NIH Guide: ENVIRONMENTAL JUSTICE: PARTNERSHIPS FOR COMMUNICATION

ENVIRONMENTAL JUSTICE: PARTNERSHIPS FOR COMMUNICATION

Release Date: June 1, 2000

RFA: ES-00-007

National Institute of Environmental Health Sciences http://www.niehs.nih.gov

Letter of Intent Receipt Date: June 30, 2000
Application Receipt Date: August 18, 2000

PURPOSE

The purpose of this program is to strengthen the National Institute of
Environmental Health Sciences= (NIEHS) support of research aimed at achieving
environmental justice for socioeconomically disadvantaged and medically
underserved populations in the United States. One goal of the NIEHS is to
stimulate investigative efforts that attempt to address questions related to
the influence of economic and social factors on the health status of
individuals exposed to environmental toxicants. This component of the research
program in environmental justice is designed to stimulate community outreach,
training, research and education efforts that will become the catalyst for
reducing exposure to environmental pollutants in underserved populations. The
main objective of this RFA is to establish methods for linking members of a
community, who are directly affected by adverse environmental conditions, with
researchers and health care providers and to enable this partnership to
develop appropriate research strategies to address environmental health
problems of concern. This effort will ensure that:

o The community is aware of basic environmental health concepts, issues, and
resources.

o The community has a role in identifying and defining problems and risks
related to environmental exposures.

o The community is included in the dialogue shaping research approaches to
the problem.

o The community actively participates with researchers and health care
providers in developing responses and setting priorities for intervention
strategies. One aim of this program is to facilitate the process of
developing the trust needed for establishment of effective partnerships among
individuals who are adversely impacted by an environmental hazard in a
socioeconomically disadvantaged community, researchers in environmental
health, and health care providers. Once this aim is achieved, the
collaborative team should then be able to initiate a research program that
incorporates all parties and seeks to reduce exposure to or health impact from
an environmental contaminant.

HEALTHY PEOPLE 2010

The Public Health Service (PHS) is committed to achieving the health promotion
and disease prevention objectives of "Healthy People 2010," a PHS-led national
activity for setting priority areas. This Request for Applications (RFA),
"Environmental Justice: Partnerships for Communication," is related to one or
more of the priority areas. Potential applicants may obtain a copy of "Healthy
People 2010" at http://www.health.gov/healthypeople/

ELIGIBILITY REQUIREMENTS

Applications may be submitted by domestic non-profit organizations, public and
private, including predominantly minority institutions, individually or as
joint efforts of minority institutions and majority institutions. Usually,
only one award under this RFA will be funded at an institution or
organization. Although a single institution or organization must be the
applicant, a multi-institutional arrangement (consortium) is possible. Such
consortia, entailing active participation by more than one organization, are
encouraged if there is clear evidence of close interaction and responsible
partnership among the participants. Competitive continuation applications
from existing grantees in the NIEHS Environmental Justice: Partnerships For
Communication Program in their fourth year of support will be accepted for
consideration under this RFA. Such applications must follow PHS 398
guidelines for competitive renewal, including a progress report. Such
applicants are strongly encouraged to contact Program Staff listed under
INQUIRIES for additional guidance. It is important to note that, because of
the wide range of environmental health problems to be addressed and the
diversity of affected communities, applications must include at least one of
each of the following:

o A research scientist in environmental health sciences (such as those at
NIEHS Environmental Health Sciences Centers or NIEHS Centers for Children=s
Environmental Health and Disease Prevention Research).

o A primary health care provider directly involved in a community affected by
an environmental pollutant. This individual must have a record of providing
health care to the participating community. He/she could, but need not
necessarily, be affiliated with a county or state public health department.

o A member of a community organization in an area having an underserved
population that is adversely affected by an environmental pollutant. This
individual must be someone who lives in or works directly and regularly with
the participating community.

At least one member of each of these three required personnel groups must have
an active and meaningful role in both development of the application and
conduct of the proposed project. These personnel must be listed on page 2 of
the PHS 398 application, and a biographical sketch must be provided for each.
Applications lacking the required personnel will not be considered. The role
of each member of these three personnel groups in developing the application
and carrying out the project must be clearly identified and fully described.
There should be an equitable distribution of responsibilities as well as of
requested financial resources among the three personnel groups. This goal is
often accomplished through the inclusion of one or more subcontract
arrangements, which may be helpful in defining all parties' programmatic and
budgetary roles. The NIEHS has a significant commitment to the support of
programs designed to increase the number of under represented minority and
female scientists participating in biomedical, environmental, and behavioral
research. Therefore, applications from minority individuals and women are
encouraged. Because of the community-based nature of this program, well-
established community-based organizations are encouraged to consider their
capacity to serve as the primary applicant organization. Due to the complex
administrative, programmatic, and financial responsibilities associated with
this role, such groups should contact Program Staff listed below for guidance.

MECHANISM OF SUPPORT

This RFA will use the National Institutes of Health (NIH) Education Project
(R25) mechanism. Responsibility for the planning, direction, and execution
of the proposed project will be solely that of the applicant. The total
project period for an application submitted in response to the present RFA may
not exceed four years.

FUNDS AVAILABLE

The estimated total funds available for the first year of support for the
entire program are anticipated to be $1.5 million. The maximum award will be
$200,000 in direct costs, including subcontract total (direct plus F&A) costs,
per year. Indirect costs will be paid at the approved indirect cost rate for
the applicant organization less appropriate exclusions. It is anticipated
that seven grants will be awarded depending upon the availability of funds for
this purpose and the quality of the applications received. Supplements are
not allowed. Although this program is provided for in the financial plans of
the NIEHS, awards pursuant to this RFA are contingent upon the availability of
funds for this purpose. Funding beyond the first and subsequent years of the
award will be contingent upon satisfactory progress during the preceding year
and upon availability of funds.

RESEARCH OBJECTIVES

Background

Americans want to live long and healthy lives, and the majority of them
achieve that goal. In general, however, people who are economically
disadvantaged and/or who live or work in areas and occupations where
conditions impart greater exposure to hazardous substances are less likely to
do so. At every stage of life, these persons suffer disproportionate levels
of morbidity and mortality. Evidence suggests that certain groups, especially
minorities and low-income communities, bear an uneven share of hazardous
environmental exposures. Socioeconomically disadvantaged people suffer the
lowest life expectancy and the highest adverse health consequences of
inadequate access to high quality health care. Additionally, they most often
experience the highest degree of exposure to environmental agents and
frequently have the least information available about the health consequences
of exposure to these agents. Environmental justice refers to the need to
remedy the unequal burden borne by socioeconomically disadvantaged persons in
terms of residential exposure to greater than acceptable levels of
environmental pollution, occupational exposure to hazardous substances, and
fewer civic benefits such as sewage and water treatment. Geographic location
plays an important role in environmental exposure of socioeconomically
disadvantaged persons. Inner-city poor often live in homes with high lead
levels. They may also be exposed to higher levels of air pollution. Toxic
waste sites are more frequent in rural, low socioeconomic counties in the
United States. Nuclear facilities and chemical plants are often located in
rural areas. Exposure to pesticides is another example where rural,
socioeconomically disadvantaged populations area at a greater than average
risk. Disadvantaged neighborhoods may rely on well water which may be
polluted with toxic chemicals. In addition, medical care is often inadequate
or unavailable to a significant proportion of the socioeconomically
disadvantaged and minority people in America today. Lead poisoning and the
cognitive and developmental damage associated with exposure to lead occur
disproportionately among minorities. High blood pressure and prostate cancer
are very common among African Americans. Low birth weight babies and other
problems during pregnancy are common among groups of women who do not have
access to good prenatal care. Some of these conditions or other diseases may
have an environmental component in their etiology. The lack of resources for
early identification of the effects of toxic agents may lead to an increased
disease burden in people who are economically least able to cope with it.

Recent Progress and Opportunities

Over the past six years, the NIEHS has supported a variety of environmental
justice and community-based prevention/intervention research programs. These
programs have been very successful in achieving open and honest communication
between researchers and community members. Working together, researchers and
community leaders have been able to identify disproportionate environmental
health risks in certain communities and have begun to formulate research
agendas. A needed step in this process is gaining participation of community
members in efforts to gather preliminary health and exposure data. Ongoing
projects within the Environmental Justice: Partnerships for Communication
Program are committed to enhancing community participation in research studies
and to facilitating communication among environmental health researchers,
community health care providers, and community members. Methods utilized in
these projects include:

o Assessment and/or surveys of environmental hazards.

o Characterization and evaluation of the distribution and health impact of
environmental contaminants.

o Provision of environmental health and toxic exposure training for health
care providers.

o Development of culturally appropriate education and communication
materials.

o Development and implementation of exposure reduction/pollution prevention
strategies.

Areas of research that are encouraged and not currently funded by existing
NIEHS Environmental Justice programs include, but are not limited to: women=s
health issues (breast cancer, osteoporosis, reproductive health, autoimmune
diseases), birth defects, hypertension, prostate cancer, and diabetes.

Objectives and Scope

One component of the mission of the cooperating agencies is to promote
research aimed at achieving environmental justice by identifying and
addressing disproportionately high and adverse effects of environmental agents
on human health in low income and minority populations. The main objectives
of this program are to: establish methods for linking members of a community,
who are directly affected by adverse environmental conditions, with
researchers and health care providers; and enable this partnership to develop
appropriate research strategies to address environmental health problems of
concern. Development of such community-based strategies to address
environmental health problems requires approaches that are not typically
familiar to the research and medical communities. Customary approaches to
risk assessment and management often neglect the knowledge and experience of
at risk populations and the sociocultural context of environmental hazards.
The distinctive needs of individual communities and their inhabitants are only
rarely considered in identifying environmental health problems and devising
appropriate disease and pollution prevention tactics. Underserved populations
are often diverse, fragmented, and isolated, making it difficult to obtain
their input and to integrate their concerns in decision-making processes.
Assays of the health effects of environmental pollution, as well as
regulations based on such assays, are often performed with little or no input
from the affected community. The purpose of this program is to institute
mechanisms to bridge this communication gap. Once communication and
collaboration have been achieved, researchers and community members should
then develop a research agenda to identify and assess environmental risks.
Establishing and maintaining trust among all personnel is important throughout
the process, as it will enhance the capacity to collect preliminary health and
exposure data. The ultimate goal of this program is to reduce health threats
to these populations. Therefore, participation of the community is essential
for both identification of health risks as well as for effective
implementation of policies to reduce exposure. Applicants are therefore
expected to create equitable partnerships among researchers in environmental
health, health care providers, and representatives of low income or medically
underserved communities affected by environmental health problems. Types of
activities that may be proposed include, but are not limited to:

o Develop efficacious methods for risk communication in low-income and
underserved communities unfavorably impacted by environmental hazards.

o Develop community-based, culturally sensitive educational programs to
mitigate adverse health effects from environmental toxicants in low-income and
underserved communities.

o Carry out community-based training to increase environmental health
literacy, i.e., increase awareness of the public, in such neighborhoods.

o Train and educate neighborhood health care professionals in the diagnosis
and treatment of disorders having an etiology related to exposure to hazardous
substances, i.e., increase awareness of health care providers. These
providers should have a direct role in assisting a community affected by
exposure to an environmental hazard.

o Develop a research agenda to measure population exposure and/or quantify
human health impacts. We wish to encourage a broad, comprehensive approach to
this problem that emphasizes both education and research. Applicants are
encouraged to consider proposing some combination of the above activities.
The following factors must be included in applications submitted in response
to this RFA. Applications lacking any one of the following factors will be
considered nonresponsive. Potential applicants are strongly encouraged to
consult Program Staff listed under INQUIRIES about their capacity to address
each of these factors. The required elements for each application are:

o Develop a means of establishing effective input from an underserved
community affected by an environmental toxicant. For example, applicants may
consider creating a community-based advisory board or steering committee to
facilitate outreach, planning, and evaluation efforts. This input could be
obtained directly from members of a community affected by an environmental
toxicant as well as from representatives of such groups as community and
neighborhood associations, churches, public housing resident councils,
community health centers, local public health service departments, and
minority educational institutions.

o An objective assessment process designed to:

- Identify priority areas in environmental health as perceived by community
members.

- Develop a consensus among community members about plausible approaches.

- Build upon existing experience and knowledge within the community.

- Detect any potential constraints in implementing the project.

o Development of appropriate education/communication modules. Proposed
projects must provide for dissemination of relevant information within the
community as well as a means for the community to have a voice that reaches
researchers and health care providers.

o Develop research and intervention approaches. For example, projects to
collect and analyze exposure/health data are appropriate and encouraged.

o Evaluation of the project's effectiveness. A procedure must be established
to assess the usefulness of the project's education, communication and
research activities. Both process and outcome measures should be addressed.
The NIEHS requires that 10% of the budget be allocated to the evaluation
component of the proposal. It is further required that a social scientist be
involved in the development of quantitative tools to assess progress and
programmatic achievements. Applications that do not contain an evaluation
component will be considered non-responsive and returned to the applicant
without review.

o Recommendations for future activities, beyond the period of NIEHS funding,
to assure continued participation of community members in research and service
programs addressing environmental injustices. Each of the above elements is
essential to fulfill the education, communication, research and outreach aims
of this RFA. Applicants lacking any of the above components will be
considered nonresponsive. It is important to note that award of a grant under
this RFA does not imply a commitment to future funding of any extensions or
new projects planned with the support of such a grant. Separate applications
must be submitted for such programs and such applications will be evaluated on
the basis of their own merits. Activities conducted under this RFA should be
consistent with Federal Executive Order No. 12988 entitled, "Federal Actions
to Address Environmental Justice in Minority Populations and Low-Income
Populations." To the extent practicable and permitted by law, grantees shall
make achieving environmental justice part of their project's mission by
identifying and addressing, as appropriate, disproportionately high and
adverse human health effects of environmental contaminants on minority, low-
income, and medically underserved populations, including African, Hispanic,
Asian, and Native Americans.

SPECIAL REQUIREMENTS

To encourage applicants to share information gained via these grants, a member
of each of the three types of required personnel on each project (scientist,
health care provider, and community member) will be asked to attend an annual
meeting in the Research Triangle Park, NC area. Applicants should include
such travel in their budget requests.

INCLUSION OF WOMEN AND MINORITIES IN RESEARCH INVOLVING HUMAN SUBJECTS

It is the policy of the NIH that women and members of minority groups and
their subpopulations must be included in all NIH supported biomedical and
behavioral research projects involving human subjects, unless a clear and
compelling rationale and justification are provided that inclusion is
inappropriate with respect to the health of the subjects or the purpose of the
research. This policy results from the NIH Revitalization Act of 1993
(Section 492B of Public Law 103-43.)

All investigators proposing research involving human subjects should read the
"NIH Guidelines for Inclusion of Women and Minorities as Subjects in Clinical
Research," which was published in the Federal Register of March 28, 1994 (FR
59 14508-14513) and in the NIH Guide for Grants and Contracts, Vol. 23, No.
11, March 18, 1994, and is available on the web at:
https://grants.nih.gov/grants/guide/notice-files/not94-100.html

INCLUSION OF CHILDREN AS PARTICIPANTS IN RESEARCH INVOLVING HUMAN SUBJECTS

It is the policy of NIH that children (individuals under the age of 21) must
be included in all human subjects research, conducted or supported by the NIH,
unless there are scientific and ethical reasons not to include them. This
policy applies to all initial (Type 1) applications submitted for receipt
dates after October 1, 1998.

All investigators proposing research involving human subjects should read the
"NIH Policy and Guidelines on the Inclusion of Children as Participants in
Research Involving Human Subjects" that was published in the NIH Guide for
Grants and Contracts, March 6, 1998, and is available at the following URL
address: https://grants.nih.gov/grants/guide/notice-files/not98-024.html

Investigators also may obtain copies of these policies from the program staff
listed under INQUIRIES. Program staff may also provide additional relevant
information concerning the policy well as with other pertinent federal laws
and regulations. Therefore, proposals for research involving human subjects
must include a description of plans for including children. If children will
be excluded from the research, the application or proposal must present an
acceptable justification for the exclusion.

URLS IN NIH GRANT APPLICATIONS OR APPENDICES

All applications and proposals for NIH funding must be self-contained within
specified page limitations. Unless otherwise specified in an NIH
solicitation, Internet addresses (URLs) should not be used to provide
information necessary to the review because reviewers are under no obligation
to view the Internet sites. Reviewers are cautioned that their anonymity may
be compromised when they directly access an Internet site.

LETTER OF INTENT

Prospective applicants are requested to submit a letter of intent that
includes a descriptive title of the proposed research, the name, address, and
telephone number of the Principal Investigator, the identities of other key
personnel and participating institutions, and the number and title of the RFA
in response to which the application may be submitted. Although a letter of
intent is not required, is not binding, and does not enter into review of a
subsequent application, the information that it contains allows NIEHS staff to
estimate the potential review workload and plan the review.

The letter of intent is to be sent by June 30, 2000 to:

J. Patrick Mastin, Ph.D.
Scientific Review Administrator
Scientific Review Branch
Office of Program Operations
Division of Extramural Research and Training
National Institute of Environmental Health Sciences
P.O. Box 12233, MD EC-24
111 T.W. Alexander Drive
Research Triangle Park, NC 27709
Telephone: (919) 541-1446
Fax: (919) 541-2503
Email: mastin@niehs.nih.gov

APPLICATION PROCEDURES

The research grant application form PHS 398 (rev. 4/98) is to be used in
applying for these grants. These forms are available at most institutional
offices of sponsored research and may be obtained from the Division of
Extramural Outreach and Information Resources, National Institutes of Health,
6701 Rockledge Drive, MSC 7910, Bethesda, MD 20892-7910, telephone 301/710-0267, Email: GrantsInfo@nih.gov.

The RFA label available in the PHS 398 (rev. 4/98) application form must be
affixed to the bottom of the face page of the application. Type the RFA
number on the label. Failure to use this label could result in delayed
processing of the application such that it may not reach the review committee
in time for review. In addition, the RFA title and number must be typed on
line 2 of the face page of the application form and the YES box must be
marked.

The sample RFA label available at:
https://grants.nih.gov/grants/funding/phs398/label-bk.pdf has been modified to
allow for this change. Please note this is in pdf format.

Submit a signed, typewritten original of the application, including the
checklist, and three signed, photocopies, in one package to:

CENTER FOR SCIENTIFIC REVIEW
NATIONAL INSTITUTES OF HEALTH
6701 ROCKLEDGE DRIVE, ROOM 1040 MSC 7710
BETHESDA, MD 20892-7710
BETHESDA, MD 20817 (for express/courier service)

At the time of submission, two additional copies of the application must be
sent to:

Applications must be received by August 18, 2000. If an application is
received after that date, it will be returned to the applicant without review.
The Center for Scientific Review (CSR) will not accept any application in
response to this RFA that is essentially the same as one currently pending
initial review, unless the applicant withdraws the pending application. The
CSR will not accept any application that is essentially the same as one
already reviewed. This does not preclude the submission of substantial
revisions of applications already reviewed, but such applications must include
an Introduction addressing the previous critique. Applicants who are
submitting revised applications based on criticisms in summary statements
received in response to previous announcements of this RFA (ES-95-002 or ES-
98-006) are urged to read the appropriate instructions on page 14 of the PHS
398.

REVIEW CONSIDERATIONS

Upon receipt, applications will be reviewed for completeness by the CSR and
responsiveness by the NIEHS. Incomplete and/or nonresponsive applications
will be returned to the applicant without further consideration. Applications
that are complete and responsive to the RFA will be evaluated for scientific
and technical merit by an appropriate peer review group convened by the NIEHS
in accordance with review criteria stated below. As part of the intial merit
review, all applications will receive a written critique and undergo a process
in which only those applications deemed to have the highest scientific merit,
generally the top half of the applications under review, will be discussed,
assigned a priority score, and receive a second level review by the NIEHS
National Advisory Council.

The major review factors listed below will be used in evaluation of
applications for this RFA:

o Scientific, technical and/or medical significance and merit of the proposed
project as determined by such factors as its content, originality, and
feasibility.

o Evidence of access to, interaction with, and input from a minority, low-
income, or underserved community, whose members' health is adversely impacted
by an environmental toxicant. There should be evidence of effective
involvement of such a community in development of the application as well as
in conduct of the project.

o Capacity of the project to:

- Identify key environmental hazards that affect the health and quality of
life of people who live in or around communities thought to be at risk.

- Establish a focus and appropriate strategies and procedures for information
exchange related to environmental health problems in socioeconomically
disadvantaged communities.

- Enhance awareness of environmental health problems among members of the
public and/or health care providers living or working in low-income or
underserved communities.

- Have a direct impact on the health or quality of life of individuals in
affected communities, e.g., by diminishing exposure to environmental
toxicants.

o Appropriateness and adequacy of the approach and methodology proposed to
accomplish the project's objectives. Effectiveness of the proposed plan in
reaching the target audience. For example, many socioeconomically
disadvantaged persons tend not to obtain information from the written word.
Low or no literacy, as well as bilingual, materials may need to be generated.

o Plans for evaluation of factors contributing to the project's
effectiveness. Evaluations should include a measure of the impact of the
project on community members' knowledge and awareness of issues and resources
related to environmental health sciences. Similarly, evaluation of the
effectiveness of health care provider training should be conducted. Both
process and outcome evaluation tools should be incorporated. Applications
without evaluation components will be returned without review.

o Qualifications and experience of the Principal Investigator and staff,
particularly but not exclusively in areas relevant to the mission of NIEHS.
Personnel should demonstrate knowledge of the needs of their target audience.
There should be evidence of effective cooperation and interaction in
development of the application as well as in execution of the project among
the three types of required personnel: a researcher in environmental health
sciences, a health care provider, and a member of a community organization in
an area having an underserved population that is adversely affected by an
environmental pollutant. There should be an equitable distribution of
responsibilities among the three types of required personnel.

o Strength of institutional commitment as evidenced by provision of
appropriate resources, services, technical support, and allocation of space.

o Availability of resources necessary to carry out the project.

o Appropriateness of the proposed budget and duration in relation to the
project's objectives. Consistent with an equitable distribution of
responsibilities, there should likewise be an equitable distribution of
requested financial support among the three types of required personnel.

o Adequacy of plans to include both genders, minorities and their subgroups,
and children as appropriate for the scientific goals of the research when
human subjects are used. Plans for the recruitment and retention of subjects
will also be evaluated.

AWARD CRITERIA

The anticipated date of award is April 1, 2001. The following will be
considered in making funding decisions:

o Quality of the proposed applications as determined by peer review.

o Significance with respect to the goals of this RFA and the priorities of
the NIEHS.

o Availability of funds.

Schedule

The following is the schedule planned for this initiative. It should be noted
that this schedule might be changed without notification due to factors that
were unanticipated at the time of the announcement. Contact the program
official below regarding any changes in the schedule.

Letter of Intent Receipt Date: June 30, 2000
Application Receipt Date: August 18, 2000
Initial Scientific Review: November 15, 2000
Advisory Council Review: February 2001
Anticipated Date of Funding: April 1, 2001

INQUIRIES

Written, telephone or Email inquiries concerning this RFA are encouraged. The
opportunity to clarify any issues or questions from potential applicants is
welcome.

Direct inquiries regarding programmatic issues to:

Frederick L. Tyson, Ph.D.
Program Administrator
Chemical Exposures and Molecular Biology Branch
Office of Program Development
Division of Extramural Research and Training
National Institute of Environmental Health Sciences
P.O. Box 12233, 111 T.W. Alexander Drive, MD EC-21
Research Triangle Park, NC 27709
Telephone: (919) 541-0176
Fax: (919) 316-4606
Email: tyson2@niehs.nih.gov

Direct inquires regarding fiscal matters to:

Ms. Dorothy G. Duke
Chief, Grants Management Branch
Office of Program Operations
Division of Extramural Research and Training
National Institute of Environmental Health Sciences
P.O. Box 12233, 111 T.W. Alexander Drive, MD EC-22
Research Triangle Park, NC 27709-2233
Telephone: (919) 541-2749
Fax: (919) 541-2860
Email: duke3@niehs.nih.gov

AUTHORITY AND REGULATIONS

This program is described in the Catalog of Federal Domestic Assistance Nos.
93.113, 93.114, and 93.115. Awards are made under authorization of Sections
301 and 405 of the Public Health Service Act as amended (42 USC 241 and 284)
and administered under NIH grants policies and Federal Regulations 42 CFR 52
and 45 CFR Parts 74 and 92. The program is not subject to the
intergovernmental review requirements of Executive Order 12372 or Health
Systems Agency review.

The PHS strongly encourages all grant and contract recipients to provide a
smoke-free workplace and promote the non-use of all tobacco products. In
addition, Public Law 103-227, the Pro-Children Act of 1994, prohibits smoking
in certain facilities (or in some cases an portion of a facility) in which
regular or routine education, library, day care, health care or early
childhood development services are provided to children. This is consistent
with the PHS mission to protect and advance the physical and mental health of
the American people.

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