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cialties as well as the private sector and clinical preventive services, as to how to put prevention into the workplace.

There are a lot of things going on, but I really believe that those companies who are bold can see that they cannot afford not to do this. You have already mentioned the reduction in absenteeism and sick leave. I am not sure the Federal Government needs to come in with up-front money. I think we have to put some calcium in their spine and say take action. For any good you have to invest up front and then recoup later. So I am not sure it is money. I cannot comment on tax law, but I think we need to be a powerful bullypulpit and encourage the private sector to get going. I think it takes courage and commitment.

PUBLIC HEALTH IMPROVEMENTS Senator HARKIN. To an extent I agree, but I am also aware of some of the really tight constrictions that some of our business entities are operating under today. There are some that can do that, but there are some that to invest that kind of up-front money would literally put them at a great disadvantage, competitive disadvantage, especially smaller businesses, let us say businesses that employ 100 or less people. There would be a great cost to doing something like that.

Since I see it as part of a societal benefit, not just to the business but of benefit to all of us, it would seem to me that all of us ought to be involved in saying, OK, if you do that the country will give you a little bit of a tax benefít, a bit of a writeoff, because we are all going to benefit from it, not just the business. We will all benefit from it.

You are right. I agree that they ought to do it, but I am just acutely aware of some of the problems that our businesses are having out there right now. They just do not have a lot of loose money to be investing in these things.

Just one other thing before I recognize Senator Adams. Perhaps one of the most important components in our health care system for meeting these objectives is a strong public health system. As you know, a number of reports, including a report by the Institute of Medicine, have found that our public health system is in disarray. I must say that over the last few years it has come down, it has sort of leveled off. We have started to put some more money into last year.

I guess my open-ended question is what public health improvements need to be made in order to help us meet the objectives for the year 2000?

Dr. MASON. We share your concern about the future of public health, and I think the report not only said they were in disarray but they said it was surprising they were doing as well as they were with the support that they have gotten at every level.

We have taken on as one of our major concerns and priorities to work with State and local health departments and do everything we can to encourage the changes that have to occur. Part of that is leadership. We are working with schools of public health to see if we can turn out more qualified leaders in the field of public health. Salaries are not particularly good, and we need to be attracting some of the best and the brightest. We need to see that more women and minority students go into public health.

Many of the programs that are carried out particularly by CDC and HRSA are grant programs that go directly to State and local public health departments. We have a major plan that we put together in the Public Health Service for strengthening State and local health departments.

Each quarter I meet with the officers of the Association of State and Territorial Health Officials, and the county officials, and the U.S. Conference of City Officials. We are working with them to strengthen their abilities and the resources that they have.

I think it is going to have to be more than a Federal level program. I think State legislatures, mayors, and city council members are recognizing that it costs far more not to prevent disease. Many times we are already paying for the costs in health care services that could be saved if we would invest into health promotion and disease prevention.

We hear the squeaky wheel, and we see that $700 billion is out there to take care of people after they have fallen over the edge of the cliff, but we are unwilling to invest in front-end health promotion and disease prevention, and we are paying dearly for that. So it means we have to look at how we are financing health services and invest where it will do the most good.

Senator HARKIN. Thank you very much, Dr. Mason.
Senator Adams.

NURSE PRACTITIONERS

Senator ADAMS. Thank you very much, Mr. Chairman.
Thank you for being here with us this morning, Dr. Mason.

I have several questions that I may want to submit in writing, in particular the ones on the hearings and on the bills that we have submitted on breast cancer. I will do that, and I will also ask Dr. Roper about some of those since they involve cancer.

You just mentioned one factor, and I have four questions here I want to go into with you briefly. You indicated that there is a shortage of Public Health Service people. I am from the State of Washington, and we used to have quite an extensive Public Health Service net both because we have a number of native American tribes in the area, we have had the Maritime Program, and so on.

Right now we are trying to develop more nurse practitioners. Can you tell the committee what you are doing to help alleviate the nurse practitioner shortage? We are trying very hard to develop this within the schools that we have there, and we are finding that it is most difficult to get people to go into this profession.

Dr. MASON. We agree with you that the nurse practitioner can assist significantly. The nurse midwife and other nurse practitioner skills can help in rural areas and intercity areas.

Senator ADAMS. They were about the only ones that were able to get down to a number of the clinics because of the malpractice problems and so on. I just wanted to know if your Department is in support of this program so that we can attempt to do more with it. As I say, we are doing a lot at the State level, but I wanted to know whether we are going to try to do this at the national level. Somehow we have to get basic health services to our low-income people.

Dr. MASON. In the National Health Service Corps we recognize not only a physician shortage in underserved areas but also a shortage of nurse practitioners. The National Health Service Corps Program assists with loans and scholarships for nurse practitioners because we really do need to increase the supply of those very, very useful health providers.

PREVENTION OF CHLAMYDLA

Senator ADAMS. Doctor, when you were head of the Centers for Disease Control, you testified it would take about $60 million per year. I am going to shift subjects with you to chlamydia screening because this is really a prevention program in many ways.

Representative Schroeder and I have just introduced legislation which is an attempt to take what my State has been doing and region 10 has been doing to receive funding to prevent the spread of this on the basis that it leads to infertility both with regard to ectopic pregnancies and to pelvic inflammation, which you mention in your report.

În your report on page 75 you refer to the programs that you are supporting but you do not indicate in there a national screening program for chlamydia as well as gonorrhea at the family planning centers and the community health centers. This is where it is most often picked up

So I wanted to know if we could count on your support this year? We are trying to get legislation through that would do more in this area to prevent, as I say, infertility by having examination in those areas where most often you would pick it up.

Dr. MASON. You are absolutely right about the terrible impact of chlamydia infection. In the United States we have more than 1 million cases reported each year. It leads to pelvic inflammatory disease and infertility.

Senator ADAMS. It is treatable if found, it is preventable.
Dr. MASON. That is right.

Senator ADAMS. Going to the chairman's point that we are trying to get to some of the preventable matters that we have here. This is not an impossible task that we have here. I know that you were in support of this when you were head of the Centers for Disease Control. Does that continue on now in your new august position?

Dr. MASON. Once a supporter, you continue to support it. I am for doing more, now that we have better tests. We did not have good tests for screening for chlamydial infection a few years ago, and these have been developed and are more available to the public. So certainly better screening and better services help, but I think it has to be more than that.

I think we have to recognize that people can infect themselves and reinfect themselves faster than we can screen and treat. Although there ought to be adequate programs to treat and screen people, we also have to change behavior in order to keep ahead. I do not think there is any clinic in the United States that can keep ahead of the new cases that are occurring. I think we need a balance between behavior, the use of safer sex practices, and at the

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same time adequate resources for screening and treating those that have the infection.

FAMILY PLANNING SERVICES Senator ADAMS. Doctor, that brings me to my next question, which is that I am really appalled by the fact that there still is what we refer to up here as a gag rule on family planning, and I guess it slides over because of that into areas such as we mentioned that are involved with preventable diseases. I am very pleased that your program has asked for $6 million more for family planning programs in title X because I am a very strong supporter of that.

I just cannot see, however, how a doctor or a nurse practitioner or a person that is assigned with medical knowledge to these clinics can give advice to people who are there if they do not mention all their options in family planning. I am not saying that they have to advocate them at all, but this prevents them from even discussing what their options are. Of course, the whole idea of infertility attaches to fertility.

I just wondered, would you explain to me if you are going to continue these regulations and implement this policy if the Supreme Court decides in favor of the administration and lets your regulations stand?

Dr. MASON. Let me first say that you are right. There is a significant increase for title X, and that increase will be there for family planning services as well as other services, so that when a woman comes in she can receive screening for STD's and for AIDS and be treated.

Senator ADAMS. We just feel that this is a place where you would pick those up more often than you might in any other place.

Dr. MASON. Sure. It is an excellent place to provide comprehensive care for those who come in for services that relate to reproductive health.

I should also mention that the Department spends more money for family planning services through Medicaid. So this is just one of several areas where resources are made available.

When it comes to sexually transmitted diseases, all the options are open and available. The options that you are talking about are directly related to abortion counseling, and I think it would be improper for me to comment on what we are going to do while the case is being decided by the Supreme Court. We will get a decision from the Court, and then we will determine our policy.

NORPLANT AND FAMILY PLANNING Senator ADAMS. On your regulations, the last question that I have, Mr. Chairman, involves Norplant. What I basically want to know—and I will submit the rest of it in writing to you, Doctoris what the administration is going to do to facilitate the availability of Norplant to low-income women, because it is prohibitively expensive now. My family planning people in my State tell me that it costs $300 to $500 for the drug itself and another $100 to $200 for it to be inserted and $200 for it to be taken out, whereas they can get birth control pills for as little as $20 per year.

What is the position of your administration in facilitating the potential of Norplant being available to low-income women?

Dr. MASON. Well, generally any product that is licensed by the Food and Drug Administration is made available through either Medicaid or title X family planning services, but if I might I would like to call upon Dr. William Archer, who is the new Deputy Assistant Secretary for Population Affairs.

Dr. Archer, would you make a comment on the availability of Norplant in our title X clinics?

Senator ADAMS. Please, would you, Doctor?
Dr. ARCHER. Thank you very much.
Thank you, Mr. Chairman.

At the present time we are developing guidelines on Norplant for the family planning clinics, and, as Dr. Mason has said, we will provide it as much as possible through family planning clinics.

We are aware of the cost-prohibitive nature of the drug. Unfortu. nately Wyeth, who is the manufacturer, is probably not in a position to diminish their cost at this time, although there is availabil

. ity of this drug throughout the world at a reduced cost. Probably their concern is the risk of litigation about their drug in the early stages, and the liability that is involved in that. As that concern is reduced, there may be a greater availability of the drug at reduced cost.

Another matter is that as we train clinicians within our program to insert and remove the drug, we can probably reduce that part of the cost.

There is also a concern of not just the availability of the drug but of followup checkups. With Norplant, how are we going to be able to follow up with cervical screening and STD prevention in women who have a 5-year method of contraception? Until we can address that fully, we have a major concern about that as well.

Senator ADAMS. Thank you, Dr. Archer, and thank you, Dr. Mason. As you can see by the questions of the chairman and myself, we are trying to determine how the health availability of really a magnificent medical system we have in this country seems to cut off at a particular income level, and to a degree this has happened to women also across the board. That is the reason for the bills on pap smears being taken with regard to the training of the people. We have gotten that through, and we are trying to work on breast cancer.

My questions to you happened to be more in the reproductive area, but it goes to the whole idea of health services being available to women as well as men in these clinics and to the low-income personnel and then, as the chairman so well put out, to the children.

I am horrified by the one chart that shows the measles outbreak again. Any of us that grew up know that whenever we went to a school and did not have such a program, the incidence was terrible. We have tried to incorporate that into other areas that may not be as well known to the general public but certainly are devastating: I happen to have mentioned several women's diseases here that if your area does not help with this nobody will.

I also want to express my appreciation for the work that has been done by CDC and your Department on doing something about

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