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BY CAUSE - PER 100,000

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Deaths Per 100,000 Population



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Data Source: NCHS, CDC

* Provisional Data for 1989, based on 10% sample


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1981 1982 1983 1984 1985 1986 1987 1988 1989*


The next chart just brings AIDS into the picture. We wanted to indicate to you that AIDS is appearing on the scene of the major causes of death. This is a chart of death rates per 100,000 for 25through 44-year-old women by cause for all races. You will notice how AIDS is creeping up and is becoming one of the major causes of death in women of this age.

BY CAUSE - PER 100,000

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Data Source: NCHS, CDC

• Provisional Data for 1989, based on 10% sample


▲ Heart Disease

♦ Homicide



O Cerebrovascular

Chronic Liver


◇ Pneumonia & Influenza


■ Accidents

▲ Heart Disease

● Neoplasms

X Suicide

• Homicide

Chronic Liver

O Cerebrovascular

Pneumonia &




This next chart shows the death rates for men of the same age, and AIDS is already one of the significant causes of death in men aged 25 through 44. This is why we are investing in the research, prevention, and treatment of AIDS. This is an extremely serious problem and we need to keep working on it.

Let me conclude. You have been very patient. I could go on all day and there is not time for that.


Senator HARKIN. Dr. Mason, thank you. Those were good charts, very descriptive. Let me just follow that up with one question. We said about one-half of the 1990 objectives were met.

Do you have a plan for meeting or exceeding some of these goals for the year 2000? In other words, looking back at what happened the last 10 years, seeing where we are, we now have the goals for the year 2000. Do you have a long-range plan that you could talk with us about as to what the role of the Federal Government would be and what kind of funding will be required in the initial stages, understanding that we have to start now to reach some of those goals, and what increases in funding should be made to insure the success in different areas? Is that represented in your budget, or are there other areas that we ought to be looking at?

Dr. MASON. There are a number of things that we need to do if we are going to meet those goals, which we intend to do. I said that about 50 percent of our 1990 goals were met, approximately 25 percent will not be met, and 25 percent we will never know because we did not have the surveillance systems to measure them.

I would say, No. 1, as we move toward "Healthy People 2000" we have learned enough to put into place the tracking and surveillance systems. They are either in place or will very rapidly be put in place. An increase in the budget of the National Center for Health Statistics will assist us with the tracking systems. In our 1992 budget there is a $15 million increase for the preventive health services block grant. There was a $9 million increase last year.

I have already mentioned the increases at CDC, almost $100 million for prevention, whether it is immunization, lead poisoning, or STD's. All of those will be targeted. Many of those will go out as grants to States and communities to assist with that process.

Now we need to do more than have tracking systems and increased resources. We need to involve the whole Nation. These are not Federal goals. They are national goals, and they were developed by cooperatively working with over 300 private and voluntary organizations, and health departments at the State and local level. We have involved the health care industry. If we are going to accomplish these goals and objectives, it will be because we as a Nation at the Federal, State, local, private, and voluntary levels, all ante in with resources.

But more than resources, we are going to have to change behavior and get right down to peer pressure. I think we have a plan in place that will develop and grow over the next 10 years, and I think we can succeed.

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Senator HARKIN. As you correctly state, Dr. Mason, it is going to take a concerted effort by Federal, State, and local, private business entities, families, and schools.

Dr. MASON. All of us.


Senator HARKIN. All of us are going to have to be involved.

Let me just ask you this question. You prodded my thinking on it. I am very interested in getting businesses throughout the United States to have a wellness program and a health promotion program as part of their internal structure in their business entity, regardless of what that business may be.

I have looked at a few business entities in different parts of the country, some small, some large, in which the owners decided at some point to have a prevention and wellness program. At least in each of the cases that I have looked at where they have had it for over at least 10 years, their insurance rates are lower, their absenteeism is less, their productivity is higher per person, and their turnover rate is lower.

You might say, well, with all of that it would seem to me in the best interest of business to do that. You can show this. I have shown this sort of data to friends of mine who run businesses, and they say fine but the startup costs are something I cannot do. We are just sort of skimming along right now. There is a recession on, and to invest that kind of money in that kind of program requires some up-front money that we just cannot find right now even though the end payoff may be greater.

Again, I see you nodding your head. You understand this, and anyone in the health field understands this. How do we get from you to the tax writing committees, let us say, and to others to promote businesses in setting up these programs, to give them the kind of up-front expensing, tax writeoffs, whatever it might be to get them to do this? It is in our national interest to do it; not just in their interest, in all of our interests.

Dr. MASON. You are absolutely right. We cannot afford not to do


Senator HARKIN. That is right. So I am trying to get from the health field and this kind of a knowledge base and support base and shift it to the business groups and tell them that they should do it. I think they all want to do it. It is a matter of up-front cost. It would seem to me that we ought to start talking about this in terms of our tax policy in this country. Perhaps that is one way, give them first-year expensing or 2 years expensing or something like that in the initial stages where they can write it off rapidly. We might promote that.

I am trying to think of how you in the Department might interface with something like that?

Dr. MASON. When we went through the 3-year process of developing "Healthy People 2000," we asked the Institute of Medicine to convene a consortium of 300 organizations, many of whom were in the private business sector. We certainly have worked very energetically to encourage them. We have a number of large committees that meet directly under the auspices of our Office of Disease Prevention and Health Promotion that includes different medical spe

cialties as well as the private sector and clinical preventive services, as to how to put prevention into the workplace.

There are a lot of things going on, but I really believe that those companies who are bold can see that they cannot afford not to do this. You have already mentioned the reduction in absenteeism and sick leave. I am not sure the Federal Government needs to come in with up-front money. I think we have to put some calcium in their spine and say take action. For any good you have to invest up front and then recoup later. So I am not sure it is money. I cannot comment on tax law, but I think we need to be a powerful bullypulpit and encourage the private sector to get going. I think it takes courage and commitment.


Senator HARKIN. To an extent I agree, but I am also aware of some of the really tight constrictions that some of our business entities are operating under today. There are some that can do that, but there are some that to invest that kind of up-front money would literally put them at a great disadvantage, competitive disadvantage, especially smaller businesses, let us say businesses that employ 100 or less people. There would be a great cost to doing something like that.

Since I see it as part of a societal benefit, not just to the business but of benefit to all of us, it would seem to me that all of us ought to be involved in saying, OK, if you do that the country will give you a little bit of a tax benefit, a bit of a writeoff, because we are all going to benefit from it, not just the business. We will all benefit from it.

You are right. I agree that they ought to do it, but I am just acutely aware of some of the problems that our businesses are having out there right now. They just do not have a lot of loose money to be investing in these things.

Just one other thing before I recognize Senator Adams. Perhaps one of the most important components in our health care system for meeting these objectives 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. I must say that over the last few years it has come down, it has sort of leveled off. We have started to put some more money into last year.

I guess my open-ended question is what public health improvements need to be made in order to help us meet the objectives for the year 2000?

Dr. MASON. We share your concern about the future of public health, and I think the report not only said they were in disarray but they said it was surprising they were doing as well as they were with the support that they have gotten at every level.

We have taken on as one of our major concerns and priorities to work with State and local health departments and do everything we can to encourage the changes that have to occur. Part of that is leadership. We are working with schools of public health to see if we can turn out more qualified leaders in the field of public health. Salaries are not particularly good, and we need to be at

tracting some of the best and the brightest. We need to see that more women and minority students go into public health.

Many of the programs that are carried out particularly by CDC and HRSA are grant programs that go directly to State and local public health departments. We have a major plan that we put together in the Public Health Service for strengthening State and local health departments.

Each quarter I meet with the officers of the Association of State and Territorial Health Officials, and the county officials, and the U.S. Conference of City Officials. We are working with them to strengthen their abilities and the resources that they have.

I think it is going to have to be more than a Federal level program. I think State legislatures, mayors, and city council members are recognizing that it costs far more not to prevent disease. Many times we are already paying for the costs in health care services that could be saved if we would invest into health promotion and disease prevention.

We hear the squeaky wheel, and we see that $700 billion is out there to take care of people after they have fallen over the edge of the cliff, but we are unwilling to invest in front-end health promotion and disease prevention, and we are paying dearly for that. So it means we have to look at how we are financing health services and invest where it will do the most good.

Senator HARKIN. Thank you very much, Dr. Mason.
Senator Adams.


Senator ADAMS. Thank you very much, Mr. Chairman.
Thank you for being here with us this morning, Dr. Mason.

I have several questions that I may want to submit in writing, in particular the ones on the hearings and on the bills that we have submitted on breast cancer. I will do that, and I will also ask Dr. Roper about some of those since they involve cancer.

You just mentioned one factor, and I have four questions here I want to go into with you briefly. You indicated that there is a shortage of Public Health Service people. I am from the State of Washington, and we used to have quite an extensive Public Health Service net both because we have a number of native American tribes in the area, we have had the Maritime Program, and so on.

Right now we are trying to develop more nurse practitioners. Can you tell the committee what you are doing to help alleviate the nurse practitioner shortage? We are trying very hard to develop this within the schools that we have there, and we are finding that it is most difficult to get people to go into this profession.

Dr. MASON. We agree with you that the nurse practitioner can assist significantly. The nurse midwife and other nurse practitioner skills can help in rural areas and intercity areas.

Senator ADAMS. They were about the only ones that were able to get down to a number of the clinics because of the malpractice problems and so on. I just wanted to know if your Department is in support of this program so that we can attempt to do more with it. As I say, we are doing a lot at the State level, but I wanted to know whether we are going to try to do this at the national level.

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