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ing will permit us to discuss a number of broad policy questions with the Secretary.

Mr. Secretary, over this last year I want to especially compliment you on speaking out against the marketing plan of Ř.J. Reynolds to target new cigarettes for use by young women. And I could not help but notice the button you have on your coat, and I appreciate that.

[The button worn was a picture of a cigarette with the universal slash signifying NO).

This kind of leadership is to be applauded and I applaud you for it. However, I would note for the record that R.J. Reynolds has continued their efforts at marketing research or testing the market for the introduction of the cigarettes that are targeted toward young women I guess—the Dakota cigarette. Evidently they are going ahead with it. Whatever else you can say about it, please continue to take the great leadership you have in the past on that issue.

I also want to compliment you on the several initiatives included in your budget that provide a 7.8-percent increase for programs focused on health promotion and disease prevention. I believe that is going in the right direction. Last month I, along with some of my colleagues, introduced a package of seven bills to increase the focus on existing and new programs for health promotion and disease prevention. And this year with your support, and hopefully the support of the subcommittee, I hope to give priority funding attention to the many programs in your Department that are focused in this area of prevention and health promotion.

At the same time I must admit that I am not overenthused with the budget for programs of rural health. You propose to discontinue funding for the Rural Health Transition Grant Program, Mr. Secretary, and we will be discussing that as we go along. It is something that, I cannot speak for other States, but I know in Iowa, these small hospitals have used these rural hospital transition grants to great effect. No funding is requested for the Essential Access Community Hospital Program or the Rural Primary Care Hospital Program. Again, these are not big programs, but they are very meaningful programs to small hospitals in rural areas of America.

Again, Mr. Secretary, I am not going to go through all of this. I will just submit a lot of this for the record. However, some of the numbers that we see in here, we will be going through that with you today.

Again, I want to compliment you on your concern and support for an expanded infant mortality initiative. I must tell you as I have in private—now I will say it in public—that I have serious concerns about the way that we have proposed to finance this initiative by retargeting some of these moneys. And we will discuss that, I am sure, in our question and answer period. As someone who has worked long and hard to fund the Maternal and Child Health Care Program, there has to be some other way of funding this new initiative, which I am all for, other than going after the Maternal and Child Health Care Block Grant Program.

And not to mention the problem in rural America for infant mortality also, and we do have a problem in rural America. In fact, the incidence of infant mortality between 1 month and 12 months is higher in rural areas, I am told, than it is in the cities. And, so, if you are just going to target the cities, that leaves a lot of the rural areas out.

But again, Mr. Secretary, as I said to Secretary Martin this morning, I do not look upon these hearings in any way as being confrontational. We have worked together in the past. We both share a number of the same concerns. I look upon this as a way of sort of conversing with you about the goals of your Department for the next fiscal years, our goals that each of us have or collectively that we might have here, give you an idea of some of the directions that we may be taking, and to get from you a policy outline of where you want to take the Department over the next couple of years so that we can mesh your requests with the budget that we have to work under.

So, in that spirit, I welcome you again to the subcommittee. I look forward to working with you.

I would yield to my distinguished colleague, ranking member of the committee, Senator Specter, for any comments that he has.

OPENING REMARKS OF SENATOR ARLEN SPECTER

Senator SPECTER. Thank you, Mr. Chairman. Mr. Secretary, I join my distinguished colleague, Chairman Harkin, in welcoming you here and congratulate you on an outstanding record. I think back 2 years ago to about this time and the confirmation process and the achievements of the past 2 years. And you have hit the ground galloping and have accomplished a great deal in a very, very difficult Department.

When the time comes for a markup, this subcommittee has enormous difficulties because of the very heavy competition on so many items of major importance. And as I look down the summary sheet of some of the items that we have to concern ourselves with on the issues of drug treatment, the issue of substance abuse for the homeless, and AIDS, and low-income home energy assistance, and the National Institutes of Health, and the various programs there, research on diabetes or cancer or mental health, it is an extraordinarily difficult job which we have with such a limitation of funds in these critical areas.

When Chairman Harkin comments about rural health, I would echo his concerns. Pennsylvania is a State with an enormous rural population. People are sometimes surprised to hear the statistic that there are more people living in rural Pennsylvania than live in the rural part of any other State in the United States, some 2.5 million people, so that is a matter where I would echo what Senator Harkin has expressed his concern about.

The issue of infant mortality is a matter of grave concern, and I applaud the initiatives which you have made. And this is something we discussed earlier, and I recollect studies which came out of Pennsylvania's city of Pittsburgh, about a very high-one of the highest in the country of infant mortality among blacks and activities which were undertaken in the early to mid 1980's on the subject. And while I am with you on the need for funding there, it is going to be a matter of finding where we can determine the offsets so that we can move ahead on those programs.

But this subcommittee has worked very cooperatively with your Department and I am sure we will do so in the future. And somehow we seem to make the accommodations necessary—at least we have in the 2 years that I have been the ranking Republican on this subcommittee working with Senator Harkin. And we follow a path blazed by our distinguished ranking member of the full committee, the former chairman, Senator Hatfield. So I look forward to working with you.

I want to say that I will be in and out today. We have Secretary Brady in another subcommittee meeting at 2:30 and I have to be on the floor, but I will return a little later.

Thank you, Mr. Chairman.
Senator HARKIN. Thank you, Senator Specter.
Senator Bumpers.
Senator BUMPERS. I have no opening statement.
Senator HARKIN. Senator Gorton. Senator Hatfield.
Senator HATFIELD. No opening statement.

PREPARED STATEMENT OF SENATOR COCHRAN

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Senator HARKIN. Thank you, again, very much. I would like to insert Senator Cochran's statement in the record.

[The statement follows:]

STATEMENT OF SENATOR THAD COCHRAN Mr. Secretary, it is a pleasure to see you again. Yours has become a familiar face in Mississippi, and we appreciate the fine remarks you have made at graduation ceremonies and other events in my state.

I am pleased to see so much emphasis in your budget request placed on infant mortality and minority health issues. As you well know, those are two of the greatest health concerns in Mississippi. I want to work with you in whatever ways I can to address those issues in a productive way. I am concerned that the infant mortality initiative is aimed at urban areas, and that funding would be redirected from community health centers, where much of the success in reducing infant mortality has occurred. But I am sure we can work through those differences.

I also appreciate your efforts to find ways to battle the escalation of health care costs. I think the two most important domestic issues facing our nation are the access, quality and affordability of education, and the access, quality and affordability of health care, especially long-term care for our elderly and disabled population. As our population ages, this problem will be magnified. There are no quick-fixes, and I appreciate your efforts to study this problem so that we don't end up just throwing money at the problem, but that we develop a long-term, sensible strategy for addressing the health care needs of our country.

I look forward to working with you this year, and I hope you will call on me for any assistance I can provide.

OPENING REMARKS OF SECRETARY SULLIVAN Senator HARKIN. Dr. Sullivan, thank you for being here. And welcome back again, and the floor is yours. Please proceed as you so desire.

Secretary SULLIVAN. Thank you, Mr. Chairman, Mr. Specter, and members of the committee.

It is a great pleasure for me to have this opportunity to appear before you to discuss my Department's priorities and our proposed budget for fiscal year 1992. I have already submitted for the record a reasonably detailed overview of our proposals. You are very familiar with these figures, and, therefore, I would like to utilize my time to emphasize a part of my written testimony with you.

I would like to specifically focus my comments on programs and initiatives on behalf of the Nation's children. And by doing that to

highlight this administration's thoughts on how best to confront the many serious economic and health threats to our Nation's children.

Let me begin by telling you about a trip that I made far from our shores. At the request of President Bush, I recently visited eight countries in Africa to assess the catastrophic rates of illness and mortality for children on that vast continent. There, during the month of January, I witnessed almost unimaginable tragedy. Millions upon millions of children dying each year from malnutrition, dehydration, dysentery, malaria, AIDS, and many other deadly, yet preventable, diseases.

In many of these countries, the family structure has been completely shattered by disease, by poverty, and by despair. In other countries on that continent, civil strife has ripped asunder the traditional sense of family and community that held many of these tribes together. But in spite of that picture and in spite of sorely inadequate resources, I witnessed valiant, dramatic efforts being made by committed professionals and political leaders, and most importantly individuals in local communities to take personal, direct action to solve these problems.

Now, strangely, Mr. Chairman, many of us in this country expect such a picture from abroad. And the magnitude of these problems is truly beyond human comprehension. But the untold story is what is being achieved by local action and personal involvement. When I returned I told President Bush that we must do more to broaden our support for Africa in cooperation with other nations and with international agencies to help these committed people help themselves.

I mention the devastation in Africa and the remarkable successes underway in spite of that, not as a counterpoint to our own problems, but rather to underline the fact that there are similar tragedies here at home within our own borders. And these tragedies need a similar prescription and that is a climate of personal responsibility, of personal involvement to address our Nation's health care concerns.

As you know, Mr. Chairman, we spend more per capita on health care than any other nation on the globe. And most of us have come to expect that our high-tech medical system operated by some of the best trained health professionals in the world sets us apart. But that belief comes from a false sense of security, a profound misunderstanding of our people and of the nature of disease and the impact of our social structures.

As a result, the suffering of our own children is sometimes ignored, often misunderstood. For example, in our country we have a shockingly high rate of infant mortality, higher than that of 23 other countries around the globe. And in the black community, the infant mortality rate is twice that of the white community.

In this country, we also allow as much as one in every five children to live in poverty. Now, many of you know what that means. Once we get beyond the facts and figures, beyond the textbooks, the graphs, the charts, and the hearings-once we get beyond all of that, we find a world of despair, of desperation, anger, and premature death.

In this country, poor health has become epidemic for our children. For many, their daily experience is virtually Third World. It includes poor diet, early and more frequent health problems, untold humiliation and deprivation. And it also includes virtual entrapment in a cycle of poverty, and that ensures that future generations will walk in the same footsteps.

In this country, we are quite familiar with family breakups. One out of every two marriages breaks up, thus many of our children are raised in single parent families. And our children pay a high price for this when a family fails. Because study after study documents that family breakups are correlated with higher rates of illness, of poverty, of domestic violence, of dropping out of school, of teen pregnancy, and trouble with the law. In fact, many of our children come to live in a world of disease, parasitic violence, and gang warfare.

It is shocking that homicide is a leading cause of premature death in our society for those under the age of 65. And homicide is the leading cause of death for young black males between the ages of 15 and 24. Some of our scholars and our social workers and clergy and our community leaders have tried to tell us about this in the past, the breadth and depth of the despair. And we have listened sometimes and at other times we have acted on their wisdom.

But I maintain that we now must listen more carefully and act more wisely. As policymakers and as a Nation, we can no longer afford to be ignorant or to shrug off responsibility or set these problems on a shelf until a more convenient moment arrives.

It is true that we need Federal dollars as part of our response, and I believe that our budget is a sound and prudent step in the right direction. In 1991 alone at HHS, we devoted almost $5 billion for infant and child health services and research. This year we must devote a substantial sum again, and the President has proposed additional funding. But we must work harder to cut the rate of infant mortality. What seems to be missing are innovative, effective programs to persuade and to motivate women in high-risk areas to seek early prenatal and perinatal care.

So in addition to our ongoing efforts, we have determined that funds must be specifically directed to targeted areas where infant mortality is extremely high. Such targeted spending would make a difference and would save the lives of many of our babies.

The 1992 request includes a new initiative for community-oriented programs to reduce barriers to appropriate prenatal and perinatal care for pregnant women and infants. Over $171 million will be directed in fiscal year 1992 to these target areas. Now, some of this money, about $30 million, would come from programs already designed to deal with children's health problems. But most of the money would be new spending authority designed to tackle infant mortality in precisely those areas most in need.

Our new initiative will help high-risk pregnant women in targeted areas to utilize Medicaid and other income-support programs. We will also examine social and nonfinancial barriers that prevent pregnant women from receiving appropriate prenatal and perinatal care for themselves and their infants. We will also work to increase

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