True or False: Public Health Core Functions Are Still Relevant Today? Mid-America Regional Public...

True or False:True or False:Public Health Core FunctionsPublic Health Core Functions

Are Still Relevant Today?Are Still Relevant Today?

Mid-America RegionalMid-America Regional

Public Health Leadership Institute Public Health Leadership Institute

St. Charles, IllinoisSt. Charles, Illinois

October 25, 2006October 25, 2006

Barney Turnock MD, MPHBarney Turnock MD, MPH

UIC School of Public HealthUIC School of Public Health

InstructionsInstructions

Be Here on TimeBe Here on Time Address the Institute’s ThemeAddress the Institute’s Theme Remember, Leaders from Outside Illinois Remember, Leaders from Outside Illinois

Are in the RoomAre in the Room Make Core Functions UnderstandableMake Core Functions Understandable Be UpbeatBe Upbeat Be ProvocativeBe Provocative

““It’s all road-kill, and never a word about the It’s all road-kill, and never a word about the chickens who get to the other side!”chickens who get to the other side!”

Provocative?Provocative?

What’s provocative about:What’s provocative about: Core Functions?Core Functions? Essential Public Health Services?Essential Public Health Services? Public Health Infrastructure?Public Health Infrastructure?

Provocative like George Carlin’s “7 words Provocative like George Carlin’s “7 words you can’t say on TV”?you can’t say on TV”?

Why Are We Here?Why Are We Here?

Don’t have all the answersDon’t have all the answers Previous performance not necessarily an Previous performance not necessarily an

indication of futureindication of future Lessons of past successes often Lessons of past successes often

misappliedmisapplied Churchill and Max DeusChurchill and Max Deus Binghamton by way of Elmira?Binghamton by way of Elmira?

A little history…A little history…

Three core functions (1988 IOM Three core functions (1988 IOM Report)Report) Assessment (What should be done? i.e. Assessment (What should be done? i.e.

Needs)Needs) Policy Development (What will be Policy Development (What will be

done? i.e. priorities)done? i.e. priorities) Assurance (How well is it done? i.e. Assurance (How well is it done? i.e.

performance)performance) Core Functions Steering Committee Core Functions Steering Committee

(1994)(1994) Public Health in AmericaPublic Health in America statement statement

Essential Public Health ServicesEssential Public Health Services

1.1. Monitor health statusMonitor health status

2.2. Diagnose and investigate Diagnose and investigate health problemshealth problems

3.3. Inform, educate and Inform, educate and empower peopleempower people

4.4. Mobilize communities to Mobilize communities to address health problemsaddress health problems

5.5. Develop policies and Develop policies and plansplans

6.6. Enforce laws and Enforce laws and regulationsregulations

7.7. Link people to needed Link people to needed health serviceshealth services

8.8. Assure a competent Assure a competent workforce - public health workforce - public health and personal careand personal care

9.9. Evaluate health servicesEvaluate health services

10.10.Conduct research for Conduct research for new innovationsnew innovations

Public Health Systems PerspectivePublic Health Systems PerspectivePublic Health Systems PerspectivePublic Health Systems Perspective

CapacityCapacity Process(Core Functions/Essential Public Health Services)

Process(Core Functions/Essential Public Health Services)

OutputsOutputs

OutcomesOutcomes

System InputsSystem Inputs

WorkforceWorkforce

InformationInformation

Organization & Organization & RelationshipsRelationships

FacilitiesFacilities

FundingFunding

WorkforceWorkforce




FundingFunding

Improved organizational performance +

Improved program performance



AssessAssess AddressAddress AssureAssure

Programs and Services consistent with mandates and community priorities


Key Processes Key Processes

Improved Outcomes& Customer Satisfaction

Improved Outcomes& Customer SatisfactionIncreased Value

& Public Support

““Well, actually they ARE written in stone!”Well, actually they ARE written in stone!”



Core Functions Still Relevant? Core Functions Still Relevant? It’s TRUE, Because…It’s TRUE, Because…

All the easy problems have All the easy problems have already been solvedalready been solved

We need a framework to assess, We need a framework to assess, address, and assure effective address, and assure effective responses to today’s wicked responses to today’s wicked problemsproblems

110.0

29.2

6.9

47.3

68.276.9

0

20

40

60

80

100

120

1900 1950 2000

Year

Life Expectancy at Birth (in years)

Infant Mortality Rate (per 1000 live births)

1446

1339

1223

1039

939

842

964 955 945878 864 854 833

869

700

800

900

1000

1100

1200

1300

1400

1500

1950 1960 1970 1980 1990 2000 2003

Year

Dea

ths

per

100,

000

Pop

ulat

ionCrude Mortality Rate

Age-Adjusted Mortality Rate

Actual Causes of Death, 2000Actual Causes of Death, 2000((SourceSource: Mokdad et al, : Mokdad et al, JAMAJAMA 2004) 2004)

TobaccoTobacco 435,000435,000

Poor diet & physical activityPoor diet & physical activity 400,000400,000

AlcoholAlcohol 85,00085,000

Microbial agentsMicrobial agents 75,00075,000

Toxic agentsToxic agents 55,00055,000

Motor vehicleMotor vehicle 43,00043,000

FirearmsFirearms 29,00029,000

Sexual behaviorSexual behavior 20,00020,000

Illicit drug useIllicit drug use 17,00017,000

Anthrax Attack 2001: Mail Flow Network…Anthrax Attack 2001: Mail Flow Network…

State Department SA-32 (VA)AMI Building (FL)

Brentwood Mail Facility (DC)

Truck to Atlanta, GA

Hamilton Processing Facility (NJ)

Morgan Central Postal Facility

(NY)

Carteret Hub & Spoke Facility (HSF) (NJ)

Boca Main Substation (FL)

Blue Lake PO (FL)

West Palm PO Main Branch (FL)

Lake Worth PO (FL)

Green Acres PO (FL)

Radio City PO (NY)

Rockefeller Ctr PO (NY)

Ansonia PO (NY)

56 USPS Facilities including:

Lenox Hill PO (NY)

Times Sq. PO (NY)

ENT Hospital (NY)

Pataki’s Office (NY)

NBC (NY)

ABC (NY)CBS (NY)

New York Post (NY)

Distribution plants including: (Bulk Mail Ctr, Dominic V Daniels,

Hackensack, Central NJ, Performance, Monmouth, Newark

Main, Patterson, West Jersey)

Dirksen Bldg

P-St. Mail Sorting (DC)

Hart Bldg

Ford Bldg

All DC City Mail for Zips 20000-20099

W. Trenton PO (NJ)

Princeton PO (NJ)

?

177 Federal Agencies including:

Bellmawr Distribution plant (NJ)

48 local Post Offices including:

Boulevard PO (NY)

Other Post

Offices

State Department SA-3 (DC)

Longworth Bldg

Landover (Justice)

Pentagon PO Branch

Southwest PO Station

Friendship PO Station

Dulles PO Branch

Anacostia mail room

Walter Reed Complex

DC VAMC

BATF

Supreme Court

Local Businesses including:

Kuser Road Business

US Embassy in Yekaterinburg,

Russia

US Embassy in Lima,

Peru

US Embassy in Vilnius, Lithuania

NYC001-47 Home

Stamp Fulfillment Kansas City, MO

Lantana PO (FL)

= Environmental samples positive

= Confirmed anthrax case associated with site

= Suspect anthrax case associated with site

November 7, 2001

Hotel MHong Kong

Guangdong Province,

China

A

A

B

J

H

CD

E

I

K †

FG †

Hospital 2Hong Kong

A

H

J

B

4 other Hong Kong Hospitals

Hospital 3 Hong Kong

Hospital 1 HK

Hospital 4 Hong Kong

2 family members

C D E

34 HCWs

HCW

B Germany

Bangkok

Singapore

United States

IL§

M§

Vietnam

IrelandK †

37 HCWs

HCW

0 HCWs

28 HCWs

156 close contacts of HCWs and

patients

Canada

G †

F

4 family members

10 HCWs

37 close contacts

99 HCWs (includes 17 medical students)

4 HCWs*

3 HCWs

HCW

HCW

2 family members

Unknown number

close contacts

2 close contactsSARS Transmission Spring 2003

Rodent Shipment Ghana

TEXAS50 Gambian giant rats (GR)

53 rope squirrels (RS) 2 brushtail porcupines (BP)

47 tree squirrels (TS)100 striped mice (SM)

~510 dormice (DM)

NJRS, BPTS, SM

TX-3RS, SM

DM

IA†

GR, DM

TX-4DM

TX-5DM

TX-6TS, SM

DM

TX-2GR

TX-8DM

TX-7DM

TX-9DM

JapanDM

TX-10DM

MNDM

WIDM

IL-2DM

IL-1§

GR, DM

MINo human

cases

SCNo human

cases

MO Human cases:

2 confirmed

KS Human cases:

1 confirmed

IN Human cases:

7 confirmed9 probable/

suspect

IL‡

Human cases:8 confirmed4 probable/

suspect

WI Human cases:17 confirmed22 probable/

suspect

1 PD traced

200 prairie dogs (PDs) at facility

1 PD traced

11 PDs traced

24 PDs traced

14 PDs traced

42 PDs traced

Monkeypox Outbreak 2003

Core Functions Still Relevant?Core Functions Still Relevant?It’s TRUE, Because…It’s TRUE, Because…

When you’re a hammer, When you’re a hammer, the whole world looks like the whole world looks like a nail…a nail…

When you’re a hammer…When you’re a hammer…

SpecializationSpecialization Categorical ApproachesCategorical Approaches Silos Instead of SystemsSilos Instead of Systems Poor Charlie’s Democratic PrinciplesPoor Charlie’s Democratic Principles

Organizations engaged in regulation, inspection and/or licensing activities

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Cosmetology businesses

Tobacco retailers

Housing (inspections)

Health-related facilities

Mobile homes

Campgrounds & RVs

Hotels/motels

School/daycare

Food service establishments

Percentage of Jurisdictions

LHD only Other local gov't onlystate gov't agency only multiple gov't agenciesnon-gov't agency only

Organizations engaged in regulation, inspection and/or licensing activities

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Milk processing

Public drinking water

Food processing

Solid waste disposal sites

Solid waste haulers

Smoke-free ordinances

Lead inspection

Private drinking water

Septic tank installation

Swimming pools (public)


LHD only Other local gov't onlystate gov't agency only multiple gov't agenciesnon-gov't agency only

Organizations providing environmental health services

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Radiation control

Hazmat response

Land use planning

Noise pollution

Hazardous waste disposal

Pollution prevention

Surface water protection

Indoor air quality

Groundwater protection

Vector control

Food safety education


LHD only other local gov't agency onlystate agency only multiple gov't agenciesnon-gov't organization only


We need a plan…We need a plan…

LHD Participation in Community LHD Participation in Community Health Assessment (CHA)Health Assessment (CHA)

CHA completion or plansCHA completion or plans PercentagePercentage

Completed CHA in past three yearsCompleted CHA in past three years 51%51%

Plans to complete CHA in next three Plans to complete CHA in next three yearsyears

65%65%

Either completed CHA in past three Either completed CHA in past three years or plans to complete in next three years or plans to complete in next three yearsyears

79%79%

Both completed CHA in past three years Both completed CHA in past three years and plans to complete in next three and plans to complete in next three yearsyears

38%38%

LHD Participation in Community LHD Participation in Community Health Improvement Planning Health Improvement Planning

(CHIP)(CHIP)PercentagePercentage

Participated in CHIPParticipated in CHIP 54%54%

CHIP based on results of CHA*CHIP based on results of CHA* 86%86%

CHIP linked to state’s health CHIP linked to state’s health

improvement plan*improvement plan*

68%68%

Participation in past three years*Of those LHDs that have participated in CHIP

Participation in CHA by StateParticipation in CHA by State

ID

AZ

UT

MT

WY

NM

CO

AL

FL

SC

TN

KY

INOH

NC

SD

KS

NE

MN

WI

IA

IL

MO

AR

MS

OK

ND

OR

CA NV

WA

TX

WV

PA

M E

VA

NY

United S tates of Am erica

LA

GA

MIRI

VT N

H

M D

C T

HI

D E

N J

AK

M A

< 25%

25-49%

50 - 75%

>75%n=2280Completed CHA in last 3 years

Participation in CHA: Comparison Participation in CHA: Comparison with 1999 Infrastructure Studywith 1999 Infrastructure Study

Population sizePopulation size 19991999 20052005

All LHDsAll LHDs 55%55% 51%51%

<25,000<25,000 44%44% 42%42%

25,000 – 49,99925,000 – 49,999 63%63% 53%53%

50,000 – 99,99950,000 – 99,999 65%65% 57%57%

100,000 – 499,999100,000 – 499,999 66%66% 61%61%

500,000 +500,000 + 72%72% 67%67%

Participation in CHIP: Comparison Participation in CHIP: Comparison with 1999 Infrastructure Studywith 1999 Infrastructure Study

Population sizePopulation size 19991999 20052005

All LHDsAll LHDs 53%53% 54%54%

<25,000<25,000 4141 4545

25,000 – 49,99925,000 – 49,999 5959 5555

50,000 – 99,99950,000 – 99,999 6868 5959

100,000 – 499,999100,000 – 499,999 6969 6161

500,000 +500,000 + 7676 6868

LHD Role in Community Health PlanningLHD Role in Community Health Planning

17%

33%28%

14%

8%

Developed primarily by LHDCoalition - LHD leadCoalition - LHD as equal partnerCoalition - some LHD involvementNo LHD involvement


It provides a job description for It provides a job description for public healthpublic health

Countering the frequently raised Countering the frequently raised argument: “That ain’t my job! argument: “That ain’t my job! Nobody told me I was supposed to Nobody told me I was supposed to do that.”do that.”

Ain’t my job?Ain’t my job?

Coming Soon to a Coming Soon to a Local Health Local Health Department in your Department in your neighborhood?neighborhood?

The MAPP ModelThe MAPP Model

Road-MAPPRoad-MAPP

Public Health Systems PerspectivePublic Health Systems PerspectivePublic Health Systems PerspectivePublic Health Systems Perspective

CapacityCapacity Process(Core Functions/Essential Public Health Services)

Process(Core Functions/Essential Public Health Services)

OutputsOutputs

OutcomesOutcomes

System InputsSystem Inputs

WorkforceWorkforce




FundingFunding

WorkforceWorkforce




FundingFunding





AssessAssess AddressAddress AssureAssure



Key Processes Key Processes

Improved Outcomes& Customer Satisfaction

Improved Outcomes& Customer SatisfactionIncreased Value

& Public Support



Core Functions Still Relevant?Core Functions Still Relevant?It’s FALSE, Because…It’s FALSE, Because…

That’s not what they taught That’s not what they taught me in public health school!me in public health school!

““Hmmm…traces of oil, gas, lead, EDBHmmm…traces of oil, gas, lead, EDB… … it’s water, all right.”it’s water, all right.”

““Go about your business. Act normal.”Go about your business. Act normal.”

““To prevent a heart attack, take one aspirin every day.To prevent a heart attack, take one aspirin every day.Take it out for jog, then take it to the gym, then take it Take it out for jog, then take it to the gym, then take it

for a bike ride…”for a bike ride…”


You get what you pay for?You get what you pay for?

Get what you pay for?Get what you pay for?

Actual Causes of Death, 2000Actual Causes of Death, 2000((SourceSource: Mokdad et al, : Mokdad et al, JAMAJAMA 2004) 2004)

TobaccoTobacco 435,000435,000

Poor diet & physical activityPoor diet & physical activity 400,000400,000

AlcoholAlcohol 85,00085,000

Microbial agentsMicrobial agents 75,00075,000

Toxic agentsToxic agents 55,00055,000

Motor vehicleMotor vehicle 43,00043,000

FirearmsFirearms 29,00029,000

Sexual behaviorSexual behavior 20,00020,000

Illicit drug useIllicit drug use 17,00017,000

““Tell the public we don’t want to hurt anyone.Tell the public we don’t want to hurt anyone. All we want is their money.”All we want is their money.”

Pop Quiz QuestionPop Quiz Question

• Over the past 50 years, total expenditures Over the past 50 years, total expenditures and per capita spending for public health and per capita spending for public health activities in the United States has been:activities in the United States has been:

a.a. Increasing steadilyIncreasing steadily

b.b. Decreasing steadilyDecreasing steadily

c.c. UnchangedUnchanged

d.d. Don’t knowDon’t know

Adjusted total public health spending (in Adjusted total public health spending (in millions) from federal and state/local sourcesmillions) from federal and state/local sources

US, 1960-2000US, 1960-2000

$0

$2,000

$4,000

$6,000

$8,000

$10,000

$12,000

$14,000

$16,000

$18,000

$20,000

1960 1965 1970 1975 1980 1985 1990 1995 2000

Adjusted total public health spending

Adjusted state/local public health spending

Federal public health spending

Per capita public health expenditures from federal Per capita public health expenditures from federal and state/local sources, US, 1960-2000and state/local sources, US, 1960-2000

$5$8

$15

$20$24

$27

$39

$51

$62

$3 $4$7

$14

$19

$28

$36

$44

$3$5

$11$13

$2

$15$11

$10 $8

$18

$0

$10

$20

$30

$40

$50

$60

$70

1960 1965 1970 1975 1980 1985 1990 1995 2000

Real per capita adjusted total public health spending

Real per capita adjusted state/local public health spending

Real per capita fedeal public health spending


We assume it to be true and our We assume it to be true and our assumptions are often incorrect!assumptions are often incorrect!

Look what happens when we get Look what happens when we get what ask for!what ask for!

““I guess he must have made it… It’s been more I guess he must have made it… It’s been more than a week since he went over the wall.”than a week since he went over the wall.”

Conventional Wisdom?Conventional Wisdom?

Public Health Workforce is shrinkingPublic Health Workforce is shrinking Average age is high (~47)Average age is high (~47) Public Health workers soon will be retiring in large Public Health workers soon will be retiring in large

numbers numbers Recruitment and retention are major issues, especially in Recruitment and retention are major issues, especially in

rural communitiesrural communities Key disciplines (such as public health nurses and Key disciplines (such as public health nurses and

epidemiologists) are increasingly scarceepidemiologists) are increasingly scarce Few public health workers have received formal training Few public health workers have received formal training

in public healthin public health Public Health Workforce is not prepared for current and Public Health Workforce is not prepared for current and

future threatsfuture threats

Pop Quiz QuestionPop Quiz Question• Over the past dozen years, the size (# and ratio) of the Over the past dozen years, the size (# and ratio) of the

public health workforce in the United States has been:public health workforce in the United States has been:



c.c. Increasing in the 1990s through 2000 and then Increasing in the 1990s through 2000 and then decreasingdecreasing

d.d. Decreasing in the 1990s through 2000 and then Decreasing in the 1990s through 2000 and then increasingincreasing

e.e. UnchangedUnchanged

f.f. Don’t KnowDon’t Know

Pop Quiz QuestionPop Quiz Question• Over the past dozen years, the size (# and ratio) of the Over the past dozen years, the size (# and ratio) of the

public health workforce in Illinois, Indiana, Wisconsin, public health workforce in Illinois, Indiana, Wisconsin, Michigan, etc. has been:Michigan, etc. has been:



c.c. Increasing in the 1990s through 2000 and then decreasingIncreasing in the 1990s through 2000 and then decreasing

d.d. Decreasing in the 1990s through 2000 and then Decreasing in the 1990s through 2000 and then increasingincreasing

e.e. UnchangedUnchanged

f.f. Don’t KnowDon’t Know

FTE Workers FTE Workers (per 100,000 pop.)(per 100,000 pop.) of State and Local of State and Local Governmental Health Agencies, U.S.Governmental Health Agencies, U.S.

(Public Employment Census Data, Selected Years)(Public Employment Census Data, Selected Years)

73

137

81

143

89

151

88

150

83

144

0

50

100

150

200

1993 1998 2001 2003 2005

Local State+Local

FTE Workers FTE Workers (per 100,000 pop.)(per 100,000 pop.) of State and Local of State and Local Governmental Health Agencies, TexasGovernmental Health Agencies, Texas

(Public Employment Census Data, Selected Years)(Public Employment Census Data, Selected Years)

81

140

93

146132

189

108

166

94

150

0

50

100

150

200

1993 1998 2001 2003 2005

Local State+Local

Full Time Equivalent (FTE) Workers of Full Time Equivalent (FTE) Workers of Governmental Health Agencies, 1995-2005Governmental Health Agencies, 1995-2005

Source:Source: Data from U.S. Bureau of the Census, Federal, State, and Local Governments, Public Data from U.S. Bureau of the Census, Federal, State, and Local Governments, Public Employment and Payroll Data. Available at Employment and Payroll Data. Available at www.census.gov/govs/www/apes.htmlwww.census.gov/govs/www/apes.html..

YearYear

Fed (F)Fed (F)

FTEFTE

State (S)State (S)

FTEFTE

Local (L)Local (L)

FTEFTE

S+LS+L

FTEFTE

F+S+LF+S+L

FTEFTE

19951995 125,048125,048 160,031160,031 208,588208,588 368,619368,619 493,667493,667

19981998 119,846119,846 166,930166,930 219,655219,655 386,585386,585 506,431506,431

20012001 122,999122,999 172,414172,414 251,399251,399 423,813423,813 546,812546,812

20022002 124,979124,979 176,345176,345 252,326252,326 428,671428,671 553,650553,650

20032003 124,828124,828 176,868176,868 253,888253,888 430,756430,756 555,584555,584

20042004 127,933127,933 174,301174,301 249,857249,857 424,128424,128 552,061552,061

20052005 125,163125,163 178,465178,465 246,300246,300 424,765424,765 549,918549,918

Approaches to Public Health Approaches to Public Health Workforce Development: Workforce Development: Pipeline vs. Willy SuttonPipeline vs. Willy Sutton

Conventional Wisdom approach to workforce Conventional Wisdom approach to workforce developmentdevelopment: more schools, increase number of : more schools, increase number of graduates, higher proportion of gradates into graduates, higher proportion of gradates into primary public health workforce through primary public health workforce through scholarships and loan repayment programs scholarships and loan repayment programs (Pipeline approach)(Pipeline approach)

Willie Sutton approach to workforce development: Willie Sutton approach to workforce development: focus on the work organizations (that’s where the focus on the work organizations (that’s where the workers are now and where they will be tomorrow).workers are now and where they will be tomorrow).

Public Health Work-Doing Public Health Work-Doing SystemSystem

What Should We Do with the Next What Should We Do with the Next $230 Million?$230 Million?

Pipeline Approach: scholarships and loan Pipeline Approach: scholarships and loan repayment programsrepayment programs

Willie Sutton: assess, enhance, recognize Willie Sutton: assess, enhance, recognize and reward ( i.e., manage) and reward ( i.e., manage)

It’s their way of thanking us for all we’ve done for them --- it’s called “tobacco”


Why else would we whine Why else would we whine so much?so much?

““That’s just great! I discover the cure for the That’s just great! I discover the cure for the common cold, and all you can do is criticize.”common cold, and all you can do is criticize.”

When’s the Last Time You Heard When’s the Last Time You Heard Someone at a Public Health Someone at a Public Health

Conference Say… Conference Say… The public health infrastructure is not The public health infrastructure is not

crumblingcrumbling Public health workers are better prepared Public health workers are better prepared

than everthan ever Accreditation and Credentialing are good Accreditation and Credentialing are good

things for public health practicethings for public health practice Those Essential Public Health Services Those Essential Public Health Services

really get my juices flowingreally get my juices flowing

Reported change in selected LHD functions over the past three years Reported change in selected LHD functions over the past three years as a result of efforts to improve emergency preparedness (N= 393)as a result of efforts to improve emergency preparedness (N= 393)

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Preparedness planning

Communication systems

Workforce training

Information systems

Public health surveillance

Epidemiology

Legal basis for PH actions

Relationships with other agencies

Immunization

Surge capacity

Access to laboratory services

Screening for diseases & conditions

Other environmental health activities

Treatment for communicable diseases

Population-based primary prevention

Other health sercices

Regulation, inspection & licensing

Maternal & child health

StrongerNo ChangeWeaker

Core Functions Still Relevant?Core Functions Still Relevant?

Maybe TRUE?Maybe TRUE? Adapts to a dynamic Adapts to a dynamic

agendaagenda Fosters systems, not Fosters systems, not

silossilos Provides the plan we Provides the plan we

lacklack Serves as public Serves as public

health’s job descriptionhealth’s job description

Maybe FALSE?Maybe FALSE? Not what they taught Not what they taught

meme Hasn’t impacted Hasn’t impacted

fundingfunding Assumptions often Assumptions often

unfoundedunfounded We continue to whineWe continue to whine

Some Days It Takes Hours to Get DressedSome Days It Takes Hours to Get Dressed

Thanks, Now Its Your Turn.. Thanks, Now Its Your Turn..

Any Questions?Any Questions?

What Do You Think?What Do You Think?

““I think you need to be more explicit here in Step 2”I think you need to be more explicit here in Step 2”

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