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HIV AIDS. The chairman and I and Senator Kennedy started on this about 4 or 5 years ago saying we are not trying to pass any judgment on people. This is an epidemic that will soon reach proportions of death that will pass all other factors. So I hope you will continue in this area because if we do not control this epidemic it will simply continue to grow.

I again was horrified by the fact that it is now in both men and women and in the age group of our most productive citizens. As you pointed out in your charts, it is growing faster than any other cause of death. That is just tragic.

Thank you very much, Doctor, and thank you, Mr. Chairman. I have no further questions.

Dr. MASON. Mr. Chairman, could I make a comment briefly?
Senator HARKIN. Yes, you may.

Dr. MASON. In introducing Dr. Archer I did not mention that he is a board certified obstetrician-gynecologist who was practicing in what I think you would call a lucrative practice in Virginia. We are very pleased that we could bring him into the Federal Government to oversee our adolescent family life and our Family Planning Program and give it that kind of professional oversight.

I have also created an Office of Women's Health in the Office of the Assistant Secretary for Health so that we can concentrate on the problems of women. As you know, both NIH and ADAMHA have also created associate directors for women's health research. So we are trying to put more emphasis on women's health.

AIDS INTERVENTION AND TREATMENT

Senator HARKIN. One last question, Dr. Mason. I understand that the number of women and children with AIDS is increasing, as is the number of cases transmitted by drug addiction. I am referring back to these charts again that you had.

In spite of these very troubling trends, what is the overall status of the AIDS epidemic? What do you view as the most important public health priority vis-a-vis the AIDS crisis?

Dr. MASON. I feel that the most important public health priority with regard to AIDS concerns women and babies, but we need to be concerned about all population groups.

Even though as a nation we are spending hundreds of millions of dollars on research for chemotherapy and for vaccine development, and we hope that we will have improved therapies and a vaccine someday, at this point in time the emphasis has to be on preventing the spread of infection from person to person. I think that is where we need to put our resources.

I guess if I had any concern to express with you, it is that one of the effects of the Ryan White bill will be to allow money that is currently being allocated by CDC for testing, counseling, and partner notification to the States to use for early intervention and treatment.

Now I am sympathetic to the early intervention and treatment needs of our Nation, but CDC is the forefront, the foremost prevention organization in the world, and I wonder if we are not being penny wise and pound foolish to allow diversion of prevention funds into early intervention. I think there ought to be adequate funds for early intervention, but I hate to see basic primary prevention money being used in that way:

That is why I would appeal to you that we not in any way curtail the funds that are going into education, particularly education for women, for minorities, and for people at extra risk. If we do not invest in education, we will have to pay for early intervention and treatment of cases that we have not prevented. That is where I would put my money.

Senator HARKIN. Dr. Mason, thank you very much for being here this morning and for your excellent testimony. We look forward to working with you as we proceed with our task of putting the budget together. Dr. MASON. Thank you, Mr. Chairman.

QUESTIONS SUBMITTED BY THE SUBCOMMITTEE Senator HARKIN. Thanks, Dr. Mason. I have to move along. I have to be out of here by noon.

There will be some additional questions from various Senators which we will submit to you for your response.

[The following questions were not asked at the hearing, but were submitted to the Department for response subsequent to the hearing:)

QUESTIONS SUBMITTED BY THE SUBCOMMITTEE

DISEASE PREVENTION/HEALTH PROMOTION

Question. Dr. Mason, you and I share a strong interest in giving higher priority to disease prevention/health promotion programs. Could you give the Committee an update on the status of disease prevention/health promotion initiatives at the Department?

Answer. Disease prevention and health promotion provides an umbrella category for much of the work carried out by the Public Health Service. This fact is underscored by the organization of Healthy People 2000: National Health Promotion and Disease Prevention Objectives into 22 priority areas, which cover preventable chronic diseases, Injuries (both unintentional and violent), mental health and mental disorders, prevalent risk factors such as smoking and substance abuse, and infectious diseases such as HIV infection and sexually transmitted diseases as well as vaccine-preventable childhood diseases. The list of PHS disease prevention/health promotion initiatives is, therefore, a very lengthy one, covering not only our health education and information activities but also our programmatic interventions, such as screening for breast and cervical cancer, infant mortality prevention, and childhood immunization programs. We are in the process of developing the PHS implementation plan for Healthy People 2000, to be published later in 1991, which will catalog the breadth and specificity of our programs that address disease prevention and health promotion and support achievement of our national prevention objectives for the year 2000.

Question. Dr. Mason, as you know only approximately half of the year 1990 Health Objectives were met. Now, we have the Year 2000 Health Objectives. These objectives set forth a fairly comprehensive set of goals for improving the health of Americans by the turn of the century. What is your plan for meeting these objectives; what changes in federal programs or increases in federal funding should be made to insure successi

Answer. It is important to emphasize that the health objectives for the year 2000 are national objectives. There is an important leadership and support role to be played by the Federal government in reaching the targets set by those objectives, but equally important are the efforts of public and private sector organizations and individuals. Overall, the national track record on the 1990 objectives was positive. We have probably met two out of every three objectives for which data are available. Even for those unlikely to be met, the trends are in the wrong direction for only a handful. With that said, however, I want to point out that we begin the decade of the 1990s with a number of significant pluses, as compared with the situation of the last decade.

First, we have the experience of the 1990 objectives to learn from. We understand the importance of careful tracking of the objectives, and we learned that their achievement required a much broader array of agencies and organizations than we were aware of and Involved with in the last decades objectives.

Second, we have Federal leadership that has made preventive health a major part of its health policy: The President's 1991 State of the Union Address and the special emphasis given to prevention in the President's Budget for Fiscal Year 1992 give evidence of this commitment.

Third, in the Department and in the Phs, we are using the year 2000 as the principal organizing framework for our prevention efforts, thus changing the objectives from a kind of "background" for our activities, as with the 1990 objectives, to a 'shaper" of our activities in the coming years. Especially in a period of constrained funding because of the national debt situation, it is

important to have such a framework so that what resources we do have can be more effectively channeled to the kinds of health issues and preventive actions that can be expected to produce the best results.

Finally, even within the constraints of Federal policy to reduce the deficit in spending and to keep within the guidelines of the budget agreements reached with Congress in 1990, we will identify specific opportunities where funding increases are appropriate and likely to produce tangible improvements, and will ask for increases in those areas. That is the case in the appropriations request for FY 1992. We seek to increase targeted efforts aimed at reducing infant mortality and low birth weight, protecting children from lead poisoning, improving immunization coverage for children, increasing efforts to reach women in need of screening for breast and cervical cancer, and intensifying efforts to reduce the use of tobacco. In subsequent years, this same kind of carefully considered targeted approach to addressing the opportunities laid out in Healthy People 2000 will be undertaken.

Question. Dr. Mason, we see a number of increases for CDC prevention activities ... increases for lead screening and the breast and cervical cancer initiative. In fact you have said that over 60 percent of the Public Health Service increases are for prevention programs. Yet we do not see any significant funding increases for the States to assist them in the lead role they will have in meeting the Year 2000 Objectives. The CDC Preventive Services Block Grant increases only $14.7 million or 15.9 percent. Is this an adequate funding level if we are serious about meeting the objectives?

Answer. The Preventive Health and Health Services Block Grant complements other funding to the states which is of a categorical nature. Thus the grant is not the only source of federal funds the states have to meet the Year 2000 Objectives. While additional funding is always more desirable, the request for additional funds for FY 1992 is submitted within the context of the availability of multiple sources of federal funds to the states, this Administration's commitment to achieving the Year 2000 Objectives, and the flexibility of the block grant to address priority problems of a state but not necessarily every health problem that exists. I believe that the block grant, with a focus on the Year 2000 Objectives and increased funds, can do much to assist the states to meet the objectives particularly in view of the data standardization, health planning, and training initiatives that are part of the request for additional funds.

Question. Perhaps one of the most important components in our health care system for meeting the Health Objectives for the Year 2000 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. What public health infrastructure improvements need to be made to help us meet our objectives?

Answer. CDC's efforts to strengthen the public health infrastructure will depend heavily on development of an integrated communications system linking CDC with public health professionals and will focus on approaches designed to enhance the capacity of state and local health agencies to carry out the core functions of public health (assessment, policy development, and assurance) as defined by the Institute of Medicine Report. Their ability to carry out these functions is determined by: i) the knowledge, skills, and abilities of the public health workforce; 2) leadership, particularly at the state and local level; 3) the availability of resources; and 4) the organizational relationships throughout the system. Efforts must be focused on these four determinants of the capacity of the public health system. Workforce: Enhance our commitment to training public health workers by continuing to update and expand our current activities and

exploring the application of the most current technology to expand our distance-based training efforts. Leadership: Undertake specific activities designed to improve the leadershig, skills among public health leaders. CDC is sponsoring an annual Public Health Leadership Institute to be conducted jointly with & nationally recognized academic institution. This Institute will be an intense one week educational experience designed to develop leadership skills and provide current Information on national public health issues. Resources: Increased flexibility in the use of resources should be explored in the process of developing new program announcements or in the reauthorization of existing programs. Organization: We must explore innovative ways for state and local health agencies to access technical assistance in the use of organizational effectiveness and community based planning models such as the Assessment Protocol for Excellence in Public Health (APEX/PH), Planned Approach to Community Health (PATCH), and Model Standards. In addition to a moderate commitment of fiscal resources, state and local agencies must make a long-term commitment to the career development and training of current staff. They must also increase their commitment to support public health at the local level by working in partnership with local health agencies to develop capacity at the community level. Local health departments must be committed to involving the community and addressing racial, ethnic, and minority interest in the development of public health policy regarding the allocation of public health dollars.

STATUS OF THE AIDS EPIDEMIC

Question. Dr. Mason, I understand that the number of women and children with AIDS is increasing as is the number of cases transmitted by drug addicts. In spite of these very troubling trends, what is the overall status of the AIDS epidemic? What do you view as the most important public health priority vis-a-vis the AIDS crisis?

Answer. 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 of AIDS were reported in the U.S. 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. We also continue to see an increasing proportion of cases in persons who are drug users both among those who inject drugs and among those who engage in sex in conjunction with drug or alcohol use.

Although our prevention efforts have been successful in reducing the numbers of new infections, we conservatively estimate that at least 40,000 Americans were newly infected with the HIV virus last year --and the actual number may be several times as high. These people will be the cases that are diagnosed at the end of this decade and into the next century.

The good news is that as we develop new therapies and refine our ability to provide effective treatments, we are able to increase both the quality and length of life of people with HIV infection and AIDS.

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