other support available to help them achieve and maintain optimal self-sufficiency and independence.  The agency comprises a range of professionals, including quality development specialists, counselors, rehabilitation staff, vocational evaluators, and casework technicians. 

The agency serves individuals with a diagnosed, chronic physical or mental disability which constitutes a significant barrier to employment.  The individual must be able to benefit from services in terms of an employmentoutcome, and must require vocational rehabilitation services in order to prepare for, secure, or retain gainful employment.

The agency provides a range of services, which include: guidance and counseling; diagnosis and treatment; post secondary, technical vocational, or other training; supported employment and work adjustment or job coaching; rehabilitation engineering; worksite, vehicle, or home modifications; and other support services to empower or enable individuals to go to work. 

During FY08-09, the agency accepted 21,878 new applications, established 12,019 new individualized plans for employment, and achieved 5,029 successful employment outcomes.  As of July 31, 2009, the salaries at time of closure ranged from $197.29 to $715.35 per week.  The average total cost for successful outcomes for that year was $3,966, and the average number of months in service was 24.88.  The average number of hours worked per week by individuals placed in employment through Vocational Rehabilitation was 29.0. 

Individuals placed in jobs through Vocational Rehabilitation work in a variety of fields.  These include: management; business and financial operations; computer and mathematical fields; legal; education and training; arts and design; healthcare; food preparation and service-related positions; sales and retail; farming and forestry; and production. 

Ms. King emphasized that Vocational Rehabilitation services are particularly valuable in these economically dire times, and unemployment rates are typically higher for persons with disabilities.  The unemployment rate in North Carolina is currently around 11 percent.  The percentage of people with disabilities in the labor force is approximately 23 percent, compared with 71.8 percent for persons with no disability.  The unemployment rate for those with disabilities is about 15.1 percent, compared with 9.5 percent for persons with no disability. 

Ms. King stated that there is a great return for the money and efforts invested in programs like Vocational Rehabilitation.  In 2008, 6,218 of the persons served by Vocational Rehabilitation achieved successful employment goals.  The average weekly earnings of these consumers before receiving employment services was $40.  Upon achieving employment, that average increased to $293.  Successfully employed individuals earned a combined total of $1.8 million per week through employment gained with Vocational Rehabilitation assistance.  Nationally, for every dollar spent on these programs, $5 will be returned in taxes from subsequent employment of consumers, and $14 to $18 will be returned to the local economy through a variety of means.  Also, tax incentives are available to employers for hiring people with disabilities and for adapting the workplace to accommodate an employee’s specific disability. 

Ms. King ended her presentation with a few success stories, including one pertaining to an individual with cerebral palsy who, through guidance and counseling and other services through Vocational Rehabilitation, is now a practicing attorney in his own law firm in the state. 

II.        Legislative Roundtable Discussion

A legislative roundtable followed the presentation which included discussion of the following topics: federal healthcare reform; laws pertaining to nursing school accreditation and admissions; food services; prison diversion and substance abuse programs; funding for trauma care; and tobacco tax increases. 

III.       Consideration of Policy Position

Representative Joni Jenkins, Kentucky, introduced a policy position regarding human trafficking, which was co-sponsored by Senator Jennie Forehand, Maryland.  The position encourages lawmakers to investigate the effects of human trafficking in their own states and to pass legislation that will address these activities.  It also encourages the U.S. Department of Health and Human Services Administration for Children and Families to work with states to further develop policies that combat crimes associated with human trafficking.  The policy position was passed unanimously by the Committee.  Subsequently, the position was adopted by the Southern Legislative Conference, Tuesday, August 18.   

IV.       Election of Officers

The Nominating Committee, chaired by Senator Emmitt Hanger, Virginia, recommended that the Human Services & Public Safety Committee elect Senator Barbara Horn, Arkansas, as its chair and Representative Sharon Cooper, Georgia, as its vice chair for 2009-2010.  The nominations were moved and seconded, and Senator Horn and Representative Cooper were elected by acclamation.

Program Session, August 17
I.          The Rise of HIV/AIDS and Teen Pregnancy in the South
R. Luke Shouse, M.D., M.P.H., Supervisor of Reporting, Analysis, and Evaluation Team for the HIV Incidence and Case Surveillance Branch, Centers for Disease Control and Prevention, Georgia
Representative Beverly Earle, North Carolina General Assembly
Evelyn Foust, Director, Communicable Diseases Branch, Department of Health, North Carolina
Kay Phillips, Director, Adolescent Pregnancy Prevention Campaign, North Carolina

Background

During the last several years, Southern states have seen the most dramatic increase of HIV/AIDS cases, as well as the greatest rise in teen pregnancy, in the nation.  States are examining the trends behind these problems and are considering ways to address them, with particular attention given to disparities among various demographic groups.

Dr. Shouse’s Presentation

Dr. Shouse began by stating that the objective of his presentation was to review terminology and basics of HIV; compare the HIV epidemic by regions of the United States; and examine the HIV epidemic in the Southern region.  First, with regard to terminology, “rate” is the number of events that occur in a defined time period, divided by the average population at risk.  “Case count” is the number of persons with the condition of interest (for HIV surveillance that means the number of people who have tested positive and have been reported). 

Core surveillance mechanisms for reporting the spectrum of HIV/AIDS morbidity and mortality is critical to this issue.  Core surveillance entails six major demarcations: HIV exposure; HIV infection (the first positive confidential test); first cluster of differentiation 4 (CD4)—the glycoprotein that is the primary receptor that the HIV virus uses to gain access to T helper cells—count; first CD4 count that is less than 200; AIDS with “opportunistic infections”; and death. 

There are several major factors that can skew reported numbers.  One of those dynamics is the existence of people who may have AIDS but have not been tested.  Another is that reporting responsibilities lie with states.  When the AIDS epidemic began in the United States, AIDS reporting was required of all states, but not necessarily HIV infection reporting.  Now, all states require HIV infection reporting, but the late “onset” can also skew the numbers.

Dr. Shouse continued by describing the extent to which the South1 is affected by rising HIV/AIDS rates.  The estimated rates (per 100,000 population) for adults and adolescents living with HIV infection (not AIDS), in 2007, were significantly higher in the South than in any other area of the country.  In six SLC states (Florida, Georgia, Louisiana, Mississippi, North Carolina, and South Carolina), that rate was 170.6 – 282.0 per 100,000 population, among the highest in the country.  In five other SLC states (Alabama, Missouri, Tennessee, Texas, and Virginia), the rate was 103.9 – 170.5 per 100,000 population, the next highest category in the country.  Even in places that were initially impacted most profoundly by HIV infection in the 1980s, such as San Francisco and New York City, infection rates today are not as severe as many areas in the South.  The South has almost double the number of HIV infections as other regions. 

In 2006, the South had approximately 17,083 cases of AIDS and an average rate of 19 per 100,000 population.  That same year, the Northeast reported 9,483 cases and a rate of 20.6 per 100,000 population; the Midwest reported 4,160 cases and a rate of 7.6 per 100,000 population; and the West reported 6,064 cases and a rate of 10.7 per 100,000 population.  Nationally, 36,790 cases were reported at a rate of 14.9.  The South reported the highest percentage of AIDS cases among adults and adolescents at 46.4 percent.  The Northeast contained 25.8 percent of cases; the West, 16.5 percent; and the Midwest, 11.3 percent.  In recent years, there has been a gradual increase in the number of people living with AIDS, due mainly to advances in treatments such as antiretroviral medications, but the South has seen the greatest increase in the nation. 

The South also has seen the greatest disparities pertaining to AIDS.  For instance, while all other regions have more males than females living with AIDS, that disparity is more pronounced in the South.  While there are more than 6,000 males and approximately 3,000 females in the Northeast living with AIDS, there are approximately 12,000 males and 5,000 females living in the South with AIDS.  The same holds true for disparities pertaining to age.  While the 35-44 age group sees the most cases of AIDS in every region, the number of cases in that category extends to over 6,000 in the South, reaching far beyond the next highest category, 45-54 (approximately 4,000 cases).  Regarding race and ethnicity, the South reports many more cases of black males living with AIDS (well over 6,000), which is significantly disproportionate to the number of white (approximately 3,500) and Hispanic (approximately 1,500) males living with AIDS.  However, the greatest disparity is seen among females.  The estimated number of black females living with AIDS in the South is close to 4,000.  Whereas, there are only around 700 white and fewer than 500 Hispanic females living with AIDS in the South. 

There are also disparities regarding type of transmission category.  For male adults, the group with the highest percentage of cases is male-to-male sexual contact (57 percent); followed by injection drug use (IDU) (22 percent); then high-risk heterosexual contact (heterosexual contact with a person known to have, or be at high risk for, HIV infection); then male-to-male sexual contact and IDU (6 percent); then finally “other” or “not identified” (includes hemophilia, blood transfusion, perinatal exposure, and risk factors not reported or not identified) (1 percent).  For females, the transmission category with the greatest number of AIDS cases is high-risk heterosexual contact (78 percent); followed by IDU (20 percent); then “other” or “not identified” (2 percent).  The South also has seen a greater percentage of cases in rural areas.  The South is experiencing what Dr. Shouse described as a “rural epidemic.” 

Death rates due to HIV disease is much higher in the South as well.  Three states (Florida, Louisiana, and Maryland) have death rates from 8.0 – 10.9 per 100,000 population, among the highest in the country.  Also, since 1987, this means that the percentage distribution of deaths due to HIV disease have been shifting from the other regions to the South. 

Dr. Shouse concluded by reiterating that the South has a significant HIV epidemic.  The region’s AIDS rate is well above the national average.  The region has the highest number of AIDS cases; the highest number of persons living with AIDS; and the greatest racial and ethnic disparities of any region.  It also is experiencing a significant “rural epidemic.”

Representative Earle’s Presentation

Representative Earle began by giving some background about her legislative district, Mecklenburg County, the largest county in North Carolina and home to the state’s largest city, Charlotte.  The county has almost 4,000 people living with HIV. 

Representative Earle then spoke about the HIV/AIDS programs in the North Carolina.  These programs are funded by a variety of sources, most notably state appropriations and federal funding.  The North Carolina General Assembly allots $15.1 million in funds to provide services for people living with HIV/AIDS.  In addition, the state receives approximately $48 million from the federal government.  Under the North Carolina program that provides drugs and healthcare, people who have incomes 300 percent of the federal poverty level or under can receive services.  There currently are 5,400 people enrolled in the program.  In addition, a variety of community-based nonprofit agencies throughout the state are awarded funds from the federal Ryan White grant.

North Carolina also has a housing program that provides funds for people living with HIV/AIDS.  The program works to assist these individuals in securing and maintaining suitable housing, noting that stable housing has been shown to contribute to healthier lifestyles, thereby reducing the likelihood that the disease will be spread. 

North Carolina also boasts a variety of robust prevention programs, Representative Earle continued.  State and federal funds are used for this purpose.  Approximately 70 percent of the people who receive these funds are African-American.  Currently, there are 80 contracts with organizations throughout the state to address such disparities in this community.  The state also employs a non-traditional testing program.  The state Department of Health is working in the community to make sure that people have access to testing and counseling during all times of the day.  North Carolina also is currently working to address problematic morbidity counties in the states, Mecklenburg being one of the highest. 

A major issue in Mecklenburg County, as is the case in many areas throughout the state and nation, Representative Earle asserted, is the number of people who are unaware that they are infected.  For this reason, the county has attempted to implement innovative testing procedures in order to address this trend.  The four main components of the prevention programs in Mecklenburg Country are risk prevention and outreach for the purpose of increased testing; jail screening (493 inmates were screened, 19 of whom were found to be HIV-positive); early intervention for people who test positive, such as strengthening the continuity of care; and medical case management (improving quality of care by assigning case managers). 

Since the inception of such programs, the county has seen a decrease in new infections and deaths related to HIV/AIDS.  However, during the current budget crisis experienced in North Carolina, as in other states, many of these programs will see major cuts in funding.
Representative Earle concluded by addressing the issue of sexual education in North Carolina public schools.  She mentioned HB8 passed by the General Assembly, which directs school units to provide comprehensive health services to all children.  The emphasis is on abstinence, but the program also provides comprehensive sexual education information as well.  The bill allows parents of students to opt-out of the program, if they choose to do so.

Ms. Foust’s Presentation

Ms. Foust began her presentation by insisting that the 10 states with the lowest ranking in overall health by the United Health Foundation all were in the South.  Regarding overall health: 14 out of 20 (70 percent) states with the lowest rankings were in the South.  Regarding lack of health insurance: 10 out of 20 (50 percent) states with the least access to healthcare were in the South.  Regarding premature deaths: 14 out of 22 (64 percent) states with the highest rates were in the South.  Regarding infectious disease: 10 out of 20 (50 percent) states with the highest rates were in the South.  Regarding children in poverty: 12 out of 22 (55 percent) states with the highest rates were in the South. 

In terms of where the South ranks regarding AIDS, Ms. Foust reiterated some of the trends described by Dr. Shouse.  Although Southern states represent only 37 percent of the U.S. population, they accounted for 40 percent of the persons living with AIDS and 46 percent of new AIDS cases in 2007.  Of the 20 states that had the highest rates of persons living with AIDS in 2007, 11 (55 percent) were in the South.  Of the 20 metropolitan areas that had the highest AIDS case rates in 2007, 14 (70 percent) were in the South.  Ms. Foust insisted that these trends are largely attributable to poverty and lack of access to care for many individuals in the region.

The South has the highest number of adults and adolescents living with AIDS in the nation, and that number increased from 1993 to 2006 at a greater rate than in any other region in the country.  In 2006, the South had the highest AIDS rate among adults and adolescents in nonmetropolitan areas (less than 50,000 residents) and in metropolitan areas.  In addition, the South had the second highest AIDS rate in cities with 50,000 to 499,999 residents.  From 2003 to 2007, deaths decreased in all regions of the United States, but the South had the smallest percentage decrease (8.5 percent). 

Rising infection rates, Ms. Foust noted, coupled with inadequate funding, as well as limited resources, have resulted in a disparate and catastrophic situation in public healthcare systems in the South.  The disproportionate impact of HIV/AIDS on populations that also experience vast poverty and inadequate support continues to fuel the challenges of reducing new infection, identifying infections as early as possible, and providing adequate care, treatment and housing. 

In North Carolina, approximately 33,000 people are living with HIV disease.  The state averages 1,800 newly reported cases of HIV each year.  Approximately 30 percent of new cases being reported are people who are in the late stages of AIDS.  African-Americans continue to be disproportionately affected by HIV disease.  Also, Latinos are the fastest growing population in North Carolina; they make up approximately 6 percent of the total population but comprise 8 percent of all new HIV/AIDS cases reported in the state.

The state receives federal funding to address the spread of HIV/AIDS.  These funds exist in the form of HIV prevention grants from the CDC ($5.7 million); HIV surveillance grants from the CDC ($1 million); STD prevention grants from the CDC ($3 million); the Ryan White HIV/AIDS Care grant ($35 million); the Housing Opportunities for People Living with AIDS grant ($2.3 million); HIV Prevention Funds from the Substance Abuse Prevention and Treatment Block Grants ($843,000); and private receipts from the Kate B. Reynolds Charitable Foundation ($500,000).  In 2007, the North Carolina General Assembly added $2 million to the HIV budget, a significant increase for the program. 

North Carolina initiated a “Get Real Get Tested” campaign in 2006 to address the growing problem of insufficient HIV testing.  The results of the campaign were profound, according to Ms. Foust.  From 2006 to 2008, HIV tests processed by the state Public Health Lab increased by 48 percent, an increase of 70,000 tests (144,000 in 2006 to 214,000 in 2008).  In 2007, there were 7,422 rapid HIV tests administered at non-traditional testing sites in the state, with 71 people testing positive for HIV.  In 2008, there were over 13,000 rapid HIV tests administered at non-traditional testing sites, as well as in jails, with 165 people testing positive for HIV.  “Get Real, Get Tested” also hosted door-to-door community testing events, and 33 people tested positive for HIV. 

There are 24 jails in North Carolina that offer HIV testing and counseling to inmates.  Funding was initiated by the CDC, and from January to September 2008, 8,188 tests were administered, with 73 inmates testing positive for HIV.  In addition, 8,791 tests for syphilis were administered, with 95 positive results.  Tests for gonorrhea, Chlamydia, and hepatitis-c also were administered.  Non-traditional HIV/STD counseling, testing and referral sites were created to address barriers to testing through collaboration with community-based organizations and leaders and through the integration of expanded services outside of the traditional public health setting and hours. 

Ms. Foust concluded by outlining best practices and strategies for addressing these trends.  Education is key, particularly informing young people about their decisions. Also, moving beyond traditional stereotypes about who gets HIV/AIDS and why they get it, also is important.  In this regard, more comprehensive approaches are needed in order to focus, not only on the people who are thought to be at risk, but on all individuals who potentially could be infected, Ms. Foust insisted.  Stigmas regarding testing need to be broken down.  Rapid testing is available today; it takes only about 25 minutes.  The sooner people find out that they are infected and get treatment, the better things will be for them and the community.  Education and treatment are paramount in limiting the likelihood that the disease will be transmitted.  Ms. Foust concluded by emphasizing that the best practice is working together to address real problems of real people and being willing to take full responsibility for the results.

Ms. Phillips’ Presentation

Ms. Phillips began her presentation by indicating that, in 2002, North Carolina began to see pregnancy rates increasing through the state.  The state approximated that there were 25,000 teen pregnancies that year, which amounts to around 68 per day.  This instigated the creation of the North Carolina Pregnancy Prevention Campaign.

The program is funded by the CDC, as well as by the state, and has lowered pregnancies in North Carolina by as much as 34 percent.  The mission of the program is to lower teen pregnancy rates in the state by providing information.  The emphasis in all of the state’s 100 counties is focusing efforts on programs that are effective, rather than simply “throwing money” at the problem.  The program has a library for staff utilization, and they have equipped over 400 people during the last year on how to perform effective outreach.  Also, given the state’s large Latino population, the Campaign includes a Hispanic outreach program.

Ms. Phillips then spoke about a new program in the Campaign, which has garnered a lot of national attention.  The program is designed to teach children about their sexuality in a responsible way, through a text messaging line.  The major goal of the program is to steer young people back to their guardians (parents, grandparents, etc.), or to health departments, but also to answer questions pertaining to sexual behavior. 

The service is in keeping with North Carolina laws, and the program has been advertised on the Internet, as well as through various print media in the state.  The staff are not medical professionals, but they provide professional, informed answers within 24 hours.  They also have links with healthcare professionals throughout the state in order to provide the most adequate information.  The service is anonymous; the only information that is recorded is date, time, and area code from where the text came. 

It took very little funding to start this program, and there is very little overhead.  It only requires the use of one cell phone through which the texts come in, and a staff person to monitor it.  The motivation behind the program, Ms. Phillips asserted, is that many young people are uneasy speaking to parents, teachers, or other adults about these issues.  The anonymity of the text line provides a safe, comfortable forum for young people to ask legitimate questions pertaining to sex.  The Campaign also provides information to other states on how to initiate such innovative programs on their own. 

Technical Tour, August 18

  1. Institute for Regenerative Medicine, Wake Forest University Baptist Medical Center and Arts Tour

Due to the joint interest in biotechnology and the economic impact it has in the state, the Economic Development, Transportation and Cultural Affairs Committee joined members of the Human Services and Public Safety Committee for a combined tour.  The first portion of the tour included a visit to the Institute for Regenerative Medicine at the Wake Forest University Baptist Medical Center; the second portion of the tour included visits to several key arts locations in the city of Winston-Salem.

For several decades, policymakers in North Carolina have focused on actively promoting biotechnology in the state.  The Wake Forest Institute for Regenerative Medicine is an important element in the state’s biotech sector and is an international leader in translating scientific discovery into clinical therapies.  According to a recent industry survey, North Carolina ranked third in the nation in the number of biotechnology companies for the fourth consecutive year, with more than 450 bioscience companies headquartered or operating in the state and employing a total of 55,000 people.  After presentations on the genesis of the Institute by scientists and officials affiliated with the Institute and Wake Forest University, members visited the laboratory where scientists were the first in the world to successfully implant a laboratory-grown organ into a human.  Members also learned about the Institute’s efforts related to creating insulin-producing cells; engineering blood vessels for heart bypass surgery; growing more than 22 different organs and tissues in the laboratory; and repairing or replacing diseased tissues and organs of soldiers injured in combat.

During the arts portion of the tour, members visited several prominent Winston-Salem arts venues including the North Carolina School of the Arts Campus/School of Film and the Sisters House at historic Salem College and the Winkler Bakery.  Milton Rhodes, president and CEO, The Arts Council of Winston-Salem and Forsyth County, North Carolina, accompanied members on this portion of the tour and provided a commentary on the economic impact of the arts in the area.

SLC Staff Contact

If you have any questions regarding this report, please contact Jeremy Williams in the Atlanta office at (404) 633-1866 or jlwilliams@csg.org.


Attendance List
Southern Legislative Conference 63rd Annual Meeting
Human Services and Public Safety Committee
August 15 – 19, 2009
Winston-Salem, North Carolina

(List reflects those attendees whose names appeared on the sign-in sheet)


Arkansas
Senator Barbara Horn
Representative Stephanie Flowers-Kirk
Representative Beverly Pyle
Kim Arnall, Bureau of Legislative Research

Alabama
Representative Howard Sanderford

Georgia
Representative Sharon Cooper
Representative Al Williams
Randi Chapman, American Diabetes Association
Frank Rogers, GlaxoSmithKline 
Lori Moore, Southern Legislative Conference
R. Luke Shouse, Centers for Disease Control and Prevention
Jeremy Williams, Southern Legislative Conference

Kentucky
Senator Denise Harper Angel
Representative John Arnold, Jr.
Representative Tom Burch
Representative Mike Cherry
Representative Joni Jenkins
Representative Mary Marzian
Representative Jody Richards
Representative Fitz Steele
Representative Addia Wuchner
Yolanda Costner, Legislative Research Commission
Kyna Koch, Legislative Research Commission
Charlotte Ellis Land, Office of the Speaker
Dee Ann Mansfield, Legislative Research Commission
Alisha Miller, Legislative Research Commission
Jodi Mitchell, McCarthy Strategic Solutions
Vicki Newberg, House Majority Caucus
Brian Traugott, Legislative Research Commission
Peggy Williams, House of Representatives

Mississippi
Senator Hillman Frazier
Representative Steve Holland
Tammy Cowart, House of Representatives

North Carolina
Senator Katie Dorsett
Representative Jamie Boles
Representative Van Braxton
Representative Beverly Earle
Representative Phillip Haire
Representative Carolyn Justus
Representative Wil Neumann
Representative Sarah Stevens
Representative Jane Whilden
Evelyn Foust, Department of Health
Kay Phillips, Adolescent Pregnancy Prevention Campaign
Dana Simpson, Society of Anesthesiologists
Holly Watkins, Department of Health
Don Willis, General Assembly
Patricia Yancey, Adolescent Pregnancy Prevention Campaign

Ohio
Heather Densmore, Merck & Company

South Carolina
Representative Joan Brady
Representative J. Roland Smith

Tennessee
Senator Thelma Harper
Senator Bo Watson
Gary Blalack, GlaxoSmithKline 
Annette Crutchfield, Office of Legislative Budget Analysis
Marlene Sanders, Merck & Company   

Texas
Richard Ponder, Johnson & Johnson

Virginia
Senator Emmett Hanger
Mike Ayotte, CVS Pharmacy

West Virginia
Delegate Charlene Marshall
Randal Elkins, Joint Committee on Government and Finance

Canada
Senator Wilfred P. Moore, Nova Scotia
June Dewetering, Canada-U.S. Interparliamentary Group, Ottawa


1 Dr. Shouse’s figures are based on the U.S. Department of Health and Human Services’ Region III statistics, which include all SLC states except Missouri.