Somehow we have to get basic health services to our low-income people.

Dr. MASON. In the National Health Service Corps we recognize not only a physician shortage in underserved areas but also a shortage of nurse practitioners. The National Health Service Corps Program assists with loans and scholarships for nurse practitioners because we really do need to increase the supply of those very, very useful health providers.

PREVENTION OF CHLAMYDIA

Senator ADAMS. Doctor, when you were head of the Centers for Disease Control, you testified it would take about $60 million per year. I am going to shift subjects with you to chlamydia screening because this is really a prevention program in many ways.

Representative Schroeder and I have just introduced legislation which is an attempt to take what my State has been doing and region 10 has been doing to receive funding to prevent the spread of this on the basis that it leads to infertility both with regard to ectopic pregnancies and to pelvic inflammation, which you mention in your report.

In your report on page 75 you refer to the programs that you are supporting but you do not indicate in there a national screening program for chlamydia as well as gonorrhea at the family planning centers and the community health centers. This is where it is most often picked up.

So I wanted to know if we could count on your support this year? We are trying to get legislation through that would do more in this area to prevent, as I say, infertility by having examination in those areas where most often you would pick it up.

Dr. MASON. You are absolutely right about the terrible impact of chlamydia infection. In the United States we have more than 1 million cases reported each year. It leads to pelvic inflammatory disease and infertility.

Senator ADAMS. It is treatable if found, it is preventable.

Dr. MASON. That is right.

Senator ADAMS. Going to the chairman's point that we are trying to get to some of the preventable matters that we have here. This is not an impossible task that we have here. I know that you were in support of this when you were head of the Centers for Disease Control. Does that continue on now in your new august position? Dr. MASON. Once a supporter, you continue to support it. I am for doing more, now that we have better tests. We did not have good tests for screening for chlamydial infection a few years ago, and these have been developed and are more available to the public. So certainly better screening and better services help, but I think it has to be more than that.

I think we have to recognize that people can infect themselves and reinfect themselves faster than we can screen and treat. Although there ought to be adequate programs to treat and screen people, we also have to change behavior in order to keep ahead. I do not think there is any clinic in the United States that can keep ahead of the new cases that are occurring. I think we need a balance between behavior, the use of safer sex practices, and at the

same time adequate resources for screening and treating those that have the infection.

FAMILY PLANNING SERVICES

Senator ADAMS. Doctor, that brings me to my next question, which is that I am really appalled by the fact that there still is what we refer to up here as a gag rule on family planning, and I guess it slides over because of that into areas such as we mentioned that are involved with preventable diseases. I am very pleased that your program has asked for $6 million more for family planning programs in title X because I am a very strong supporter of that.

I just cannot see, however, how a doctor or a nurse practitioner or a person that is assigned with medical knowledge to these clinics can give advice to people who are there if they do not mention all their options in family planning. I am not saying that they have to advocate them at all, but this prevents them from even discussing what their options are. Of course, the whole idea of infertility attaches to fertility.

I just wondered, would you explain to me if you are going to continue these regulations and implement this policy if the Supreme Court decides in favor of the administration and lets your regulations stand?

Dr. MASON. Let me first say that you are right. There is a significant increase for title X, and that increase will be there for family planning services as well as other services, so that when a woman comes in she can receive screening for STD's and for AIDS and be treated.

Senator ADAMS. We just feel that this is a place where you would pick those up more often than you might in any other place.

Dr. MASON. Sure. It is an excellent place to provide comprehensive care for those who come in for services that relate to reproductive health.

I should also mention that the Department spends more money for family planning services through Medicaid. So this is just one of several areas where resources are made available.

When it comes to sexually transmitted diseases, all the options are open and available. The options that you are talking about are directly related to abortion counseling, and I think it would be improper for me to comment on what we are going to do while the case is being decided by the Supreme Court. We will get a decision from the Court, and then we will determine our policy.

NORPLANT AND FAMILY PLANNING

Senator ADAMS. On your regulations, the last question that I have, Mr. Chairman, involves Norplant. What I basically want to know-and I will submit the rest of it in writing to you, Doctoris what the administration is going to do to facilitate the availability of Norplant to low-income women, because it is prohibitively expensive now. My family planning people in my State tell me that it costs $300 to $500 for the drug itself and another $100 to $200 for it to be inserted and $200 for it to be taken out, whereas they can get birth control pills for as little as $20 per year.

What is the position of your administration in facilitating the potential of Norplant being available to low-income women?

Dr. MASON. Well, generally any product that is licensed by the Food and Drug Administration is made available_through either Medicaid or title X family planning services, but if I might I would like to call upon Dr. William Archer, who is the new Deputy Assistant Secretary for Population Affairs.

Dr. Archer, would you make a comment on the availability of Norplant in our title X clinics?

Senator ADAMS. Please, would you, Doctor?

Dr. ARCHER. Thank you very much.

Thank you, Mr. Chairman.

At the present time we are developing guidelines on Norplant for the family planning clinics, and, as Dr. Mason has said, we will provide it as much as possible through family planning clinics.

We are aware of the cost-prohibitive nature of the drug. Unfortunately Wyeth, who is the manufacturer, is probably not in a position to diminish their cost at this time, although there is availability of this drug throughout the world at a reduced cost. Probably their concern is the risk of litigation about their drug in the early stages, and the liability that is involved in that. As that concern is reduced, there may be a greater availability of the drug at reduced cost.

Another matter is that as we train clinicians within our program to insert and remove the drug, we can probably reduce that part of the cost.

There is also a concern of not just the availability of the drug but of followup checkups. With Norplant, how are we going to be able to follow up with cervical screening and STD prevention in women who have a 5-year method of contraception? Until we can address that fully, we have a major concern about that as well.

Senator ADAMS. Thank you, Dr. Archer, and thank you, Dr. Mason. As you can see by the questions of the chairman and myself, we are trying to determine how the health availability of really a magnificent medical system we have in this country seems to cut off at a particular income level, and to a degree this has happened to women also across the board. That is the reason for the bills on pap smears being taken with regard to the training of the people. We have gotten that through, and we are trying to work on breast cancer.

My questions to you happened to be more in the reproductive area, but it goes to the whole idea of health services being available to women as well as men in these clinics and to the low-income personnel and then, as the chairman so well put out, to the children.

I am horrified by the one chart that shows the measles outbreak again. Any of us that grew up know that whenever we went to a school and did not have such a program, the incidence was terrible. We have tried to incorporate that into other areas that may not be as well known to the general public but certainly are devastating. I happen to have mentioned several women's diseases here that if your area does not help with this nobody will.

I also want to express my appreciation for the work that has been done by CDC and your Department on doing something about

HIV AIDS. The chairman and I and Senator Kennedy started on this about 4 or 5 years ago saying we are not trying to pass any judgment on people. This is an epidemic that will soon reach proportions of death that will pass all other factors. So I hope you will continue in this area because if we do not control this epidemic it will simply continue to grow.

I again was horrified by the fact that it is now in both men and women and in the age group of our most productive citizens. As you pointed out in your charts, it is growing faster than any other cause of death. That is just tragic.

Thank you very much, Doctor, and thank you, Mr. Chairman. I have no further questions.

Dr. MASON. Mr. Chairman, could I make a comment briefly?
Senator HARKIN. Yes; you may.

Dr. MASON. In introducing Dr. Archer I did not mention that he is a board certified obstetrician-gynecologist who was practicing in what I think you would call a lucrative practice in Virginia. We are very pleased that we could bring him into the Federal Government to oversee our adolescent family life and our Family Planning Program and give it that kind of professional oversight.

I have also created an Office of Women's Health in the Office of the Assistant Secretary for Health so that we can concentrate on the problems of women. As you know, both NIH and ADAMHA have also created associate directors for women's health research. So we are trying to put more emphasis on women's health.

AIDS INTERVENTION AND TREATMENT

Senator HARKIN. One last question, Dr. Mason. I understand that the number of women and children with AIDS is increasing, as is the number of cases transmitted by drug addiction. I am referring back to these charts again that you had.

In spite of these very troubling trends, what is the overall status of the AIDS epidemic? What do you view as the most important public health priority vis-a-vis the AIDS crisis?

Dr. MASON. I feel that the most important public health priority with regard to AIDS concerns women and babies, but we need to be concerned about all population groups.

Even though as a nation we are spending hundreds of millions of dollars on research for chemotherapy and for vaccine development, and we hope that we will have improved therapies and a vaccine someday, at this point in time the emphasis has to be on preventing the spread of infection from person to person. I think that is where we need to put our resources.

I guess if I had any concern to express with you, it is that one of the effects of the Ryan White bill will be to allow money that is currently being allocated by CDC for testing, counseling, and partner notification to the States to use for early intervention and treatment.

Now I am sympathetic to the early intervention and treatment needs of our Nation, but CDC is the forefront, the foremost prevention organization in the world, and I wonder if we are not being penny wise and pound foolish to allow diversion of prevention funds into early intervention. I think there ought to be adequate

funds for early intervention, but I hate to see basic primary prevention money being used in that way.

That is why I would appeal to you that we not in any way curtail the funds that are going into education, particularly education for women, for minorities, and for people at extra risk. If we do not invest in education, we will have to pay for early intervention and treatment of cases that we have not prevented. That is where I would put my money.

Senator HARKIN. Dr. Mason, thank you very much for being here this morning and for your excellent testimony. We look forward to working with you as we proceed with our task of putting the budget together.

Dr. MASON. Thank you, Mr. Chairman.

QUESTIONS SUBMITTED BY THE SUBCOMMITTEE

Senator HARKIN. Thanks, Dr. Mason. I have to move along. I have to be out of here by noon.

There will be some additional questions from various Senators which we will submit to you for your response.

[The following questions were not asked at the hearing, but were submitted to the Department for response subsequent to the hearing:]