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We know from the figures it is a leading cause of death. Yet, we turn right around and make it a Federal policy that those who advertise tobacco products get a tax deduction for doing so. All advertising is deductible as a cost of doing business. But that is a policy of the Government to promote business activities in those areas.

This is outside of your bailiwick, but I am questioning it. I question whether or not we should look at this whole structure of the tax deductibility for advertising for tobacco. We have taken tobacco off the airways, but in your newspapers and magazines, all the things that kids get their hands on, young people, and read, tobacco is still glorified as socially acceptable. I am wondering if we should examine that policy.

Dr. ROPER. I appreciate your caveat.

Senator HARKIN. You do not have to comment.

Dr. ROPER. I would like to comment. I appreciate your caveat that I do not do tax policy, but I agree with your point earlier that we need to take a number of steps, as a Nation, to say that smoking and all of the things that go to support smoking are socially unacceptable. We are just not going to say that we look with favor or even tolerate such activities. That is the direction in which we are headed.

Secretary Sullivan has been by far the most outspoken Secretary on this issue, and this budget from the President which I have just quoted doubles the budget in the Office on Smoking and Health, the first increase in more than a decade.

We need to do much more, though, and it is directed at smoking on airlines, tax policy, vending machine availability, a whole variety of things that could be done if we were of a mind to say we are just going to make smoking, if not illegal, very hard to do.

Senator HARKIN. I do not know that we want to go so far as to make it illegal. Prohibition just does not work, but at least we could cut down on the glorification of tobacco as being socially acceptable, the usage of it for young people.

Dr. ROPER. Yes, sir.

Senator HARKIN. We ought to look at whatever ways we can to cut down on that.

Anyway, I was just throwing that out. I suppose I will hear more about what I just said later on.

Senator Bumpers.

Senator BUMPERS. Thank you, Mr. Chairman. Doonesbury is doing a pretty good job.

Senator HARKIN. Who?

Senator BUMPERS. Doonesbury. Do you not read Doonesbury?
Senator HARKIN. Yes, sure.

Senator BUMPERS. Maybe he is doing more good than all the money we are spending on educating people against the evils of smoking.

Senator HARKIN. What do you think, Senator Bumpers, about the tax deductibility for advertising tobacco? Is that something you think we should be looking at or not? I do not know. It occurs to me that on the one hand we are putting out all this money to stop it, and on the other hand we say you can write it off on your taxes. Senator BUMPERS. Do you have a bill in to do that? [Pause.] Do you have so many in you cannot remember? [Laughter.]

Senator HARKIN. For a number of years Congressman Brown and I on the House side did have a bill in on both alcohol and tobacco. Obviously we never got anywhere.

Senator BUMPERS. I think it is certainly constitutional, and it might be highly desirable.

You know, I have just read a book called "Barbarians at the Gate," which is a story that reads much more interestingly than "Gone With the Wind," on a leveraged buyout of the RJR-Nabisco Co. One of the reasons that Ross Johnson, who is president of the company, wanted to buy it was because the stock stayed static, and the company was just a cash cow. It made a lot of money, took in a lot of money; it was all cash and had a tremendous cash-flow. He was always agitated because the stock did not go up according to their profits. He says it was because the public reception was they were trying to sell cancer with Winston-Salem cigarettes.

It is an interesting story. I would recommend that book to anybody. It is one of the most fascinating books, and I think about the abuse Members of Congress take about ethics. I will go no further. I will just recommend that book to you.

Dr. Roper, first let me publicly thank you for the magnificent hospitality all of you extended to me while I was in Atlanta. Dr. ROPER. It was kind of you to come, sir.


Senator BUMPERS. It was very educational.

Just for the record, one of the things I learned there, Mr. Chairman, that I found fascinating was that 10 percent of all the hospital admissions of U.S. children are for diarrhea. About 500 kids die needlessly every year from this condition. When our babies were young, it was a real threat and it scared us to death all the time.

I saw just this morning, Dr. Roper, in this morning's Post about the shortage of rehydration salts in Peru where the cholera outbreak is so great. When I think about what a simple package that is, it is just incredible that anybody in any nation would be short on those little packages of rehydration salts, which solve a big percentage of the problems apparently.

Dr. ROPER. Yes, sir.

[Senator Harkin left the hearing for another, Senator Bumpers agreed to assume chair.]


Senator BUMPERS [presiding]. Let me get down first of all to measles. Without going through ground that we covered in Atlanta and that you probably already covered before I got here, what does it look like right now? In 1990 preliminary estimates were about 25,000 measle cases, up from 18,000 in 1989. Where are we headed now so far in 1991?

Dr. ROPER. We are happy to report, though we do not fully have an explanation for it, that in 1991 cases are substantially down from what they were in 1990. We believe that is due in part to aggressive vaccination programs in the cities that have been hardest

hit with the epidemic. If this current pattern persists, we will have fewer cases of measles in 1991 than we had in 1990.

The principal problem, though, remains; that is, large numbers of young children, 1- and 2-year-olds, in inner-city poor neighborhoods who are not appropriately immunized against measles. That problem still remains whatever the up and down fluctuations may be.


Senator BUMPERS. Just a very quick note, Dr. Roper. As you know, the Supreme Court has just recently sort of limited what people can do in the name of religious freedom. I must say I am ambivalent about it. It is an immensely complex thing, but I do not believe that people ought to be allowed to refuse immunizations for . their children on religious grounds, because that affects everybody else.

As you know, we have cases in this country right now, several cases of people who will not allow their children to be immunized, and that poses a real threat.

To get back to a more macro subject, are these measles outbreaks caused more by breakdown in the delivery system or because we have now discovered the vaccine is not as efficacious as we thought it was; or is it both?

Dr. ROPER. It may be some of both. It is dominantly a problem in the delivery system. We have work underway. CDC has the leaders in this area looking at how efficacious the measles vaccine is.

The problem we have is of children just not being immunized at all.

Senator BUMPERS. I am sorry, Dr. Roper?

Dr. ROPER. The problem is children just never getting any kind of shot, whether it is good, or bad, or indifferent. They are never immunized at least at the appropriate age, 15 months or, in some cases, 12 months.

Senator BUMPERS. Now we talked about how it is a problem in the inner city. On college campuses it is probably more a question of the vaccine not being as efficacious. Would that be a correct statement?

Dr. ROPER. Yes, sir.

Senator BUMPERS. In the inner cities and areas like the delta of Arkansas, Mississippi, and Louisiana, it is probably more of a delivery system problem.

Dr. ROPER. Right.

Senator BUMPERS. Where they never got their first shot.

Dr. ROPER. Right.

Senator BUMPERS. So we are going to have to make a twopronged attack on measles if we are going to succeed. Is that correct?

Dr. ROPER. Yes, sir; we have a problem of very young children not being immunized and then the need to give a second dose of measles to school enterers, junior high, or college age, along in there.


Senator BUMPERS. Now there are two things in your budget here. No. 1, the President, to his credit, has asked for and obviously will receive a $40 million increase this year in this program; $20 million of the increase is in what you call incentive grants.

Dr. ROPER. Yes, sir.

Senator BUMPERS. Now also there is a $6,300,000 addition for vaccine delivery. Now how do incentive grants and vaccine delivery differ? How do those two programs work?

Dr. ROPER. The vaccine delivery line is to support Federal personnel who would deliver technical assistance; that is, advice to State and local health departments and others about how to remove barriers and improve vaccine delivery. So it is CDC sending experts out into the field.

The $20 million incentive grants are grants particularly to State health departments to give them incentives to improve their vaccination levels among young children, again these preschoolers that we have been talking about. So it is money that would go out to support their activities.

Senator BUMPERS. This is an outreach program, in effect. Is that what you are saying?

Dr. ROPER. Yes, sir; as you know, the Federal Government has for years spent a large amount of money in grants to support particularly State and local health departments. In the President's budget there is a total of $208 million which would be so spent. This $20 million is a part of that $208 million.

Senator BUMPERS. OK. In that connection, we have a lot of States who say that they just do not have the money to provide the kinds of incentives and vaccine delivery systems that they would like to have. Now would you say your incentive grant program is designed more to help those States that are already doing a good job? Do you think that is a good idea when you have other States who simply do not have the money to do a good job?

Dr. ROPER. Yes, sir; the design we have put forward to you is one that would say States that are not doing a good job now or were not doing a good job in the past but who have made an effort to help themselves and have begun to improve would be rewarded for those first steps in improvement and would be able to go on and do yet more. I guess the theory behind it is sort of the Federal Government will help those who help themselves.

I understand your concern that there are some States like yours of Arkansas and mine of Alabama that are in desperate financial shape generally, but our design here is to give a boost to those who are beginning to improve themselves.


Senator BUMPERS. Do you have a formula worked out on how you are going to do this?

Dr. ROPER. My staff is working on that, but we do not

Senator BUMPERS. I would like to have access to that as soon as you finish it, because that is really troublesome to me.

Dr. ROPER. The alternative way to formulate it, if I understand you, would be to say those who are worst off, the lowest level,

ought to get the money, and it could be done that way. I take your point.

Senator BUMPERS. As I say, I am ambivalent about it because I am reluctant to reward people who are not trying to help themselves. By the same token, we are dealing with a health problem, and that transcends normal rationales that we use around here in cases like that.


Staff was telling me about Los Angeles, who said that they would not go into the demo projects unless they thought this kind of assistance was going to be continued. Are you talking about once they do it that it would be continued?

They are saying it is not worth it to do a one shot.

Dr. ROPER. What we are talking about is the need to step up total commitment, State, local and, in this case, Federal commitment to vaccine delivery. No question about that. It is not a onetime effort. There are going to be children next year who need to be immunized, too.

Senator BUMPERS. You know, you and I talked about the possibility of sort of a one-stop shopping demonstration project in the delta.

Dr. ROPER. Yes, sir.

Senator BUMPERS. Could you use this money for something like that?

Dr. ROPER. We have asked for another chunk of money on the immunization line, $8.7 million, to do demonstrations of the sort that you have described. Yes, sir; some of that money could go to support a demo like what you have suggested.

We currently have demonstrations underway in New York City, Jersey City, and Chicago, and what we would hope to use this $8.7 million for is to do other demonstrations of that sort.


Senator BUMPERS. Dr. Roper, when I first got into this, and I should say when Mrs. Bumpers first got into it, we immunized almost 300,000 children one Saturday. We did it in National Guard armories, we did it in churches, we did it in schools, we used every public facility we could find. You and I have discussed before that no matter how much money we have in this program, unless we can somehow convince the mamas and papas to bring the children in to be immunized it will never be successful.

I cannot speak for the inner city, but I can speak for the delta regions, and I can tell you that the problems are probably the same. The most common thing you hear is: No. 1, I have no transportation, I cannot get to the clinic; and No. 2, usually if it is a single head of household with a mother as the head of the household and she is holding down an 8 a.m. to 5 p.m. job or an 8:30 a.m. to 4:30 p.m. job the clinic is closed. The clinic is open precisely during the hours she works, and there is no other availability to her.

I think back about how we did that on sort of a massive scale on a Saturday with all the volunteers, and I know that is not a

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