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HEALTH OBJECTIVES 2000/DATA COLLECTION

Question. Dr. Roper, as you know, I sponsored the Year 2000 Health Objectives Planning Act (P.L. 101-582). This law authorizes funding to the States to help the States prepare to meet the Year 2000 Health Objectives. I sent you a letter requesting that monies be made available to begin this process in FY 1991, and you responded to my request that you are moving forward to implement this Act. Where are you at this point, and what do you plan for FY 1992?

Answer. Currently, we are proceeding with development of uniform health status indicators in conjunction with national public health organizations and with the official State health agencies. We plan to complete the design for the health status indicators by May 1991.

We are continuing our efforts to develop uniform data sets for the Year 2000 Health Objectives through a variety of activities including identification of sources of data for monitoring the objectives and through many technical assistance visits to States to develop their capabilities to collect the needed data. We are also continuing the development of data systems which permit the exchange of data between CDC and the States and which permits the rapid transfer of State data to CDC. Finally, we are continuing our activities in assisting States to develop State health plans.

During FY 1992, we intend to continue our efforts in developing uniform data sets and providing State health planning assistance. We plan to disseminate the results of our health status indicators development through the MMWR and through meetings of the varied public health organizations which are concerned with the indicators. We also intend to provide some funds to selected States to support their efforts to develop State health plans. The funds to the States will be FY 1991 funds about $35,000 per state. The number of States to receive these funds is not known at this point, but will probably be nine. We also intend to conduct workshops with the states to derive uniform data reporting systems consistent with the Year 2000 Health Objectives and to improve the accountability of the Preventive Health and Health Services Block Grant.

Furthermore, the FY 1992 President's budget requests an increase of $4 million within the additional $15 million proposed for the Preventive Health and Health Services Block Grant to improve the capacity of State health departments to conduct their own State health status assessments. This information can be used by the States to more efficiently target the director of disease prevention/health promotion programs and to monitor the progress of these public health programs in meeting their Year 2000 goals and objectives.

FARM HEALTH AND SAFETY

Question. The FY 1991 appropriation bill provided $19.8 million to continue farm health and safety initiatives and to provide for some expansion. In spite of the fact that agriculture is an extremely hazardous occupation, this is the first time that a concerted effort has been made to directly deal with problems affecting our nations' farmers and their families.

Where do we currently stand on implementing these new initiatives?

Answer: CDC has initiated a comprehensive agricultural safety and health program in collaboration with universities, State health departments and other parties in 23 States. The objectives of the program are to identify and to prevent the causes of injury and disease among agricultural workers and their families through surveillance, research, and outreach and educational efforts. The following are major components of the program:

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Supported six States to conduct surveillance
identifying hazards to which agricultural workers are
exposed, the circumstances of exposures, and the health
status of these workers and their families.

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Supported eight State health departments to employ
nurses in rural areas to: promote safety and health
among rural families; assist in surveillance of
diseases and injuries; and provide safety and health
instruction in schools. We will support two additional
States this year.

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Established two Centers for Agricultural Research,
Education, and Disease and Injury Prevention. The
Centers are conducting prevention research and outreach
programs.

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Supported 15 land grant universities work with State
and local health departments to increase dissemination
of safety and health information to agricultural
workers and to identify worker groups with special
needs including minority and migrant workers. Funds
will support an additional eight universities this
year.

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Conducted four programs in the upper mid-west to
provide cancer screening and early treatment for
agricultural workers and conducting research on
pulmonary health hazards and pesticide exposures to
farmers and their families.

Question. initiatives?

When can we expect to see some results from these

Answer. Our various surveillance and intervention activities, which were initiated last fall, should already be beginning to improve health and safety conditions. It will be several years before these activities are operating in full scale, but we should already be getting health and safety information into the hands of farmers, their families, and others in position to assist these rural populations. We will be holding a Surgeon Generals' Conference on Agricultural Safety and Health this Spring to begin building a national coalition of people and organizations who will be instrumental in achieving effective national disease

and injury prevention in agriculture. We are also presently conducting research to improve the effectiveness of our recommendations and technology for preventing agriculture related injury and disease.

In 1993, we plan to evaluate the impact of our surveillance and intervention activities towards identifying and preventing the priority causes of injury and disease among people working in agriculture.

HEALTH OBJECTIVES/BLOCK GRANT

Question. During the FY 1990 oversight hearings on the budget, discussion centered around the Institute of Medicine Report that basically found that our public health system was suffering from a lack of national leadership and inadequate resources. What is your assessment of the ability of State, local and county health departments to meet the Health Objectives 2000 goals?

Answer. According to the IOM Report, the public health system of the United States presently suffers from fragmentation, a lack of clear objectives, and limited resources. While the problem of resources will continue to be problematic during the nineties, I firmly believe the direction provided by the Year 2000 Health Objectives and a national commitment to building the infrastructure of the public health system will do much to see that States meet their objectives. During my tenure as Director of the Centers for Disease Control, I intend to focus CDC's energy on enhancing the capability of State and local health agencies to meet the objectives.

Question. One program that provides support to State, county, and local public health departments is the Preventive Health Services Block Grant. Should funding for the block grant be increased as one mechanism for meeting the Health Objectives for the Year 2000 and to rebuild our State and local public health system?

Answer. I believe the Preventive Health and Health Services Block Grant is one of the most effective means we have for meeting the Health Objectives for the Year 2000. Consequently, the President's Budget has requested an additional $15 million in appropriations for the block grant for FY 1992 a 16% increase over FY 1991. Concurrently, we are developing a legislative proposal that directs the sole purpose of this grant should be to serve as a vehicle to achieve the Year 2000 Health Objectives.

FETAL ALCOHOL SYNDROME

Question: Dr. Roper, there are so many neonatal problems that are easily reduced through simple prevention activities. Fetal Alcohol Syndrome is one of these.

Over the past few years, we've learned a lot more about the enormous problem alcohol poses to the proper development of the fetus.

A recent study by the University of California indicates that a large number of mentally disabled individuals in permanent

residential care facilities are impaired because of exposure to alcohol while in utero. The experts also estimate that Fetal Alcohol Syndrome costs the Nation over $1.6 billion for neonatal and residential care each year.

What is CDC doing to prevent Fetal Alcohol Syndrome by targeting education programs to pregnant women?

Answer: CDC is sponsoring a conference titled "Fetal Alcohol Syndrome and Other Congenital Alcohol Disorders: A National Conference on Surveillance and Prevention," to be held in Atlanta on April 1-3, 1991. One of the purposes of this conference is to promote discussion among federal, State, and local health agencies, academic and research institutions, and public and private organizations concerning methods for locating women at risk before they become pregnant, or early during pregnancy, to prevent exposure to alcohol during pregnancy.

CDC collects data using the Pregnancy Risk Assessment Monitoring System (PRAMS), a population-based system that gathers information from new mothers about their behaviors during and around pregnancy. The PRAMS questionnaire includes questions about the use of alcohol during pregnancy and if they have received information on the effects of alcohol during pregnancy. It is designed to oversample high risk sub-populations of special interest. It therefore provides useful information about the use of alcohol during pregnancy specific to high risk subpopulations, as well as providing State-wide estimates.

CDC has a surveillance program which monitors the incidence of Fetal Alcohol Syndrome in newborn infants. We are currently working to improve this program since we strongly suspect underreporting in certain groups, specifically the white, middle class population. Good surveillance programs can be used to determine which populations should be targeted for prevention programs and are required in order to know if prevention programs are working. CDC assists States in beginning or improving their surveillance programs.

Technical assistance is provided to States and communities to develop and evaluate programs to prevent Fetal Alcohol Syndrome. Many of these programs target educational programs to pregnant

some of them specifically for high risk populations.

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CDC is working with the Indian Health Service to evaluate Fetal Alcohol Syndrome prevention programs in Alaska and will expand to include programs in other States.

TUBERCULOSIS

Question. Although tuberculosis has been a preventable disease for almost 40 years, yet, more than 1/3 of the world population harbors the bacillus that causes TB and 10 to 15 million persons in the U.s. Although the elimination of TB was part of our 1990 health objectives, TB is still prevalent and the number of cases are on the rise. In your professional judgement, is this budget sufficient to set us on the path to eradicate TB by the Year 2000?

Answer. The provisional tuberculosis case count for 1990 is 25,739. This represents an increase of 9.6 percent over the final 1989 count of 23,495. In my professional judgement, A total of $40.7 million would be needed in FY 1992 to fully implement CDC's portion of the Departmental Strategic Plan for the Elimination of Tuberculosis in the United States by 2010. Such a level would, of course, require reduction of other programs within the domestic discretionary spending cap. Given full funding of elimination by 2010 can still be achieved. The longer full implementation takes, the greater the likelihood of missing the 2010 objective.

Question. What is required to fully implement the plan for eradication of this disease by the Year 2000?

Answer. A total of $40.7 million is needed in FY 1992 to fully implement CDC's portion of the Departmental Strategic Plan for the Elimination of Tuberculosis in the United States. Such a level would of course require a reduction of other programs within the domestic discretionary cap.

INFECTIOUS DISEASES

Question. Infectious disease problems such as AIDS, Lyme Disease, hepatitis, chronic fatigue syndrome, and polio have been the focus of Congress and the Administration in the past few years. However, there are a number of new and emerging diseases that are being tracked by CDC. Could you give this Subcommittee some insight into these new and emerging diseases, the hazards they pose to health, and your professional judgment as to what is required to intervene and prevent these diseases from becoming full-scale health threats?

Answer. While Congress and the Administration have been prudent in providing resources to address many of the high priority infectious disease problems facing our nation, core support for infectious disease prevention activities in general has eroded. The CDC is responsible for maintaining surveillance, and epidemiologic and laboratory expertise and resources for the prevention of over 130 infectious diseases. In this regard, several infectious diseases are emerging or reemerging, posing new threats to the public health both nationally and internationally. For example: cholera, a disease for which CDC has responsibility but has devoted few resources in recent years, is now emerging as a ma jor threat in Peru, Ecuador, Colombia, the middle East and southern Africa; papillomatosis (papillomaviruses infection), an infection long known as the cause of genital warts, is now seen as the key in the development of cervical cancer; rabies, a disease subjected to intense control efforts throughout the world for many years, is now reemerging as a threat in the northeastern United States; dengue a disease transmitted by mosquitoes, is now emerging in its most virulent form, epidemic dengue hemorrhagic fever in the Caribbean basin just as it did in southeast Asia in the 1960s. These and other diseases not yet fully characterized pose a potential threat which can best be addressed by development of a strong surveillance base and laboratory expertise. This is the kind of responsibility which CDC has traditionally met. Strong and steady support for core infectious disease programs, with an

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