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sistant Secretary for Management and Budget; Dr. Robinson, who heads our Office of Minority Health; Mr. Harell Little in my Budget Office; and Dr. McGinnis, who heads the Office of Disease Prevention and Health Promotion; and I have other resources behind me.

Senator HARKIN. It is always nice to have those resources behind you, is it not? (Laughter.]

Dr. MASON. It is good to have them.

DISEASE PREVENTION AND HEALTH PROMOTION INITIATIVES Senator HARKIN. I know what you mean.

Dr. Mason, thank you again. Speaking for myself and, I think, for other members of the subcommittee, I congratulate you on the fine job you are doing down there. We may have some differences here in some approaches and perhaps funding, but that is to be worked out, and that is what we are all about here.

I had given to me different charts and things that you had prepared, and I would like to share those with the people here today and the staff. We share a strong interest in giving higher priority to disease prevention and health promotion. I am glad you listed that as No. 1. I appreciate that. That is good.

Could you give the committee an update on the status of disease prevention and health promotion initiatives of the Department?

Dr. MASON. Thank you. I would be very pleased to do this. I will be working from these charts, and I believe you have a handout as well.

Senator HARKIN. You can turn those a little bit more if you like. Has staff got these?

We have those, and maybe people out there would like to see them.

Dr. MASON. We could turn them.
Does Senator Stevens have a copy of that as well?
Senator STEVENS. I do. Thank you, sir.

Senator HARKIN. Yes; he does. So just turn it more the other way so people out there can see it.

DEATHS
Selected Diseases/Causes
AIDS (1.1%) 7

Cancer (22.4%)
Other (25.6%)

[graphic]

Infant Mortality

(1.8%)

Injuries*

(6.9%)

Stroke
(6.9%)

Heart Disease (35.3%) -
* Injuries include unintentional injuries, homicides, and suicides

Dr. MASON. The first chart shows deaths caused by selected diseases in the United States in 1988; these are the big killers and cripplers in our country. You will notice that many of these affect people in adulthood or their senior years, while others occur when a person is very young, infant mortality as an example.

YEARS OF POTENTIAL LIFE LOST*

Selected Diseases/Causes

Other (13.8%)

[graphic]

Infant Mortality

(22.0%)

Cancer
(14.9%)

Heart Disease

(12.1%)

Stroke (2.0%) * Represents years of life lost before age 65. Injuries include unintentional injuries, homicides, and suicides.

The second chart shows selected diseases and their causes with regard to potential years of life lost before age 65. This really highlights those diseases and conditions where we can do a great deal to prevent both disability and disease.

Notice the higher percentage for infant mortality, for example, on this chart versus the first one that deals with the total crude death rate. This also holds true for injuries and AIDS, which takes on a greater proportionality when you look at years of potential life lost before age 65. ESTIMATED ANNUAL DEATHS

By Major Risk Factor

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On the third chart, which is estimated annual deaths by major risk factor, the lefthand side of the chart lists the various risk factors that are playing havoc with our health here in the United States. One really has to gasp when you look at the pall that tobacco smoke casts over our land with 434,000 deaths occurring because of the use of tobacco, most of which are preventable.

This chart also demonstrates the influence of diet, alcohol, unintentional injuries, suicide, and violence. We have put on this chart for the first time what we are categorizing as unsafe sex, although we do not have a very good measure as to the annual deaths associated with unsafe sex. These are just those attributable to AIDS deaths in the year the chart was formulated. It minimizes the problems associated with infant mortality, sexually transmitted diseases, cancer of the cervix, and other causes of death that we have not been able to place under unsafe sex,

SOCIAL DISAPPROVAL OF TOBACCO Senator HARKIN. Dr. Mason, let us look at tobacco. I mean, it is startling if you look at the estimated annual deaths. The "Healthy Youth 2000“ plan aims to reduce the proportion of young people who have used alcohol, marijuana, and cocaine, increase the proportion of high school seniors who perceive a social disapproval associated with the heavy use of alcohol, occasional use of marijuana, and experimentation with cocaine.

I am just reading here from the list.
Dr. MASON. Yes.

Senator HARKIN. To increase the social disapproval of the proportion of high school seniors who associate risk of physical and psychological harm with heavy use of alcohol, marijuana, and cocaine. It is always alcohol, marijuana, and cocaine.

Now having one kid in high school and one approaching, I can tell you—and you know this as any parent knows this the

perception of social disapproval or risk of personal harm can be powerful in determining behavior. Quite frankly, I think sometimes social disapproval takes the lead over personal harm. So I think promoting these perceptions about alcohol and drugs is very worthwhile. In other words, there is social disapproval of that.

Why is tobacco not listed there?

Dr. MASON. I would like to answer that by simply saying that alcohol and drugs are one of our priority areas, and I think you are reading from that priority area while there is another priority area that talks simply about tobacco and its effects on our goals. One of the 22 priority areas discusses nothing but tobacco, and then there is another priority area that gets into alcohol and drugs.

Senator HARKIN. I appreciate that, but the report, I understand, has two tobacco goals: reduce from 30 percent to 15 percent the proportion of those who

smoke regularly by age 20; and to reduce smokeless tobacco use. There is no mention, however, of educating kids about tobacco's risks or trying to reduce smoking by encouraging social disapproval of it.

Dr. MASON. Dr. McGinnis, do you want to comment on that? This was developed under Dr. McGinnis' coordinating capacity. Dr. MCGINNIS. Thank you, Dr. Mason, Mr. Chairman.

Indeed, the issue of social disapproval with respect to tobacco use among school children is a major priority. One of the first objectives in services and protection under tobacco, for example, is to establish tobacco-free environments and to include tobacco use prevention in the curricula of all the elementary, middle, and secondary schools. There are various related targets that challenge the Nation to insure that tobacco education is prominent throughout the educational process, and moreover, that the school is a healthy work environment with respect to tobacco use as well.

So we agree with you that it is a very important priority, and I think you will find initiatives targeted to increasing social disapproval with respect to tobacco use among youth reflected throughout the program proposals of the Public Health Service.

SOCIAL DISAPPROVAL OF ABUSED SUBSTANCES Senator HARKIN. I am concerned about increasing the social disapproval. Here it is. Increase the proportion of high school seniors who perceive social disapproval associated with heavy use of alcohol, marijuana, and cocaine. Your target for cocaine is reduce it 95 percent, marijuana 85 percent, heavy use of alcohol 70 percent. That is reduction; right?

Oh, those who perceive it. I see. In other words, you want 95 percent of high school seniors who perceive a social disapproval associated with the use of cocaine, 85 percent who perceive a social disapproval with use of marijuana, and 70 percent with the heavy use of alcohol. I see nothing listed for use of tobacco there. That is what I am trying to focus on, the social disapproval. I congratulate your focusing in those areas, but how do you fold tobacco in there?

It is a drug. We know that.

Dr. MCGINNIS. The reason for the difference between the way the targets are stated for alcohol and drugs versus tobacco is reflective of the pluralistic process by which the objectives were developed. We tried to make this very much a participatory process involving literally thousands of people across the country. What this means is that from area to area there is going to be some slight variation in the way the targets are stated.

I think if you look throughout the tobacco targets, you will see, perhaps not as explicitly stated as in the alcohol area, implicitly a very strong message seeking social disapproval for tobacco use among youth. It is clearly reflected as well in our program priorities.

Dr. MASON. We agree with you that all of those things must be done, not only with regard to substance abuse but also with tobacco, which is an abused substance as well.

Dr. MCGINNIS. Let me add one thing. The survey that will be tracking perceptions of the socially disapproved use of alcohol and drugs will also track perceptions of the social disapproval of tobacco. So we will be monitoring and focusing on it, as it is a priority for the Public Health Service. Senator HARKIN. I appreciate that.

You used one word, though, Dr. McGinnis. You said implicit in the areas covered by tobacco. In other areas it is explicit. Why could we not make it explicit with tobacco?

Dr. MCGINNIS. Well, again, it reflects the many people involved in the process and the fact that there were two different working groups involved in this. We tried to effect a uniformity where we could but without being heavy handed in it.

I can assure you that there is no waiver in our commitment in that regard. We will track and pursue it.

Senator HARKIN. I appreciate that. Thank you.

Dr. MASON. Thank you, sir. We appreciate your calling our attention to that. I believe that both explicitly and implicitly we need to do everything we can to reduce the use of tobacco particularly among young people, because we know that very few smokers begin after the age of 21. If we can educate them in their adolescence, then they will never start. Senator HARKIN. Very true. Thank you, Dr. Mason.

"HEALTHY PEOPLE 2000” GOALS Dr. MASON. The next chart shows the overriding goals of “Healthy People 2000.” There are three of these: increase the span of healthy life for Americans; reduce health disparities among Americans—and I should mention with regard to reducing health disparities that one of the reasons that we failed in approximately 25 percent of the 1990 objectives was because we allowed those disparities to continue.

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