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HEALTHY PEOPLE 2000 GOALS FOR THE NATION
Goal I: Increase the span of healthy life for Americans.
Goal II: Reduce health disparities among Americans.
Goal III: Achieve access to preventive services for all Americans.

It was the lack of effective targeting of our minority populations. Had we been able to reduce a number of disease states in minority populations, we would have met those national 1990 goals. One of the things we want to accomplish during the decade of the 1990's is to make sure that those discrepancies are reduced.

Senator HARKIN. That is very interesting. I never thought about that.

So do you have a methodology through which you are going to do that over the next 10 years?

Dr. MASON. Within "Healthy People 2000," in addition to the 22 priority areas we also target special populations. We target, for example, various ages. We specifically target minority and disadvantaged populations in the objectives. In other words, we have identified a series of special populations and almost a type of matrix where simultaneously we want to focus and target our efforts where the needs are the greatest.

Senator HARKIN. Very good. Thank you, Doctor.

Dr. MASON. The third goal is to achieve access to preventive services for all Americans. We cannot accomplish these goals if all Americans are not part of this promotion/prevention process.

The next chart shows that 21 of the 22 priority areas are grouped under three categories: health promotion; health protection; and preventive services. Then spinning out from these priority areas are the 300 realistic achievable, measurable objectives.

HEALTHY PEOPLE 2000 PRIORITY AREAS Health promotion: Physical activity and fitness; nutrition; tobacco; alcohol and drugs; family planning; mental health and mental disorders; violent and abusive behavior, and educational and community-based programs.

Health protection: Unintentional injuries; occupational safety and health, environ. mental health; food and drug safety; and oral health.

Preventive services; Maternal and infant health; heart disease and stroke; cancer; diabetes and chronic disabling conditions; HIV infection; sexually transmitted diseases; immunization and infectious diseases; and clinical preventive services.

Surveillance and data systems.

Senator HARKIN. Excuse me, Dr. Mason. Please hold up for a second. I just want to make sure.

[Pause.)
Senator HARKIN. OK, thank you.

PHS SPENDING

FY 1992 Total* Other PHS Programs

$10.0 billion

[graphic]

• Represents discretionary operational

level excluding FDA and IHS

Other Prevention Programs

$3.2 billion PUBLIC HEALTH SERVICE SPENDING Dr. MASON. Chart 1 shows how the Public Health Service intends to spend money in fiscal year 1992. This shows the operational level and how it is distributed between prevention programs. There is $3.2 billion, or 20 percent of our budget, that is largely CDC, HRSA, and part of ADAMHA; $2.3 billion in prevention research, approximately 15 percent, most of that is in NIH, ADAMHA, Agency for Health Care Policy and Research, and, to a lesser extent, CDC; and then other PHS programs, $10 billion, largely for research and treatment services. But it shows the general priorities that have been established.

PHS SPENDING

FY 1992 Increases* Other PHS Programs

Prevention Research + $284 million

+ $160 million

[graphic]

• Represents discretionary operational

increases excluding FDA and IHS

Other Prevention Programs

+ $218 million Chart 2 shows the increases for 1992. It shows that 33 percent of our increases are targeted for prevention programs, 24 percent or $160 million for prevention research; and then $284 million for other Public Health Service programs.

So you see that the majority of the 1992 increases will go into prevention activities.

INFANT MORTALITY

HEALTHY START
200
180

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FY 1989 FY 1990 FY 1991 FY 1992

HEALTHY START Chart 3 shows what we call healthy start. This shows that in fiscal year 1991, our current fiscal year, we hope to be able to target $57 million to begin healthy start, and then increase to $171 million in fiscal year 1992. This will enable us to target 10 communities and rural areas that have exceptionally high rates of infant mortality. Through this 5-year program we intend to provide access, community outreach, help with personal responsibility, and gain a 50-percent reduction in those exceedingly high infant mortality rates during that 5-year period of targeting those resources.

Senator HARKIN. I am sure you know about my exchange with the Secretary on this. Dr. MASON. Yes; I have heard about that exchange.

INFANT MORTALITY Senator HARKIN. Again, I have no problems with this. I think it is good. Go ahead and do it and see what we can target. See if there are some new approaches to reducing it. It was after that that we had the inspector general here, and they had done a study of community health centers in some of the major cities.

I did not know about this, but there was a direct correlation between the activity of a community health center and infant mortality. In a city where there is a community health center that is, funded and active, the infant mortality is down. In a similar city

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where the community health center is not active and not funded, infant mortality is up.

I do not know if you have seen this report or not. Have you seen this study, Dr. Mason?

Dr. MASON. No; I do not believe I have.

Senator HARKIN. Please get your hands on it. I did not see it until last week myself. I was not even aware of it. I asked the inspector general specifically. I asked, is there a direct correlation between the activities of the community health center and infant mortality, and he said yes, their investigations and studies have shown that. So I hope you will look at that.

I say that because we were being asked to reprogram some money out of community health centers to help fund healthy start and out of maternal and child health block grants to fund it this year. I balk at that because these are two programs that are actively reducing infant mortality right now. So to the extent that this program targets 10 cities and rural areas, that's fine, but there is going to have to be some other place that money is going to have to come from, but not from maternal and child health care and not from the community health centers. That is just the point I am making.

Dr. MASON. I appreciate very much your point of view.

I have met with the officers and leaders of the National Community Health Center Organization, and one of the first things I did was tell them that in no way was our desire to move the increase, not to take money from them but to move the increase that was intended for fiscal year 1991 from community health centers in general, over 500 of them, to those 10 areas that will be identified.

We agree that the community health centers are doing a tremendous job, but to accomplish what we wanted to do in those 10 areas, we needed a critical mass of money. We needed enough money so that we do not just tinker around the edges. We know what to do, but nowhere in the United States have we been able to comprehensively do all of the things that need to be done if we are really going to have an impact upon infant mortality.

It was a sacrifice. We felt we needed a critical mass of money so that there would be enough resources in those 10 areas. Instead of tinkering with one or two of the things that we know need to be done, we could do them all and we could do them right. Let us be just like Roger Bannister when he broke the 4-minute mile. If we train properly and if we invest properly in those 10 areas, we can show the Nation that one can really do something in those cities and rural communities that have the highest infant mortality rates in the Nation.

That is why we wanted to redirect planned increases from over 500 areas averaging $40,000 and move that increase into these 10 areas where we could substantially increase it and do the job that every one of us wants to accomplish. Those are hard choices, and we recognize it.

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INFANT MORTALITY RATES BY RACE The next chart shows again what we are facing in the United States with regard to infant mortality. This chart on infant mortality rates by race has a number of key points in it. First of all, as you look at the dots, whether they are red or blue, you will see that we have a slowing of the rate of decrease.

Second, there is a dramatic disparity between white and black infant mortality in the United States, and as a result of these trends that you see depicted here, the United States is now in the 24th position among industrialized nations in infant mortality. We can do better, and I think we want to work together to accomplish this.

It is not just these deaths that we are concerned about. It is the 250,000 low birth weight babies that are born in this country, that not only run up high costs for neonatal intensive care, but even after we have invested all the dollars required in intensive care, we have to often put money into remedial education and supporting programs for the rest of the lives of these infants that had problems during gestation. We have to do more here, and this is a healthy start at accomplishing what we are capable of doing.

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