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sociated with the heavy use of alcohol, occasional use of marijuana, and experimentation with cocaine.

I am just reading here from the list.
Dr. MASON. Yes.

Senator HARKIN. To increase the social disapproval of the proportion of high school seniors who associate risk of physical and psychological harm with heavy use of alcohol, marijuana, and cocaine. It is always alcohol, marijuana, and cocaine.

Now having one kid in high school and one approaching, I can tell you—and you know this as any parent knows this—the perception of social disapproval or risk of personal harm can be powerful in determining behavior. Quite frankly, I think sometimes social disapproval takes the lead over personal harm. So I think promoting these perceptions about alcohol and drugs is very worthwhile. In other words, there is social disapproval of that. Why is tobacco not listed there?

Dr. MASON. I would like to answer that by simply saying that alcohol and drugs are one of our priority areas, and I think you are reading from that priority area while there is another priority area that talks simply about tobacco and its effects on our goals. One of the 22 priority areas discusses nothing but tobacco, and then there is another priority area that gets into alcohol and drugs.

Senator HARKIN. I appreciate that, but the report, I understand, has two tobacco goals: reduce from 30 percent to 15 percent the proportion of those who smoke regularly by age 20; and to reduce smokeless tobacco use. There is no mention, however, of educating kids about tobacco's risks or trying to reduce smoking by encouraging social disapproval of it.

Dr. MASON. Dr. McGinnis, do you want to comment on that? This was developed under Dr. McGinnis' coordinating capacity. Dr. MCGINNIS. Thank you, Dr. Mason, Mr. Chairman.

Indeed, the issue of social disapproval with respect to tobacco use among school children is a major priority. One of the first objectives in services and protection under tobacco, for example, is to establish tobacco-free environments and to include tobacco use prevention in the curricula of all the elementary, middle, and secondary schools. There are various related targets that challenge the Nation to insure that tobacco education is prominent throughout the educational process, and moreover, that the school is a healthy work environment with respect to tobacco use as well.

So we agree with you that it is a very important priority, and I think you will find initiatives targeted to increasing social disapproval with respect to tobacco use among youth reflected throughout the program proposals of the Public Health Service.

SOCIAL DISAPPROVAL OF ABUSED SUBSTANCES

Senator HARKIN. I am concerned about increasing the social disapproval. Here it is. Increase the proportion of high school seniors who perceive social disapproval associated with heavy use of alcohol, marijuana, and cocaine. Your target for cocaine is reduce it 95 percent, marijuana 85 percent, heavy use of alcohol 70 percent. That is reduction; right?

Oh, those who perceive it. I see. In other words, you want 95 percent of high school seniors who perceive a social disapproval associ

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ated with the use of cocaine, 85 percent who perceive a social disapproval with use of marijuana, and 70 percent with the heavy use of alcohol. I see nothing listed for use of tobacco there. That is what I am trying to focus on, the social disapproval. I congratulate your focusing in those areas, but how do you fold tobacco in there?

It is a drug. We know that.

Dr. MCGINNIS. The reason for the difference between the way the targets are stated for alcohol and drugs versus tobacco is reflective of the pluralistic process by which the objectives were developed. We tried to make this very much a participatory process involving literally thousands of people across the country. What this means is that from area to area there is going to be some slight variation in the way the targets are stated.

I think if you look throughout the tobacco targets, you will see, perhaps not as explicitly stated as in the alcohol area, implicitly a very strong message seeking social disapproval for tobacco use among youth. It is clearly reflected as well in our program priorities.

Dr. MASON. We agree with you that all of those things must be done, not only with regard to substance abuse but also with tobacco, which is an abused substance as well.

Dr. MCGINNIS. Let me add one thing. The survey that will be tracking perceptions of the socially disapproved use of alcohol and drugs will also track perceptions of the social disapproval of tobacco. So we will be monitoring and focusing on it, as it is a priority for the Public Health Service. Senator HARKIN. I appreciate that.

You used one word, though, Dr. McGinnis. You said implicit in the areas covered by tobacco. In other areas it is explicit. Why could we not make it explicit with tobacco?

Dr. MCGINNIS. Well, again, it reflects the many people involved in the process and the fact that there were two different working groups involved in this. We tried to effect a uniformity where we could but without being heavy handed in it.

I can assure you that there is no waiver in our commitment in that regard. We will track and pursue it.

Senator HARKIN. I appreciate that. Thank you.

Dr. MASON. Thank you, sir. We appreciate your calling our attention to that. I believe that both explicitly and implicitly we need to do everything we can to reduce the use of tobacco particularly among young people, because we know that very few smokers begin after the age of 21. If we can educate them in their adolescence, then they will never start. Senator HARKIN. Very true. Thank you, Dr. Mason.

“HEALTHY PEOPLE 2000” GOALS Dr. MASON. The next chart shows the overriding goals of "Healthy People 2000.” There are three of these: increase the span of healthy life for Americans; reduce health disparities among Americans--and I should mention with regard to reducing health disparities that one of the reasons that we failed in approximately 25 percent of the 1990 objectives was because we allowed those disparities to continue.

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HEALTHY PEOPLE 2000 GOALS FOR THE NATION

Goal I: Increase the span of healthy life for Americans.
Goal II: Reduce health disparities among Americans.
Goal III: Achieve access to preventive services for all Americans.

It was the lack of effective targeting of our minority populations. Had we been able to reduce a number of disease states in minority populations, we would have met those national 1990 goals. One of the things we want to accomplish during the decade of the 1990's is to make sure that those discrepancies are reduced.

Senator HARKIN. That is very interesting. I never thought about that.

So do you have a methodology through which you are going to do that over the next 10 years?

Dr. MASON. Within "Healthy People 2000,” in addition to the 22 priority areas we also target special populations. We target, for example, various ages. We specifically target minority and disadvantaged populations in the objectives. In other words, we have identified a series of special populations and almost a type of matrix where simultaneously we want to focus and target our efforts where the needs are the greatest.

Senator HARKIN. Very good. Thank you, Doctor, .

Dr. MASON. The third goal is to achieve access to preventive services for all Americans. We cannot accomplish these goals if all Americans are not part of this promotion/prevention process.

The next chart shows that 21 of the 22 priority areas are grouped under three categories: health promotion; health protection; and preventive services. Then spinning out from these priority areas are the 300 realistic achievable, measurable objectives.

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HEALTHY PEOPLE 2000 PRIORITY AREAS

Health promotion: Physical activity and fitness; nutrition; tobacco; alcohol and drugs; family planning; mental health and mental disorders; violent and abusive behavior; and educational and community-based programs.

Health protection: Unintentional injuries; occupational safety and health, environmental health; food and drug safety; and oral health.

Preventive services; Maternal and infant health; heart disease and stroke; cancer; diabetes and chronic disabling conditions; HIV infection; sexually transmitted diseases; immunization and infectious diseases; and clinical preventive services. Surveillance and data systems.

Senator HARKIN. Excuse me, Dr. Mason. Please hold up for a second. I just want to make sure.

[Pause.)
Senator HARKIN. OK, thank you.

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PUBLIC HEALTH SERVICE SPENDING Dr. MASON. Chart 1 shows how the Public Health Service intends to spend money in fiscal year 1992. This shows the operational level and how it is distributed between prevention programs. There is $3.2 billion, or 20 percent of our budget, that is largely CDC, HRSA, and part of ADAMHA; $2.3 billion in prevention research, approximately 15 percent, most of that is in NIH, ADAMHA, Agency for Health Care Policy and Research, and, to a lesser extent, CDC; and then other PHS programs, $10 billion, largely for research and treatment services. But it shows the general priorities that have been established.

PHS SPENDING
FY 1992 increases

Other PHS Programs

+ $284 million

Prevention Research

+ $160 million

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• Represents discretionary operational Increases excluding FDA and IHS

Other Prevention Programs

+ $218 million Chart 2 shows the increases for 1992. It shows that 33 percent of our increases are targeted for prevention programs, 24 percent or $160 million for prevention research; and then $284 million for other Public Health Service programs.

So you see that the majority of the 1992 increases will go into prevention activities.

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Chart 3 shows what we call healthy start. This shows that in fiscal year 1991, our current fiscal year, we hope to be able to target $57 million to begin healthy start, and then increase to $171 million in fiscal year 1992. This will enable us to target 10 communities and rural areas that have exceptionally high rates of infant mortality. Through this 5-year program we intend to provide access, community outreach, help with personal responsibility, and gain a 50-percent reduction in those exceedingly high infant mortality rates during that 5-year period of targeting those resources.

Senator HARKIN. I am sure you know about my exchange with the Secretary on this.

Dr. MASON. Yes; I have heard about that exchange.

INFANT MORTALITY

Senator HARKIN. Again, I have no problems with this. I ink it is good. Go ahead and do it and see what we can target. See if there are some new approaches to reducing it. It was after that that we had the inspector general here, and they had done a study of community health centers in some of the major cities.

I did not know about this, but there was a direct correlation between the activity of a community health center and infant mortality. In a city where there is a community health center that is funded and active, the infant mortality is down. In a similar city

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