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activity and violence directed at others and at themselves-all take a huge toll in American lives.
These changes may be the most difficult preventive actions to take because so many are so rooted in social problems, such as disintegrated families, drug-infested communities, and a general culture that seems to support excess rather than moderation and mutual care. PHS intends to sharpen its efforts, in cooperation with partners in the private sector and the States, to address health education and information so as to support enhancement of personal responsibility and family and community support for healthy personal behavior.
Equally, this budget proposal recognizes that prevention calls for changes in the physical and social environment, especially of those at highest risk for preventable disease and death. For example, as stated in the Strategic Plan for the Elimination of Childhood Lead Poisoning, "Lead poisoning is the number one preventable environmental hazard. High blood levels of lead can lead to irreversible learning disabilities, thus, robbing those children of the ability to reach their fullest potential".
And finally, we recognize, and indeed we emphasize, the need for changes in the availability and provision of preventive services. We contend that it is time to redress the balance and to put what we know about prevention into this Nation's health care practice.
You will see this intent in the President's budget request for FY 1992: from the emphasis on prenatal care to immunizations to early detection and control of breast and cervical cancer. In a year when we all recognize the imperative to restrain spending, we are seeking increases in preventive services.
Healthy People 2000's challenge to the Nation to increase the span of healthy life for Americans rests on three kinds of changes : in behavior, in environment, and in services. Perhaps no single national problem better exemplifies the need for all three approaches than the national shame of infant mortality, about which I will have more to say.
HEALTH PROMOTION AND DISEASE PREVENTION
In 1989, the Nation's spending on health reached $604 billion, or about 11.6 percent of our Gross National Product, up from 11.2 percent in 1988 and 8.6 percent 10 years earlier. Clearly, something needs to be done. Preventing illnesses and injuries is a major way to increase the quality of life and diminish the burden of health care costs in the long run.
Secretary Sullivan has stated that "good health must be an equal opportunity, available to all Americans". Some of that equal opportunity we can provide for ourselves.
Although the current generation of Americans enjoys the longest life expectancy (75 years) of any in the Nation's history, preventable illnesses and conditions still cause death, disability and disease among many Americans. About half of the 2.2 million deaths which occur in the U.S. every year are potentially preventable, as are many of the illnesses that afflict millions of Americans. One national goal is to avoid having people become sick from preventable illnesses and injuries, and to reduce the number of years of potential life
lost due to preventable conditions. By not waiting for people to require treatment, prevention can both improve lives and reduce medical costs.
The state of infant health is often regarded as an indication of a society's economic development and medical sophistication. By this standard, it is appalling that the United States ranks 24th in infant mortality. While our Nation's infant mortality rates are improving, the rate of decline has slowed in recent years, to annual reductions of less than two percent a year. The rates for blacks and several other minority groups remain unacceptably high. Many of these infant deaths can be avoided through early intervention activities.
To better address this priority, one prevention activity that the Health Resources and Services Administration (HRSA) is beginning in FY 1991 and continuing in earnest with this request is called "Healthy Start". Its purpose is to target 10 areas in the United States that have extremely high rates of infant mortality for special and intensive intervention activities that are designed to bring more pregnant women into early prenatal care.
Bringing women into the care system early in pregnancy allows many problems to be avoided altogether or identified, treated, and managed before they adversely affect the fetus. Unfortunately, high risk women are less likely than other women to get appropriate prenatal care. We need to change this and ensure that the necessary providers and services are also available. We also need to learn what really works at the community level so we can "export" the most productive techniques we discover in intensified projects like those we envision in "Healthy Start" to all other areas of the Nation. The keystone of this program is innovation. We want communities to show us what they think needs to be done and how they would go about doing it, and then join us in a commitment to results. Our target is a 50 percent reduction in the infant mortality rates in the selected areas over 5 years.
The HRSA Healthy Start projects will also address the need for prevention efforts and treatment services for behaviors harmful to the fetus during pregnancy, especially smoking, alcohol and drug abuse, and poor nutrition.
However, access to services is not sufficient. Healthy Start will also seek to enlist the efforts of the community and the families as partners in the effort to reduce infant mortality. Projects will encourage development of a social environment, including the family and expectant fathers, to get the message across that doing drugs, drinking, and smoking are unacceptable for a pregnant woman. And, projects will build on a network of community organizations --schools, churches, businesses -- to reach pregnant women with the message that they need to come in for care and where to get services.
I am very pleased that the President's budget emphasizes prevention programs throughout our request. For example, the Centers for Disease Control (CDC), our national prevention agency, would receive $1.4 billion under this budget. This 18 an $85 million increase over FY 1991.
With increased funds for prevention in FY 1992, CDC will expand the application of proven prevention strategies, with special attention to children and adolescents, women, and
economically disadvantaged populations. Increases will provide funds for CÚC programs on smoking and health, breast and cervical cancer mortality prevention, injury control, tuberculosis control, and prevention effectiveness.
CDC will also emphasize programs that focus on the health of children, such as elimination of lead poisoning, immunization, reduction of infant mortality, and prevention of congenital syphilis. CDC will also work to improve the Nation's public health system - a need demonstrated by the Institute of Medicine's report, The Future of Public Health. With increased funds for the Preventive Health and Health Services block grant, CDC will be better able to track progresstoward the disease prevention and health promotion objectives set out in Healthy People 2000. Other Phs_agencies, not under the jurisdiction of this Subcommittee (the Food and Drug Administration, the Indian Health Service and the Agency for Toxic Substances and Disease Registry) will also play strong health promotion and disease prevention roles in our efforts to achieve the objectives included in Healthy People 2000.
The benefits of biomedical research lead directly to improvements in the Nation's health status and reductions in the societal cost of illnesses. Biomedical research builds for the future, enhances the competitiveness of the United States in science and technology, yields innovations that can be developed by industry, and contributes to a climate of increased private sector investment in applied and developmental research. Basic research is also the bedrock of prevention activities for the future.
In the research area, the FY 1992 budget requests $8.8 billion for the National Institutes of Health (NIH) and $1.1 billion for the Alcohol, Drug Abuse and Mental Health Administration (ADAMHA). This request continues the Administration's investment in biomedical research and research training, while at the same time, enhancing biomedical science opportunities and promoting science education and literacy in the United States.
Investigator initiated research continues to be a very high priority of the Phs. The FY 1992 budget request will support 24,291 research project grants, 665 more than in FY 1991. The NIH portion of this request (21,818 grants, a 632 grant increase) represents the highest grant level ever funded. In addition, we will be able to increase the amount of the average award by 5.6 percent.
The Agency for Health Care Policy Research will continue to support research studies to improve the effectiveness and appropriateness of health care by enhancing our understanding as to what medical and surgical interventions are most effective.
ANTI-DRUG ABUSE ACTIVITIES
The "War on Drugs" continues to show succe88. Current overall drug use has declined 11 percent from 1988 to 1990. Adolescent drug use has declined 13 percent during the same period of time. Occasional cocaine use has declined 29 percent and frequent cocaine use has declined 23 percent. Current
adolescent cocaine use has declined 49 percent. Drug related medical emergencies have been reduced 18 percent.
This budget proposal continues the PHS commitment to the "War on Drugs" by requesting an additional $117 million for anti-drug abuse activities aimed at research, treatment and prevention in ADAMHA and FDA. Long term, stable, and concerted efforts are beginning to show that improved prevention and treatment programs and techniques can be developed.
A new $99 million Treatment Capacity Expansion Program will be instrumental in closing the gap in treatment services. The purpose of this program is to assist states to expand effective and comprehensive drug treatment. Special emphasis will be placed on high-risk populations, with careful attention to the unique needs of racial and ethnic minorities, pregnant and postpartum women and their substance-exposed infants, the homeless, residents of public housing, and adolescents (particularly those involved with the criminal justice system). The new program, together with other ADAMHA programs, will increase FY 1991 treatment levels by about 25,000 people.
The PHS budget includes $485 million of activities that directly impact minority health, a $47 million increase over FY 1991. Highlights of this request include: $15 million to provide extramural construction at Historical Black Colleges and Universities and similar institutions so that researchers at minority institutions may be better able to compete for NIH research grants; recapitalizing HRSA's Health Professions Student Loan program ($12 million) and expanding the National Health Service Corps scholarship and loan repayment program ($5 million) to provide additional loan repayments and scholarships to disadvantaged and minority health professionals; and $9 million for NIH HIV/AIDS research activities.
HIV INFECTION AND AIDS: RESEARCH AND PREVENTION AIDS continues to be a major public health problem in the nation and around the world. In the last 12 months, more than 42,000 new cases were reported. Women are now almost 12 percent of new cases. Almost 800 new cases in children were reported last year; nearly 90 percent of them were born to an infected woman.
The epidemic continues to ravage our racial and ethnic minority populations: Among men, more than 41 percent of cases are in minorities. For women, the figure is more than 73 percent, and for children with AIDS it is above 78 percent. Most cases continue to occur in the large cities of our Nation, but increasingly reports of cases are coming from smaller cities, towns and rural areas across our country.
In the face of these problems, our budget request of $1.9 billion for AIDS reflects a continuing emphasis on the basic areas in which we have the best opportunity for longterm benefits (basic research, development and testing of new therapies and vaccines, and risk assessment, education, and prevention programs). We have also requested monies to continue treatment programs authorized under the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act. Also, we are requesting money for CDC prevention programs under Title III of the CARE Act. We are concerned, however, that this
authorization divides the money between traditional prevention efforts and early intervention activities for people who are infected, thus, reducing monies available for counseling, testing, and partner notification programs.
OFFICE OF THE ASSISTANT SECRETARY FOR HEALTH BUDGET REQUEST
The major programs funded in the FY 1992 budget request for the Office of the Assistant Secretary for Health (OASH), focus on finding approaches that encourage healthy behavior and lifestyle changes. The Adolescent Family Life (AFL) Program, with a budget request of $12 million, is the only Federal program solely focused on the complex issues and problems of early adolescent sexual behavior, adolescent pregnancy and parenting. An increase of $4 million in the AFL program will permit support of evaluation intensive projects to measure the effects of new and innovative approaches; increase the geographic scope and range of intervention model demonstrations; and increase the number of research projects.
The Office of Disease Prevention and Health Promotion oversees, coordinates and manages the "Healthy People 2000" objectives. In implementing the objectives, the office provides special focus to school health and worksite health promotion. The Office also is responsible for coordinating the Department's nutrition policy with the Department of Agriculture. The FY 1992 Président's Budget includes $4.6 million for these efforts.
The President's Council of Physical Fitness and Sports, with a $1.4 million budget request, is responsible for promoting knowledge and understanding about physical fitness, sports and health as well as encouraging participation in physical fitness activities.
The Office of Minority Health has assumed increasing responsibilities as the Department's advocate in issue areas which impact on the health of minority populations. In FY 1990, the Office assumed a leadership role for implementing the Secretary's initiatives for minority males and is continuing in this role in FY 1991. The Office also acts as a catalyst to spur PHS agencies and other public and private entities to identify opportunities where existing programs and resources can be directed to promoting health and preventing disease among minority populations, and to develop innovate strategies to improve the health status of minorities. The FY 1992 request of $20 million will allow us to continue these cooperative activities and to develop a network of private and public partnerships to address minority health needs.
Finally, OASH is requesting $2.3 million for coordination of PHS immunization activities by the National Vaccine Program Office (NVPO). The decrease of $7 million in this program is offset by corresponding increases in the budgets of CDC, NIH and FDA to support vaccine initiatives that were previously funded by NVPO.
Mr. Chairman, I will be happy to answer any questions you may have.