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QUESTIONS SUBMITTED BY THE SUBCOMMITTEE

DISEASE PREVENTION/HEALTH PROMOTION

Question. Dr. Mason, you and I share a strong interest in giving higher priority to disease prevention/health promotion programs. Could you give the Committee an update on the status of disease prevention/health promotion initiatives at the Department?

Answer. Disease prevention and health promotion provides an umbrella category for much of the work carried out by the Public Health Service. This fact is underscored by the organization of Healthy People 2000: National Health Promotion and Disease Prevention Objectives into 22 priority areas, which cover preventable chronic diseases, injuries (both unintentional and violent), mental health and mental disorders, prevalent risk factors such as smoking and substance abuse, and infectious diseases such as HIV infection and sexually transmitted diseases as well as vaccine-preventable childhood diseases. The list of phs disease prevention/health promotion initiatives is, therefore, a very lengthy one, covering not only our health education and information activities but also our programmatic interventions, such as screening for breast and cervical cancer, infant mortality prevention, and childhood immunization programs. We are in the process of developing the PHS implementation plan for Healthy People 2000, to be published later in 1991, which will catalog the breadth and specificity of our programs that address disease prevention and health promotion and support achievement of our national prevention objectives for the year 2000.

Question. Dr. Mason, as you know only approximately half of the year 1990 Health Objectives were met. Now, we have the Year 2000 Health Objectives. These objectives set forth a fairly comprehensive set of goals for improving the health of Americans by the turn of the century. What is your plan for meeting these objectives; what changes in federal programs or increases in federal funding should be made to insure success?

Answer. It is important to emphasize that the health objectives for the year 2000 are national objectives. There is an important leadership, and support role to be played by the Federal government in reaching the targets set by those objectives, but equally important are the efforts of public and private sector organizations and individuals. Overall, the national track record on the 1990 objectives was positive. We have probably met two out of every three objectives for which data are available. Even for those unlikely to be met, the trends are in the wrong direction for only a handful. With that said, however, I want to point out that we begin the decade of the 1990s with a number of significant pluses, as compared with the situation of the last decade.

First, we have the experience of the 1990 objectives to learn from. We understand the importance of careful tracking of the objectives, and we learned that their achievement required a much broader array of agencies and organizations than we were aware of and involved with in the last decade's objectives.

Second, we have Federal leadership that has made preventive health a major part of its health policy: The President's 1991 State of the Union Address and the special emphasis given to prevention in the President's Budget for Fiscal Year 1992 give evidence of this commitment.

Third, in the Department and in the PHS, we are using the year 2000 as the principal organizing framework for our prevention efforts, thus changing the objectives from a kind of "background" for our activities, as with the 1990 objectives, to a "shaper" of our activities in the coming years. Especially in a period of constrained funding because of the national debt situation, it is

important to have such a framework so that what resources we do have can be more effectively channeled to the kinds of health issues and preventive actions that can be expected to produce the best results.

Finally, even within the constraints of Federal policy to reduce the deficit in spending and to keep within the guidelines of the budget agreements reached with Congress in 1990, we will identify specific opportunities where funding increases are appropriate and likely to produce tangible improvements, and will ask for increases in those areas. That is the case in the appropriations request for FY 1992. We seek to increase targeted efforts aimed at reducing infant mortality and low birth weight, protecting children from lead poisoning, improving immunization coverage for children, increasing efforts to reach women in need of screening for breast and cervical cancer, and intensifying efforts to reduce the use of tobacco. In subsequent years, this same kind of carefully considered targeted approach to addressing the opportunities laid out in Healthy People 2000 will be undertaken.

Question. Dr. Mason, we see a number of increases for CDC prevention activities increases for lead screening and the breast and cervical cancer initiative. In fact you have said that over 60 percent of the Public Health Service increases are for prevention programs. Yet we do not see any significant funding increases for the States to assist them in the lead role they will have in meeting the Year 2000 Objectives. The CDC Preventive Services Block Grant increases only $14.7 million or 15.9 percent. Is this an adequate funding level if we are serious about meeting the objectives?

Answer. The Preventive Health and Health Services Block Grant complements other funding to the states which is of a categorical nature. Thus the grant is not the only source of federal funds the states have to meet the Year 2000 Objectives. While additional funding is always more desirable, the request for additional funds for FY 1992 is submitted within the context of the availability of multiple sources of federal funds to the states, this Administration's commitment to achieving the Year 2000 Objectives, and the flexibility of the block grant to address priority problems of a state but not necessarily every health problem that exists. I believe that the block grant, with a focus on the Year 2000 Objectives and increased funds, can do much to assist the states to meet the objectives particularly in view of the data standardization, health planning, and training initiatives that are part of the request for additional funds.

Question. Perhaps one of the most important components in our health care system for meeting the Health Objectives for the Year 2000 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. What public health infrastructure improvements need to be made to help us meet our objectives?

Answer. CDC's efforts to strengthen the public health infrastructure will depend heavily on development of an integrated communications system linking CDC with public health professionals and will focus on approaches designed to enhance the capacity of state and local health agencies to carry out the core functions of public health (assessment, policy development, and assurance) as defined by the Institute of Medicine Report. Their ability to carry out these functions is determined by: i) the knowledge, skills, and abilities of the public health workforce; 2) leadership, particularly at the state and local level; 3) the availability of resources; and 4) the organizational relationships throughout the system. Efforts must be focused on these four determinants of the capacity of the public health system. Workforce: Enhance our commitment to training public health workers by continuing to update and expand our current activities and

exploring the application of the most current technology to expand our distance-based training efforts. Leadership: Undertake specific activities designed to improve the leadership skills among public health leaders. CDC is sponsoring an annual Public Health Leadership Institute to be conducted jointly with a nationally recognized academic institution. This Institute will be an intense one week educational experience designed to develop leadership skills and provide current information on national public health issues. Resources: Increased flexibility in the use of resources should be explored in the process of developing new program announcements or in the reauthorization of existing programs. Organization: We must explore innovative ways for state and local health agencies to access technical assistance in the use of organizational effectiveness and community based planning models such as the Assessment Protocol for Excellence in Public Health (APEX/PH), Planned Approach to Community Health (PATCH), and Model Standards. In addition to a moderate commitment of fiscal resources, state and local agencies must make a long-term commitment to the career development and training of current staff. They must also increase their commitment to support public health at the local level by working in partnership with local health agencies to develop capacity at the community level. Local health departments must be committed to involving the community and addressing racial, ethnic, and minority interest in the development of public health policy regarding the allocation of public health dollars.

STATUS OF THE AIDS EPIDEMIC

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 addicts. 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?

Answer. AIDS continues to be a major public health problem in the nation and around the world. In the last 12 months, more than 42,000 new cases of AIDS were reported in the U.S. Women are now almost 12 percent of new cases. Almost 800 new cases in children were reported last year; nearly 90 percent of them were born to an infected woman.

The epidemic continues to ravage our racial and ethnic minority populations: Among men, more than 41 percent of cases are in minorities. For women, the figure is more than 73 percent, and for children with AIDS, it is above 78 percent. Most cases continue to occur in the large cities of our Nation, but increasingly reports of cases are coming from smaller cities, towns and rural areas across our country. We also continue to see an increasing proportion of cases in persons who are drug users both among those who inject drugs and among those who engage in sex in conjunction with drug or alcohol use.

Although our prevention efforts have been successful in reducing the numbers of new infections, we conservatively estimate that at least 40,000 Americans were newly infected with the HIV virus last year --and the actual number may be several times as high. These people will be the cases that are diagnosed at the end of this decade and into the next century.

The good news is that as we develop new therapies and refine our ability to provide effective treatments, we are able to increase both the quality and length of life of people with HIV infection and AIDS. As we do so, however, we are increasing the demands on the health care and social service systems of our Nation.

Our budget request of $1.9 billion for AIDS reflects a continuing emphasis on the basic areas in which we have the best opportunity for long-term benefits: basic research, development and testing of new therapies and vaccines, and risk assessment, education and prevention programs. We have also requested funds to continue treatment programs authorized under the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act. Further, HCFA estimates that in FY 1992, its expenditures for AIDS treatment will increase $310 million from FY 1991, to $1.36 billion, a 30 percent increase. Also, we are requesting funds for CDC prevention programs under Title III of the CARE Act. We are concerned, however, that this authorization divides the money between traditional prevention efforts and early intervention activities for people who are infected, thus, reducing Federal monies available for counseling, testing, and partner notification programs.

Question. Dr. Mason, the Public Health Service request for AIDS is $1.950 billion: $899 million for research, up to 5.8 percent from last year; $220 million for Ryan White, $655 million short of the authorized level with no increase from last year, and $1.119 billion for information, prevention, testing and counseling programs, up 1.8 percent from 1990.

I understand that the Public Health Service request for AIDS to the Department was $2.022 billion, or $83 million more than the number we now see. And the difference was in ADAMHA and NIH research.

If additional funding were available for 1992 for AIDS, which area should be given priority for additional funding?

Answer. If additional funding were received in 1992 for AIDS the priority given would be to increase prevention activities.

PEDIATRIC AIDS

Question. As you know, increases for pediatric AIDS have far outstripped the increase for non-pediatric AIDS. For example, last year the two rates were 16.9 percent as the general increase and 24 percent for pediatric AIDS.

Also, because of the priority given to pediatric AIDS clinical trial units last year, 37 percent of all clinical trial funding will go to pediatric units while only approximately 1.5 percent of the cases are pediatric cases. Has too much priority been given to pediatric AIDS?

Answer. Basic research on pediatric AIDS should continue to be of high priority, and more research needs to be done in this area to provide information that will improve the management of HIV infected children and provide the basis for development of therapeutics and vaccines for this population.

During the last several years, the changing demographics of the epidemic and the paucity of information about therapeutics for children with AIDS has resulted in a marked increase in funding for pediatric AIDS clinical trials. As a result, AZT has been licensed for use in children and an increased number of protocols are evaluating additional drugs for use in children. However, as noted, a result of this increase has been that the funding for AIDS clinical trials for children is disproportionate to the number of cases in children. Some of this disproportionate funding is inevitable because of the demands of research; for example, a clinical trial that needs 200 patients to achieve significant results needs 200 patients regardless of whether they are adults or children. Also,

the special needs of the clinical trials for children may require per patient costs that are considerably higher than for adults. Nevertheless, the recent congressional earmark for pediatric AIDS clinical trials has further increased the level of funding for this effort and has caused the NIH concern since sufficient additional funds were rot provided and ongoing research in other areas will have to be reduced. of particular concern is the increasing trend to divert scarce research dollars for health care needs. The NIH agrees that a certain level of ancillary services are required to ensure that pediatric populations are able to participate in clinical trials. However, these ancillary services should be commensurate with the level required to ensure that pediatric patients may participate in trials rather than providing the full range of health care coverage.

Broad based efforts are needed in vaccine and drug development, epidemiology studies, and clinical trials for all populations. We want to continue intensive efforts in all areas of basic research that will be of benefit to all affected populations, as well as to continue research targeted to understanding the disease in different affected populations as the demographics of the epidemic evolve.

FAMILY PLANNING

Question. Late last year, the Department opted to change the Title x funding formula, without consulting the authorizing or Appropriations Committees. I opposed the change, and was pleased that the Department agreed to leave the formula as it is.

The FY 92 budget proposes turning the family planning program into a State-run block grant. Yet I understand plans are also being drawn up to centralize the grant-making authority for Title x here in Washington. Congress has rejected both of these proposals in the past. Needless to say these proposals raise the concern that awards will be made on an ideological or political basis.

Dr. Mason, you know that old saying, "if it ain't broke, don't fix it". Why is the Department proposing to centralize the grantmaking authority for Title x in Washington?

Answer. Although no final decision has been make, we are moving toward recentralization of grant authorities and realignment of staff for the agency programs of Health Resources and Services Administration, the Centers for Disease Control and the Indian Health Service.

Title X, as an Office of the Assistant Secretary for Health (OASH) program, would continue to be managed, as it is now, with authority delegated from me to Dr. Archer, the Deputy Assistant Secretary for Population Affairs, and from him to the Regional Health Administrators.

As we have indicated previously to the Committee, we would not make any changes in Title x without consulting with Congress.

Question. In the next few months, the U.S. Supreme Court will rule on the cases now before it, which challenge the "gag rule" promulgated by your Department in 1988. As you know, that rule forbids Federally funded family planning clinics from providing information about the legal right to abortion services.

I'd like an update on the Department's plans for implementing these regulations, should the Court decide in favor of the Administration and allow the regulations to stand. How much time will Title X providers have to decide whether they will comply with the 1988 regulations?

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