IJE Advance Access originally published online on June 7, 2008
International Journal of Epidemiology 2008 37(5):966-977; doi:10.1093/ije/dyn108
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Public health in New York City, 2002–2007: confronting epidemics of the modern era
1 New York City Department of Health and Mental Hygiene, New York, NY, USA.
2 Tulane University School of Public Health and Tropical Medicine, New Orleans, LA.
* Corresponding author. Department of Health and Mental Hygiene, 125 Worth St, Rm 331, New York, NY 10013, USA. E-mail: tfrieden{at}health.nyc.gov
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Abstract |
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Long after the leading causes of death in the United States shifted from infectious diseases to chronic diseases, many public health agencies have not established effective policies and programmes to prevent current health problems. Starting in 2002, the New York City health department, an agency with a long history of innovation, undertook initiatives to address chronic disease prevention and control, as well as to modernize methods to address persistent health problems. All the initiatives relied on an expansive use of epidemiology; actions to prevent disease were based on policy change to create health-promoting environments as well as engagement with the health care system to improve its focus on prevention. Examples of policy-based initiatives are: a multi-component tobacco control programme that included a tax increase, a comprehensive smoke-free air law, hard-hitting anti-tobacco advertising and cessation services; elimination of trans fats from restaurants and a mandate that restaurants post-calorie information on menu boards. Examples of health care initiatives are public health ‘detailing’ to primary care providers, creation of a city-wide diabetes registry and development of a public health-oriented electronic health record. The infrastructure needed by local health departments to prevent chronic diseases and other modern health problems includes strong information technology systems, skilful epidemiology, expertise in communications using modern media, policy-making authority and, most importantly, political support.
Keywords Epidemiology, health policy, public health, tobacco control, trans fat, calorie posting, electronic health records, health disparities, obesity, heart disease, HIV/AIDS, diabetes
Accepted 8 May 2008
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Introduction |
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It has been 20 years since a report of the Institute of Medicine described the public health system in the United States as being ‘in disarray’.1 This report highlighted many interconnected problems, including disjointed decision making, weak leadership, poor public image, limitations in assessment capability and even ‘lack of consensus on the content of the public health mission’. The report signalled a long fall from the image of public health a century earlier, when the field made great strides in the control of epidemic infectious diseases and was generally held in high regard as a result. Underlying much of this deterioration was the epidemiological transition of the 20th century, in which the leading causes of death shifted from infectious diseases to chronic diseases, and the difficulty the public health field had in determining its role in addressing this new morbidity, particularly in comparison with the booming field of medical care. While health experts have written for decades about the need for sound public health approaches to the leading causes of death of the modern era,2,3 public health agencies have had limited success addressing them.4
New York City (NYC) is unique in the United States. With more than 8 million inhabitants, it is more populous than 39 of the 50 US states, and its population is unusually diverse, with 40% foreign born, >60% non-white and 20% below the federal poverty line. The NYC health department is similarly unusual in having the combination of much of the resources and regulatory authority of a state public health agency as well as direct implementation capacity and access to a large population. The agency has a long tradition of innovation and public health leadership, particularly in controlling infectious diseases.5 In this new century, the NYC Department of Health and Mental Hygiene (DOHMH) sought to continue this tradition by implementing innovative approaches to solve today's health problems, while updating its approaches to persistent public health issues. The agency's initiatives are grounded in a broader use of information and epidemiology and often address chronic diseases through both policy change and improved health care.
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Data, information and epidemiology |
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To make effective decisions that improve the health of populations, public health has always needed population-level health data and a key role is to disseminate accurate health information with related recommendations. Our information age provides many new possibilities for collection, analysis, interpretation and dissemination of information about health. At the close of 2001, DOHMH, like most city health departments, had strong systems to track infectious diseases, but little or no surveillance data regarding chronic diseases or their risk factors. Since then it has established new surveillance systems to fill these gaps:
- In 2002 and annually thereafter, the DOHMH has conducted a large random-digit dialled cross-sectional telephone survey of adult NYC residents known as the Community Health Survey (CHS). The survey gathers information about a broad range of health measures and is based on the national Behavioral Risk Factor Surveillance System coordinated by the U.S. Centers for Disease Control and Prevention (CDC). Each year, the CHS interviews approximately 10 000 individuals, and it is able to provide robust data on the health of New Yorkers, using city-wide, neighbourhood and subpopulation prevalence estimates. In addition, DOHMH collaborates with the city school system to conduct the Youth Risk Behavior Surveillance (YRBS) survey, a biennial self-administered survey of between 5000 and 8000 NYC high school students to assess a variety of risky behaviours. By increasing the sample size of the YRBS, we have been able to provide geographically specific risk factor estimates.
- To address the inherent limitations of assessing health status and risk behaviours with self-report surveys, in 2004 the DOHMH conducted the nation's first community-level health and nutrition examination survey. The New York City Health and Nutrition Examination Survey (NYC HANES), modelled after the CDC's national HANES, used household-based recruitment to interview, examine and collect biological samples for laboratory testing on 2000 adult residents.6 NYC HANES complements the CHS in providing information on the health status of adult residents essential to prioritizing health problems, designing interventions and evaluating the effect of initiatives.
- To track and address the rapidly growing epidemic of diabetes, in 2006 DOHMH mandated electronic reporting of haemoglobin A1C results by laboratories. With this information, the DOHMH can better understand trajectories of the diabetes epidemic and develop programmes to improve quality of care for New Yorkers with diabetes. With neighbourhood-level estimates of self-reported diabetes from CHS, objective measures of undiagnosed diabetes and impaired fasting glucose from NYC HANES and disease management profiles from the haemoglobin A1C Registry, NYC currently has the most sophisticated diabetes surveillance system in the United States.
- To detect and characterize diseases and epidemics rapidly, DOHMH has established surveillance for syndromes such as influenza-like illness and gastrointestinal disease. Reports of syndromes are sent electronically within 24 h from emergency departments and ambulance services; pharmacies send information on over-the-counter and prescription medication sales. Monitoring of fluctuations in aggregate data provides an early warning system for some disease outbreaks.7,8
- In the wake of the September 11, 2001 World Trade Center disaster, DOHMH established a registry and enrolled 71 437 persons exposed to event trauma and noxious agents from the attack, collapsing towers and disaster site. Potentially eligible people were identified from lists provided by building managers and employers as well as through notices in the media. Analyses of these registry data have characterized two major long-term health outcomes of survivors: post-traumatic stress disorder and respiratory illness.9–11 The agency continues to contact persons in the registry periodically to assess the long-term health impact of the disaster and connect people to needed services.
As our ability to gather and analyse information has greatly increased, so has our need to disseminate the results of these analyses and recommendations to policy-makers, health professionals and city residents. DOHMH produces several different publications, including: City Health Information, a monthly bulletin with information and recommendations sent to all of the more than 20 000 licensed city physicians and other selected health professionals; Vital Signs, policy-driven data briefs directed at policy-makers and opinion leaders and Health Bulletins, health education briefs for NYC residents themselves (all publications available at http://www.nyc.gov/html/doh/html/pub/pub.shtml). These are distributed via the internet, e-mail lists, mail lists and display racks city-wide. These publications have simple text and high-quality graphics, and give clear, understandable recommendations relevant to the intended audience.
Information dissemination goes beyond summary reports. The databases managed by the agency also provide invaluable information to researchers, reporters and residents with specific questions about the city's health. To enable them to answer these questions, the agency has developed EpiQuery, an internet-based interactive system that allows users to produce frequencies and cross-tabulations for data elements from four different surveys: the CHS, the Youth Risk Behavior Survey, the 2000 U.S. Census and the city's vital statistics registry (available at http://www.nyc.gov/html/doh/html/community/community.shtml). For researchers, full datasets and supporting documents are available for download via the internet.
The department has also used the techniques of modern advertising to inform NYC residents and promote healthy behaviours. We have conducted focus groups, developed ads and purchased media time for tobacco control, consumption of water (instead of sweetened beverages), influenza immunization, promotion of condom use and other topics. The tobacco campaign was evaluated most thoroughly. In a panel of smokers and recent quitters we surveyed, 90% reported seeing at least one ad and more than three quarters saw two or more ads; almost 95% of those who saw an ad reported that the ad said something important to them and more than half reported that an ad increased their motivation to quit. During the 2006 campaign, which had hard-hitting advertisements in English and Spanish, telephone calls for help quitting smoking quadrupled compared with the same time period the year before. Smoking prevalence among Hispanic New Yorkers decreased by 15% from 2005 to 2006.12
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Initiatives to prevent chronic diseases |
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Policy change
It is easy in public health to become overwhelmed with the number of health problems and lose focus on those with the greatest prevention opportunities. To draw attention to a limited number of high-priority preventable health problems, we developed Take Care New York, the City's first comprehensive health policy (Table 1).13 Take Care New York sets city-wide goals for 10 preventable health problems, and by emphasizing partnerships with other governmental, private and non-profit organizations, it focuses the attention of the broader community on steps to solve them.
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Chronic diseases such as heart disease and cancer have long been the leading causes of death in America, but few local health departments have sizeable programmes to address these problems. Many behavioural risk factors for chronic diseases are well characterized, and there are policy tools to promote healthy behaviours. Since 2002, DOHMH has identified policies to alter the NYC environment and support healthy behaviours.
- Smoking is the leading ‘actual’ cause of preventable death in NYC and the United States.14 In 2002, DOHMH began a comprehensive tobacco control programme, including: an increase in the city's cigarette tax from $0.08 to $1.50 per pack; a Smoke-Free Air Act that prohibited smoking in virtually all indoor workplaces, including restaurants and bars; a mass media campaign emphasizing the health risks of smoking, the benefits of quitting and the dangers of indoor tobacco smoke pollution; distribution of nicotine-dependence treatment guidelines to all physicians, expansion of public hospital smoking cessation clinics and widespread distribution of nicotine patches and gum to adult smokers.15,16 The programmes were targeted to New York's different demographic groups (e.g. media messages created specifically for Russian and for Chinese populations, which our surveys showed had higher smoking rates), and different geographic areas. After a decade of stable smoking prevalence, between 2002 and 2007 the adult smoking prevalence in NYC fell from 21.5% to 16.9%, representing approximately 300 000 fewer adult smokers,12 and between 2001 and 2007 the prevalence of teen smoking dropped by half, from 17.6% to 8.5%. If approximately one-third of smokers die of smoking-related diseases, this programme will prevent 100 000 unnecessary deaths. While most of these deaths will be prevented in the future, it is encouraging that from 2002 to 2006 NYC's smoking-related age-adjusted mortality (estimated using a method developed by the CDC)17 fell 17%, from 217/100 000 (8722 deaths) to 181/100 000 (7744 deaths).
- Regulation of food establishments to protect health has long been a core function of public health agencies, but traditionally it has been used to protect people only from infectious agents and other contaminants. In 2006, DOHMH expanded its regulation of restaurants to reduce the risks of acquiring chronic diseases from food. The first of two new regulations phases out the use of artificial trans fat, which contributes to heart disease by lowering HDL blood serum cholesterol levels and raising LDL cholesterol.18 As of July, 2007, all restaurants were required to use trans fat-free oils for cooking and frying and for spreads. Health Department inspectors were trained to review content labels and document trans fat use. By late 2007, > 95% of restaurants were complying and more than 50 national chains had reformulated their products to be trans fat-free after passage of the mandate. By July, 2008, all foods served by restaurants, including baked items and fried dough, must contain <0.5 g of trans fat per serving.19,20 The second new regulation requires chain restaurants to provide information on the calorie content of their foods conspicuously on menus and menu boards. The rationale for this regulation is that chain fast-food restaurants serve food that is high in calories and associated with weight gain,21 and nutritional information is seen by <5% of customers at most chain restaurants;22 customers substantially underestimate the calorie content of the foods they purchase,23 and if provided calorie information at the time of purchase many customers are likely to choose lower calorie items.22 While a first version of the calorie-labelling rule was struck down by a federal court, DOHMH has proposed a revised rule that should withstand legal challenges.
Improved health care
In recent decades, public health and the health care system have often been antagonistic, and it is tempting for public health agencies simply to avoid work and conflict by viewing health care as outside of their purview. Nonetheless, substantial reductions in chronic diseases can be achieved by refocusing health care on high-priority preventive interventions.24 The DOHMH has chosen to engage the health care system in efforts to reduce the morbidity and mortality of common diseases:
- The DOHMH has implemented a Public Health Detailing program, modelled after the pharmaceutical industry's sales-oriented detailing programmes, that works with primary health care providers in communities with the highest disease rates. In business terms, the programme markets the product line of public health initiatives using the strong brand name of the health department. DOHMH representatives visit providers to promote clinical preventive services and chronic disease management organized around clinical topics with the potential to prevent the greatest amount of disease and death, such as hypertension, treatment of tobacco addiction, influenza immunization and diabetes management. Detailing visits include delivery of brief, targeted messages and distribution of ‘Action Kits’ that contain clinical tools, informational resources for providers and patient education materials.25
- Through the Primary Care Information Project (PCIP), our agency is using its expertise to refine and expand adoption of an electronic health record (EHR) system with a strong focus on prevention. EHRs can ensure that crucial medical information on individual patients is always available to providers, and can generate reminders for patients to come in for preventive health maintenance—reminders that in the US. are currently sent routinely by dentists, veterinarians and auto mechanics but rarely by primary care providers. EHRs can also give providers data on the health of their entire patient populations so they can better understand patterns of disease occurrence, measure how well illness is managed, identify patients in need of more intensive intervention and systematically improve the quality of their care. While many different EHR systems are in use or in development, none that we reviewed gave sufficient emphasis to prevention. The PCIP EHR system will also provide the health department with aggregate data on disease, and clinical preventive interventions. The software for PCIP is offered with a substantial subsidy and with user support to more than 2000 primary care providers, potentially improving care for more than 1.5 million people.
- The haemoglobin A1C registry, in addition to its surveillance functions, offers a novel opportunity to provide feedback to treating physicians and, through their physicians, to patients regarding degree of glycaemic control. On a pilot basis, the department has begun to provide rosters of patients’ A1C levels, together with guidance on diabetes management, to physicians in one of NYC's five boroughs where diabetes and diabetes complications are most prevalent. Other interventions that are planned using the registry are generation of letters from physicians to patients with high A1C levels, and distribution of glucose strips and self-blood pressure monitors.
Updated approaches to other persistent health problems
Although chronic diseases are the leading causes of death, many longstanding health problems persist and require ongoing attention. DOHMH has attempted to refocus or update its approaches in many existing programmes, ranging from rodent control to lead poisoning prevention. Table 2 shows some initiatives the agency undertook during 2002–07. Two in particular represent innovations in traditional programmes:
- DOHMH has begun two home-visiting initiatives that echo similar programmes conducted by NYC in the early 1900s, only with a stronger foundation on scientific evidence. The Nurse-Family Partnership helps high-risk first-time mothers and their infants with home visits every 1–2 weeks, starting during pregnancy and continuing until the child's second birthday, following a model reported to cause greater spacing of subsequent pregnancies and improved partnership stability among parents, accelerated language development and greater school achievement among children and reduced maternal substance abuse and child abuse and neglect.26–29 The less intensive but more extensive Newborn Home Visiting Program attempts to conduct single home visits to every new mother within high-risk neighbourhoods of Brooklyn, Harlem and the Bronx, providing health education with a particular focus on breastfeeding, identification and abatement of home environmental risks (e.g. lead paint) and referrals to community services.
- Based on evidence that large-scale condom distribution can increase condom use,30,31 in 2005 DOHMH began distributing large quantities of condoms to organizations and businesses for free through internet-based ordering, which increased the number of condoms distributed from 250 000/month to 1.5 million/month.32 Condoms were placed particularly in locations frequented by groups with high HIV prevalence such as gay bars; in a 2006 evaluation 64% of patrons at these locations reported seeing free condoms and 58% of those seeing them reported obtaining and using the condoms. In 2007, the agency took the additional step of launching its own ‘NYC’ condom brand, supported by a mass-media campaign, and the number of condoms distributed increased further to 3.1 million/month.
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Addressing health disparities
In NYC, the poor and people of colour, groups that often overlap, experience excess disease incidence and mortality. For example, although life expectancy has steadily increased for all groups, our most recent life table data (1999–2001) show that Black men live 69.1 years compared with 74.9 years for white men.33
Increased surveillance capacity has permitted more detailed assessments of racial and socioeconomic health disparities.34 Because NYC has a high degree of racial and economic segregation, maps can be particularly persuasive in demonstrating stark differences in health outcomes and prompting action. A new Geographic Information System (GIS) unit has increased the agency's capacity to map health and other data by neighbourhood. In 2007, the Health Department made these data available to a mayoral commission on poverty, which recommended a broad agenda for investment in job creation, education, job training and housing.35
To address disparities, the Department's own policies and programmes have been more narrowly focused. First, we expect that policy initiatives, many described here, which focus on increasing the availability for healthy choices and reducing exposure to unhealthy influences will be ‘pro-poor’ in their implementation, as the poor usually have less access to healthful environments. Second, our public health programmes are usually designed to emphasize low-income persons. Because well-defined areas of the city have poor health, we established new District Public Health offices in these areas and programmes—including smoking cessation services, public health detailing, EHRs, free condom distribution, nurse visiting programmes—are preferentially targeted to these areas.
Continuing challenges
Unfortunately, DOHMH has not been able to make substantial progress on some key causes of mortality and morbidity. While we have reduced smoking rates, we have not been able to reduce the use of alcohol and illicit drugs or the adverse health consequences of their use; in particular, fatal drug overdose, which is a leading cause of death in persons under age 55, continues at a high rate. Our efforts to better identify, counsel and treat HIV-infected persons have been limited by legal requirements for cumbersome written consent for HIV testing and lack of accountability in the HIV treatment system.36 And management of every common chronic medical condition, including asthma, diabetes and hypertension, is hampered by a US health care financing system that rewards intensive treatment of long-term sequelae of chronic conditions far more than effective management of those conditions to prevent sequelae. We also need to further reduce the number of teen pregnancies in NYC. There has been a steady but too-slight decline since 2000 when the rate was 101.1 pregnancies per 1000 females ages 15–19. In 2006, the teen pregnancy rate had dropped to 89.7 pregnancies per 1000 females. This remains far higher than the national rate that is itself far higher than rates in most developed countries. To encourage greater decline, we need to work to change social norms related to teen birth and provide accessible reproductive health services, including school-based health clinics, among other interventions.
The difficulties implementing DOHMH's public health initiatives have been both political and bureaucratic. A small but vocal minority of residents often strongly opposes public health programmes even when the majority favours them. Recipients of government contracts may also resist innovation, even when their services proved marginally effective. In the past 5 years, the DOHMH has had to confront—sometimes successfully and sometimes not—powerful groups such as the tobacco and hospitality industries with regard to smoke-free workplace legislation,37 the restaurant industry with regard to trans fat and calorie labelling regulations and ‘anti-nanny state’ conservatives at many other points.
Unfortunately, many other difficulties—both large and small—were caused by ongoing, systemic problems of government. Effective public health action requires highly skilled staff, facilities and equipment than enable staff members to do their jobs, and the ability to quickly direct people and financial resources toward problems. Laws and rules defining how government must operate—usually established in the name of accountability—interfere with all of these. Low salaries and rigid civil service rules make it difficult to hire and retain the most talented staff. Outdated or inadequate facilities and equipment interfere with the staff's ability to function at their best. A long contracting process makes it extraordinarily difficult for government agencies to work with contractors and other outside organizations to implement projects in anything close to a timely fashion. These problems of government are by no means unique to NYC or to public health agencies. Nonetheless, solving them might have a greater impact on the effectiveness of public health agencies (and thus improvement in health of the public) than many individual programmes.
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Infrastructure needed for public health success in the 21st century |
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Our department's success and failures have highlighted capabilities necessary for a modern public health agency to prevent and control modern health problems. When the NYC Health Department was established in 1866, it was given broad executive powers to enact and enforce a wide range of regulations to promote the public's health under oversight by the Board of Health. This policy-making and enforcement authority has long been recognized as crucial to controlling communicable diseases; we have seen that this authority can be equally effective in promoting healthy behaviours and preventing chronic diseases.
Over recent decades, public health in the US has been seen increasingly as separate from health care, mental health, substance abuse and environmental protection. These artificial divisions are obstacles to improving the health of populations. We believe future strides in chronic disease prevention and control will depend on close collaboration with the health care system. Our ability to make substantial improvements in other areas of health has often depended on our ability to bridge other divisions. An opportunity to do this occurred in 2002, when a city charter amendment merged the former Department of Health with the Department of Mental Health, Mental Retardation and Alcoholism Services. The newly formed DOHMH was created for collaboration between the City's medical and mental health systems. This has enabled us, for example, to study the epidemiology of mental illness, to promote treatment of depression by primary care physicians, to include mental health outcomes among those tracked in the World Trade Center Health Registry and to promote the use of buprenorphine by primary care physicians for treatment of opiate addiction. The integration of what have been seen as separate health functions is crucial to new, creative approaches to public health problems.
One of the most important infrastructure changes we have made has been strengthening our capacity in epidemiology. After internal discussions about the relative merits of a separate epidemiology unit vs greater epidemiologic capacity within units, we decided to create both: DOHMH has a new Division of Epidemiology, which conducts independent analyses and which supports other units. At the same time, most units in the agency have increased their capacity for epidemiological analyses of data and evaluation of programmes. Among other activities to support this data-driven work environment, week-long epidemiology courses taught by in-house staff members are offered 4–5 times per year for 15–20 agency personnel at a time.
Another decision we made was to create a Division of Health Promotion and Disease Prevention and, within it, a Bureaus of Chronic Disease Prevention and Tobacco Control. State and local health departments are often organized, almost by default, according to the streams of funding provided by the federal government. There is no categorical federally funded programme for chronic disease prevention and control (although there are more narrowly defined programmes to address diabetes treatment, screening for breast and cervical cancer and cardiovascular disease), but given the magnitude of this health problem we felt that there was a need for it to have an organizational home. In 2002, DOHMH had not a single staff member working exclusively on cardiovascular disease, cancer or diabetes; in 2007 more than 100 staff members work on these topics. While funding in this area remains inadequate, this division has taken leadership on promotion of healthy behaviours and creation of health-promoting environments.
In the US, federal funding for control of communicable diseases is reliable and has created a uniform national capacity to address important national problems such as tuberculosis and HIV/AIDS. However, chronic diseases are more common and are no less amenable to control through public health interventions. In the US, and likely in other countries, there is a gross mismatch between funding levels for different categories of diseases and the number of premature deaths caused by those diseases (Figure 1). It is crucial to continue funding for communicable disease control, but federal, state and local governments should also provide the funds necessary to implement effective programmes to prevent and control chronic diseases.
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As we have designed and implemented new approaches to public health, we have come to recognize the particular need for strength in three key functions: information systems, communications and legal/policy expertise.
Public health rests on a foundation of sound epidemiology, and as more data are computerized, epidemiology in turn rests on a foundation of a strong information systems infrastructure. Beyond hardware, this means a need for staff members who are highly skilled at creating, maintaining and linking datasets, ensuring confidentiality38 and at providing data analysts with reliable and efficient access to stored datasets and the latest analytic software to explore them.
The revolution in information technology in recent years has enabled a parallel revolution in communications. The media environment is overflowing with information and images from a rapidly growing number and diversity of sources that influence health-related behaviour, perceptions of health and disease and public policy. Public health agencies, which have access to the information on population health and the expertise to interpret this information, should be the leading voice on health. If they are not, the agenda tends to be driven not by the imperative to improve the public's health but by other concerns ranging from the profits of drug companies to a desire by media outlets for sensational stories. Maintaining leadership in health communications requires staff with the experience and skills to operate skilfully in the fast-changing media world. Those skills include those of working with news outlets, public relations and advertising.
Policy-making requires lawyers who can not only provide opinions about whether actions are within the agency's authority, but also help shape a legal strategy that will simultaneously achieve a policy goal and withstand legal challenges. It also requires staff who have intimate familiarity with the policy-making process in city, state and federal governments, who advise on the wording of policies and who can persuasively brief elected officials and other policy-makers.
Finally, and most importantly, progress in public health requires enlightened political leadership. During these 6 years, NYC Mayor Michael Bloomberg has been a strong advocate for public health on controversial issues, including tobacco control, needle exchange programmes, condom distribution, calorie labelling in chain restaurants and the elimination of trans fats from restaurants. Actions that make measurable differences in the public's health will usually be controversial. Political leaders who either do not understand public health or do not value it highly will avoid the risks of controversy by failing to take action. Those of us in public health practice do the best we can within the limits of political systems in which we operate, but as we do our day-to-day work it is a good investment for us also to educate current and future political leaders about the methods and value of public health.
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We thank Mayor Michael R. Bloomberg for his leadership and commitment to public health, and the enormously dedicated and talented staff of the New York City Department of Health and Mental Hygiene who conceived, implemented and evaluated the initiatives described in this article.
Conflict of interest: None declared.
KEY MESSAGES
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