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search. Then we will conclude this morning with testimony from Dr. William Roper, Director of the Centers for Disease Control.

The fiscal year 1992 request for the Public Health Service is $15.6 billion, which is 3.3 percent more than last year. Excluded from this total but within the Public Health Service are budget requests for the Food and Drug Administration and the Indian Health Service. These agencies fall under the jurisdiction of the Agriculture and Interior Appropriations Subcommittees.

Dr. Mason, first I want to commend you for the level of effort that you have devoted to actively pursuing the Nation's 1990 and 2000 health care objectives. Certainly the three overall national health goals that you have outlined-increasing the healthy lifespan of the population, reducing health disparities, and achieving access to preventive services for all Americans—are critical ones if we hope to begin the next century as a productive and vigorous Nation.

I am concerned, however, that we have met only one-half of the 1990 health objectives and that diseases that we once thought were nearly eradicated such as tuberculosis are on the increase again.

Recently, I along with several other Senators, introduced legislation which we hope will get us on the right track to meet the goals that we have set for the year 2000. This is a package of seven bills to expand the number of prevention programs available for young people and adults. That legislation includes Medicare-reimbursed breast cancer screening for women age 50 and over; a wider range of health promotion programs targeted to older Americans; and a comprehensive 50-State program to educate children and adults on the dangers of lead poisoning.

I believe this legislation will ensure that we use our health dollars to promote wellness today instead of devoting resources to costly treatments tomorrow. I keep saying, Dr. Mason, that we are very good in this country at patching and filling and mending and remedying things. We spend $700 billion per year on health care, and less than 1 percent of that goes to prevention. I think that it is time to start reversing that.

We have to put more emphasis, I believe, on prevention and on wellness. That starts in medical schools. This is beyond your jurisdiction, of course, but I am just sort of sketching out the picture, drawing the picture where I think we ought to be going and where I intend to hopefully get this subcommittee directed. That is one of the goals that you have outlined, too, and I appreciate that. We need to get more attuned to prevention. Quite frankly, the Public Health Service can play a very active and leading role in that.

So, I am pleased to see that your budget request reflects a commitment to these preventive services. I understand that about $5.4 billion of your total request this year falls under the category of prevention spending. I appreciate that. That is about a 7.4-percent increase over last year. I look forward to anything you have to say about these programs this morning.

There is one other issue that I wanted to highlight for you and discuss this morning; that is, the issue of family planning. I am concerned with reports I have heard that the Department intends to centralize the award of family planning funds in Washington,

and I want to discuss that with you perhaps in our question and answer session.

Dr. Mason, we are pleased to have you with us this morning. I will leave the record open at this point for any statements which Senator Specter, our ranking member, may wish to make, and at this time would recognize the distinguished Senator from Alaska for any opening statement he has.

Senator STEVENS. No; I have no opening statement. I am sort of wandering between subcommittee meetings today, so I will be back later after we have another one. Thank you very much.


Senator HARKIN. Dr. Mason, welcome, and please proceed as you so desire. Your complete statement will be included in the record. [The information follows:]


Mr. Chairman and Members of the Subcommittee:

I am pleased to appear before you again to discuss the Fiscal Year (FY) 1992 budget request for the Public Health Service (PHS).

The discretionary budget request for PHS agencies under the jurisdiction of this Subcommittee totals $15.3 billion, an increase of $542 million, or 3.7 percent over FY 1991 appropriations.

This represent a deep commitment on the part of the President and the Secretary of Health and Human Services to the major health problems that we as a Nation face.

I am committed to the idea that in these difficult budgetary times, government must make the most possible sense out of every dollar available to help us meet the needs of the people we serve.

This budget proposal is an effort to do just that. Thus, we have grouped our spending priorities around three principal themes:


The prevention of disease with special emphasis on health promotion and prevention of infant mortality and childhood diseases;

The stabilization and enhancement of biomedical research.

The enhancement of Anti-Drug Abuse activities.

Let me outline for you some of the major elements of this proposal as they relate to these priorities.

Many of the prevention activities envisioned under this proposal center around, or stem from, Healthy People 2000, which Secretary Sullivan unveiled last fall.

This is a truly national plan of 300 measurable targets to enhance the healthy lives of our people by reducing preventable death, disease and disability.

It was formulated under the leadership of the PHS in close consultation with nearly 300 Federal, State, local and voluntary health agencies and organizations.

The subtitle of this document is "National Health Promotion and Disease Prevention Objectives." Its implementation will require the direct involvement of every sector of our society. Most important to its implementation will be the attitudes and behavior of the American people themselves.

We recognize that the kind of prevention envisioned in Healthy People 2000 calls for difficult changes. Perhaps the most difficult of all are changes in personal behaviors. So much of the needless suffering and death that afflict our citizens could have been avoided if different choices' had been made about how they have lived their lives: smoking cigarettes, poor dietary habits, abusing alcohol and drugs, recklessness in the use of automobiles, promiscuous sexual

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.


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.


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. an $85 million increase over FY 1991.

This is

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

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