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Senator HATFIELD. I have one here, Mark O. Hatfield. 1-800 753–9596. What happens is this is registered in a central registry, and any person that is found with this particular identification, can receive immediate helpit does not solve the problem-but certainly it will help reduce the risks associated with wandering.

My question to you—first of all, will you accept this as a symbol of maybe your continued interest in this cause? And I will have one here of myself as well. But have you conducted any study in your agency or have you made any evaluation of this problem among the estimated 4 million Alzheimer's victims?

Senator HARKIN. I just want to take a look at this. I have never heard of this.

Senator HATFIELD. Sorry, I forgot about you. [Laughter.]
Senator HARKIN. That is all right.

Senator HATFIELD. The question is has this agency addressed this particular part of the Alzheimer's problem and I emphasize it is a very small part? As you know, I have had a long interest in the Alzheimer's problem and have been supportive of those institutes and centers that we have created to conduct research on this disease and am proud to have one located in Portland.

Do you have any thoughts about whether this bracelet project should be replicated or are you familiar with this very small beginning?

Secretary SULLIVAN. Senator, I feel I am not familiar with that specific effort, but I am familiar with similar kinds of braceletsthe medic alert bracelet and others. On the surface it would seem to be a very useful kind of registry because of the problem that we have with some of our Alzheimer's patients. I would be very pleased to have members of my staff review this in more detail because that is a problem.

I am concerned and committed to the problem of Alzheimer's disease. This is the third budget cycle that I have been involved in since becoming Secretary, and during that time our budget for Alzheimer's has gone from $130 million in 1989 to $241 million for fiscal year 1992.

Within that the NIH budget for research on Alzheimer's has gone from $105 million to $209 million, so it is almost double. Dr. Franklin Williams, head of the National Institute on Aging, and his staff who oversee that research are individuals in whom I have great confidence as I do with the various volunteer agencies.

Senator HATFIELD. Thank you for your expressed interest. But more than just reviewing this particular project, which is based upon the medic alert system that has been deployed for other causes, or other reasons, I would hope that you would review just that one facet at least to see what might be done from a national perspective. I am not suggesting we necessarily adopt it as an agency program, but how it might be expanded or improved upon.

Because part of this $90-some billion that we are spending this year for the care of Alzheimer victims will only be controlled and reduced as we find some medical cures and prevention, but also much of that forces the family to put these members of their family into full-time, 24-hour care. It seems to me this is a small step to try to help reduce that risk of wandering that might even permit that family member to remain in the home rather than to be put into institutional full-time care.

So it is preventive in a sense, and I would like to have you take a look at it from the national perspective and see if there is a system that can be implemented that would at least help diminish the risk of wandering.

Secretary SULLIVAN. I would be very happy to, Senator Hatfield.

As we have increased our understanding about Alzheimer's in the last 10 years or so we have been rather stunned to see the number of individuals diagnosed with Alzheimer's. It is a problem of significant magnitude.

We are investing in research to see if there are ways we can understand more about Alzheimer's, with the idea of intervening to prevent this degenerative process.

I think we are all very heartened by reports within the past month coming out of research in Guy's Hospital in London that suggest that they may have further information about the process that leads to the deposition of this amyloid-type protein within the nerve cells in the brain that are associated with this degeneration. With this increased understanding about how this process works we may be able to ultimately reverse it. It may seem farfetched to some, but I believe that this is certainly within the realm of possibility.

By comparison, while we still have much to do before we feel that we have a satisfactory treatment for AIDS, another great problem, we do have some very encouraging research underway with new drugs that seem to extend the therapeutic range with perhaps less toxicity, and promising research on the development of a vaccine.

As we learn more about Alzheimer's, we hope we will be able to find a way to intervene and prevent the onset of this disease so that these individuals will lead happier lives with their families in their senior years. [The information follows:)

ALZHEIMER'S ALERT PROGRAM I have recently been made aware of the work of the Alzheimer's Alert Program. I understand that the program utilizes an identification system employing ID bracelets similar to the Medic Alert bracelets used by many individuals, and that a trial program has been initiated in New York City. The identification system is designed to speed the identification and safe return of people who wander, are lost, and cannot adequately identify themselves.

In order to learn more about the problem of wandering, the National Institute on Aging (NIA) recently supported a small study of 106 Alzheimer's disease patients. The study found that about one-quarter Alzheimer's disease patients were reported by family members to wander. The study also found that half of those afflicted with Alzheimer's disease experience periods of restlessness. Researchers be. lieve that the frequency with which Alzheimer's disease patients wander is affected by the stage of the illness and the patient's living environment.

To begin to address the problem nationally, the National Institute on Aging, in collaboration with the National Center for Nursing Research and the Alzheimer's Association, has initiated a research program to determine how to manage symptoms of Alzheimer's disease such as wandering and other behavioral problems. In response to an NIA issued Request for Applications (RFA), NIA expects to award 7 to 10 research grants for studies aimed at identifying the factors underlying the behavioral symptoms of Alzheimer's related problems such as wandering. The stud

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ies will also seek to develop better means of diagnosis and treatment for these problems.

RETURN ON INVESTMENT Senator HATFIELD. Mr. Chairman, I will only make one observation in closing my portion of time. Dr. Sullivan, you know, we are locked into a budgetary process that sometimes fails to give us the full and complete picture. I really hate to look at these programs

I with the same dollar measurement that I use to look at accounts and costs and appropriations in other budgets, because Mr. Chairman, let us remind ourselves that it is not the total number of dollars we spend, but it is the multiplier, and the character of the dollar and how we invest it.

Of all the people that will appear before our Appropriations Committee representing political policymakers as well as programs, Dr. Sullivan represents the highest cost-benefit ratio multiplier of any Federal dollar that we will appropriate.

For every $1 allocated to health, research, prevention, and care programs, we will get $13 back into the economy. We have heard this figure many times, to the point it becomes redundant, but I just think that when we are looking at dollars here and the impact it has on our general economy we ought to have a different measure than the measure applied to appropriated dollars made to other programs.

In my view, and I believe backed by the statistics, there are no dollars that will bring more back into our economy than the dollars that you represent in the programs of health.

I wish somehow we could get OMB and all the bean counters in the CBO and every other place that they make these adjustments and evaluations to begin to look at the health dollar in a little different light. I will not identify any one of the other programs to make a comparison, but I can tell you that there are zero for zero multipliers, and there is a 1 for 13 multiplier,

I thank the chairman.

Secretary SULLIVAN. Senator Hatfield, I agree with you on the return on the dollars invested. But, in addition to the financial return, the fact is the quality of the lives of our citizens are much improved

Mr. Chairman, your comments about prevention in terms of birth injury from good prenatal care, is a good example of how we could spend thousands of dollars and still have an impaired individual who is not going to be a productive citizen. I agree fully that the productivity and the quality of the lives of our citizens is another important part of the equation.

Senator HATFIELD. Thank you, Mr. Chairman.
Senator HARKIN. Senator Gorton.

RATIONALE FOR CHANGES Senator GORTON. Thank you, Mr. Chairman.

Mr. Secretary, you are almost as candid in your written statement as you were in that forceful and eloquent opening statement, and you list a number of fields in which there are changed priorities upward-that is to say, increases which are greater than your 9 percent overall increase. I think those are properly highlighted. As you get to the end of your written statement, however, on page 10, you tell us, "As you”-that is, we are well aware, the Budget Enforcement Act of 1990 established absolute spending limits for all discretionary programs. In order to stay within the prescribed ceilings, we propose the following spending reductions." You list three: low-income energy assistance, community services block grant, and health professionals training program.

I note as I go through the rest of the statement that in addition to those absolute decreases, you highlight a number of areas in which the increase is considerably less than the 9 percent average for your entire Department. Among those are expenditures for biomedical and behavioral research through the National Institutes of Health, and some other research programs. While it is not specifically in your statement, I think AIDS falls into that category.

Now, I believe that it is totally correct and proper to constantly set new priorities and to reexamine old programs; I believe that to a considerable extent you have done that. This is a different mix, and perhaps even a different philosophy, than a budget of even i year ago.

I would like you to explain what kind of value judgments or philosophic judgments led you to these changes—not just the three in which there are actual decreases, but some of the others. Perhaps I am most sensitive to the National Institutes of Health and basic research. Why are they either cut or increased at a slower rate than your average?

Secretary SULLIVAN. Yes; Senator Gorton, you are quite correct in saying that it is a different environment this year. One of the most important differences is the budget agreement under which we are operating. That has caused us to make some painful decisions.

We have a target that we cannot exceed and we are no longer competing with the Defense Department or with foreign aid, et cetera. We are competing with other domestic programs. When it comes to programs, most of my Department falls within the domestic discretionary area, so a lot of competition is within my Department. This excludes several large areas that are mandatory.

We are trying to make judgments on the best use of the dollars available to us in terms of the comparative need for the program and the return on our investment. For example, we proposed to reduce the low-income energy assistance program. I have learned in the last 2 years that every dollar has a constituency attached to it that can be very vocal. We have to try to make rational judgments.

The low-income energy assistance program was started during the oil embargo back in the late 1970's as a temporary measure because of the high cost of fuel. There are other programs in my Department that provide funds that can be used for energy assistance such as the AFDC program, emergency assistance, and others.

In many of these low-income energy assistance grants made to the States as part of our block grants, not all of these dollars are used. The States can, and do, transfer funds from this program into other programs. They also have the option of transferring funds from other programs into this.

That is not happening. There is no question that the program has value. Yet, when we look at high infant mortality, or the need

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for more biomedical research, or the need to expand our National Health Service Corps because in virtually every State there are many underserved areas where people do not have health professionals, we must make judgments as to where the greatest need is and where the greatest return is. We are forced to make those kinds of judgments since we must live within the budget agreement.

I am strongly committed to the National Institutes of Health. Our NIH budget for research project grants increases by 8.8 percent, and our goal is to award at least 5,000 new and competing grants every year. Our budget will allow about 5,700 new and competing grants. The overall NIH budget during the three budget cycles with which I have been involved has increased by approximately $2 billion.

We look at the NIH not simply 1 year at a time but over a period of several years, and we have had significant increases overall. There are always additional opportunities, but we must weigh these in relation to the discretionary dollars that are available to us.

BUDGET CHOICES Senator GORTON. Thank you, Mr. Secretary. I have been a member of this subcommittee for about 4 weeks. This is the first day on which it has had any hearings, but I have heard exactly what you reported. There are many constituencies from home with sincere and hardworking people competing over this money. The lesson to them is that as they ask for more, they are taking it away from someone else, probably in a very closely allied field. This is not a welcome lesson or one easy to learn.

But it seems you are saying at a more cosmic level exactly the same thing. If we do not like your priorities—if we wish to add, for all practical purposes, we are going to have to subtract from somewhere within your own budget. We must find one of the areas of increase that we can reduce in order to make up for any increase. Even as a beginning member of this subcommittee, Mr. Chairman, that does not look like a particularly easy task.


Secretary SULLIVAN. Senator Gorton, I would respond with the example of infant mortality funding. This is a very controversial topic which has been widely discussed as it relates to the community and migrant health center programs to which I am strongly committed.

I spoke at the 25th anniversary banquet 1 year ago and know many of the people. I have high regard for those programs. Last week I spoke at the 20th anniversary of one of our centers out in Arizona. What we propose to do is to fund 10 demonstration grants to get data as to how we can more effectively decrease infant mortality.

We spend more dollars per capita for health care than any other Nation in the world, but in spite of that, when it comes to infant mortality we rank 24th. What that says to me is that we are not

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