each other. We should note that the activities envisioned in S. 2191 parallel activities underway using our existing authorities.

Dr. MCGINNIS. Thank you very much, Mr. Chairman.

In addition, with me today is Ms. Rhoda Abrams from the Health Resources and Services Administration; Dr. Mary Jansen, from the Alcohol, Drug Abuse and Mental Health Administration, and Dr. Elaine Stone from the National Institutes of Health, who will join us shortly.

I'd like also, if I may, to submit my testimony for the record and speak less formally from notes.

Senator BINGAMAN. Thank you.

Dr. MCGINNIS. The importance of understanding the link between education and health is as old as humanity itself. "Man sano in kapuri sano" is the way the ancients put it, or "a sound mind in a sound body." Simply stated, that's why the educational process is such a priority for the health community.

I'd like to make just three points if I may before we move to discuss those issues of particular interest to the committee.

First, school health programs can improve the health prospects of our children, both near-term and long-term. Second, we believe that school health programs can also improve the educational prospects for our children. And third, the Department of Health and Human Services is committed to working with our colleagues in the Department of Education and other national partners to strengthen and expand school health efforts.

On the first point, that school health programs work, the evidence is growing. Schools have in many ways been the single most important means of changing the immunization status of our children. In 1977 when the national childhood immunization program initiative began, the immunization rates for childhood disease, vaccine-preventable diseases, was below two-thirds. The most important measure in bringing it up to between 90 and 95 percent was that passage of school entry laws around the country.

Anecdotal evidence is also available about programs in individual schools that have reduced tobacco and drug abuse profiles among students, reduced teen pregnancies, improved awareness and behaviors on nutritional factors.

Some controlled studies have shown that school health education can substantially change risk profiles for our Nation's leading killer, cardiovascular disease. The national school health education evaluation study looked at all major curricula in school health and found that school health education could be effective in changing attitudes and behaviors conducive to long-term health prospects.

The second point, that school health can improve educational prospects as well, I think is key. We have learned from our positive experience in worksite health promotion that employee health promotion not only improves employee health profiles but decreases absenteeism, increases productivity, reduces employee turnover-in short, it helps the corporate profit margin.

We think the same thing can apply to school health. We think that we can see, with effective school health programs, decreased absenteeism, increased test scores, and improved graduation rates. There is not enough work on this today, but I can give you one example as a prominent one in Indiana, in which the concerted inte

gration of health education into the science curriculum in fourth and fifth grades led to an improved test score on science tests for those who were offered that integrated health education component relative to those who were not offered it, and the difference between the two groups expanded as the years went on.

We are committed, as I mentioned, to strengthening our own work in this area in order to improve our understanding of the relationship between school performance and school health programs, and that brings me to my third point, the commitment of the Department of Health and Human Services to a strong effort in school health.

I think testimony to that is the presence here of some of my colleagues from the Department of Health and Human Services. Dr. Kolbe, as we have mentioned, directs the Division of Adolescent and School Health at the Centers for Disease Control, which is our largest school health effort. He now has a staff of nearly 60 and devotes approximately $30 million to school health issues including curriculum development, technical assistance and training, grants to States, surveillance of youth risk behavior, and providing important and fundamental leadership to our national efforts in school health.

Dr. Elaine Stone directs the school health activities at the National Heart, Lung and Blood Institute of the National Institutes of Health, which has supported research for 15 years on school-based interventions to reduce cardiovascular risk, including several of the studies that were incorporated into the school health education evaluation study that I mentioned earlier.

In addition, school-based efforts in research are also important components of the agendas at the National Cancer Institute, the National Institute for Child Health and Human Development, the National Institute for Allergies and Infectious Diseases, and others. Dr. Mary Jansen helps coordinate school health efforts at our Alcohol, Drug Abuse and Mental Health Administration which funds, through the National Institute on Drug Abuse, the national high school senior survey of drug, alcohol and tobacco use; through the National Institute of Mental Health, funds research on the use of schools to address mental health issues of children and adolescents, and through its Office of Substance Abuse Prevention sponsors materials and demonstrations for school-based drug and alcohol abuse prevention programs.

Ms. Rhoda Abrams represents the Bureau of Community Health Care Delivery and Assistance at the Health Resources and Services Administration and can speak to the new $6 million Ready-toLearn program launched as part of Secretary Sullivan's five-point plan to reduce minority health disparities, which will link elementary schools in poverty areas with HRSA-funded community and migrant health centers to ensure the delivery of basic health services to these children in particularly vulnerable situations.

In addition, HRSA through its maternal and child health block grant program sets aside 15 percent of those block grant moneys to target special projects. Many of those special projects are undertaken in and through the school setting.

Other Health and Human Services sponsored school health programs are supported by the Indian Health Service, by the Office of

Adolescent Pregnancy, by the President's Council on Physical Fitness and Sports, and by the Administration on Children and Families.

To coordinate these efforts with those in other departments, since 1983 the Public Health Service has sponsored an administration-wide Federal interagency ad hoc committee on coordinating health promotion through the schools. That committee includes seven Cabinet departments among its members as well as individual components within those departments that are focused on school health activities. It targets meeting on a bimonthly basis.

A summary of the administration-wide activities in school health promotion is now in draft form. A draft copy has been provided to your staff, and it indicates the breadth and depth of activity in this area that is sponsored throughout the Government. I should note that this committee has been co-chaired by the Department of Education since 1990.

To help establish both the philosophical context and the specific targets for these efforts, school health was featured prominently, as you noted, Mr. Chairman, in Healthy People 2000, our Nation's prevention agenda for the decade. Fifteen of the specific measurable targets to be accomplished by the year 2000 specifically require changes in the way we deal with health programs and health education in schools, but nearly 170 of the 300 objectives that are included in Healthy People 2000 are related to the health of children and can be affected by schools.

In sum, it should be clear, Mr. Chairman, that for us in the Department of Health and Human Services, school health is a very high priority.

I thank you for the opportunity to be with you at this session, and my colleagues and I look forward to answering questions that you may have.

[The prepared statement of Dr. McGinnis follows:]

PREPARED STATEMENT OF MICHAEL MCGINNIS

Good morning, Mr. Chairman and members of the committee. I am Dr. Michael McGinnis, Deputy Assistant Secretary for Health (Disease Prevention and Health Promotion) in the Public Health Service, and in that capacity responsible for coordinating activities within the Department of Health and Human Services (HHS) which relate to disease prevention, health promotion, preventive health services, and health information and education. I am accompanied today by Dr. Lloyd Kolbe, Director of the Division of Adolescent and School Health in the Centers for Disease Control's National Center for Chronic Disease Prevention and Health Promotion.

I am pleased to have the opportunity to talk about the importance of health promotion and prevention efforts targeted at children and specifically about the importance of health promotion through the schools. I would also like to discuss some of the programs and activities of the Department of Health and Human Services in this area and our work with other Federal agencies. We note that activities underway parallel the additional, permissive authorities envisioned in S. 2191, the "Healthy Students-Healthy Schools Act of 1992."

CHANGING RISK FACTORS IN CHILDHOOD AND ADOLESCENCE

Good health is essential to children's growth and development, to their ability to take advantage of educational opportunities, and to their future prospects. While most American children are born and remain healthy, far too many are vulnerable to problems that lead to serious illness, disability, and even death. The health profile of American children has shifted markedly in the past 40 years. Once dominated by the threat of major infectious diseases, such as polio, diphtheria, scarlet fever, pneumonia, measles, and whooping cough, widespread immunization has virtually

eliminated many of these concerns, and others are in steep decline. Now our most prominent risks are generated by social, behavioral, and environmental factors. For example, unintentional injuries, what we used to call "accidents," have replaced infectious diseases as the leading cause of death in childhood. About half of these deaths are due to motor vehicle crashes: other preventable causes include drowning and fires. Other major, preventable health problems facing children include homicide, suicide, child abuse and neglect, developmental problems, and poisoning by lead and other environmental toxins. Many of the deaths from these causes are preventable and result from a small number of behaviors that usually are established during childhood and adolescence. For example, about half of all deaths from motor vehicle crashes could have been prevented if those involved had worn seatbelts. Alcohol is a major contributor to both motor vehicle crashes and violence, two of the leading causes of death and disability among young people. About half of all deaths from motor vehicle crashes among teenagers involved a teenage driver using alcohol or drugs. Alcohol and drug use contribute enormously to other unintentional injuries as well, and to injuries intentionally inflicted, including homicide and suicide. Thus, although alcohol and drug use may not be listed among the leading causes of mortality and morbidity, these behaviors are certainly major contributors.

As pointed out in Healthy People 2000, our national prevention agenda for the decade, many of the most important risk factors for chronic disease in later years have their roots in youthful behavior. Childhood is the prime time of human development. This is no less true for development of good health than it is for social, educational, emotional, and moral development. It is equally true that the most influential child developers are children's families. While we are here to talk about schools, we must remember a basic but not unrelated need to support and equip parents so that, in the words of the President's Education Goals, children arrive at school healthy and ready to learn.

There can be little doubt that it is easier to prevent the initiation of some behaviors, such as smoking and alcohol and drug use, than to intervene once they have become established. Likewise, it may be easier to establish healthful habits, such as those related to basic hygiene and those related to dietary and physical activity patterns, during childhood than later in life. Parents, as well as schools, are crucial players in efforts to lay a solid foundation against the onslaught of preventable chronic diseases later in life.

Early use of tobacco, alcohol, and marijuana is associated with alcohol and other drug abuse later in adolescence or adulthood. Although cigarette smoking is declining among all age groups, those who do smoke are starting at younger ages. Threefourths of high school seniors who smoke report they smoked their first cigarette by age 9. Although the average age of first use of alcohol and marijuana is 13, pressure to begin use starts at even younger ages. Twenty-six percent of 4th graders and 40 percent of 6th graders have reported that many of their peers had tried alcohol. Experimentation with illicit drugs often starts early.

For example, in 1987 survey of 8th and 10th graders, 6 and 10 percent, respectively, reported using marijuana in the preceding month. Slightly smaller percentages reported trying cocaine, and about a third of these had tried "crack." An estimated 78 percent of adolescent girls and 86 percent of adolescent boys have engaged in sexual intercourse by age 20. One million teenage girls become pregnant each year. Five of every six pregnancies among 15 to 19 year olds in the United States are unintended. In addition, every year, 3 million U.S. teenagers are infected with a sexually transmitted disease. The number of reported AIDS cases in the United States among adolescent females aged 13-19 increased a startling 71 percent from September 1989 to September 1990.

It is important that we help children and adolescents lay the foundation for chronic disease prevention by the promotion and maintenance of healthy lifestyles. The adoption of low-fat and low-salt dietary patterns is important for many people in the prevention of coronary heart disease and high blood pressure and certain cancers. Further, the adoption of dietary and physical activity habits that will reduce the onset of obesity will help reduce the likelihood of coronary heart disease, diabetes, and high blood pressure. The case of physical activity is important because as students leave the school setting they lose physical and social supports for physical activity. It is especially important for adolescents and young adults to establish behaviors that include regular light to moderate physical activity to prevent weight gain that often occurs aiter leaving the high school setting.

Healthy lifestyles established in childhood and adolescence can help change the social norms related to health and prevent much of the illness and disability associated with disease in adulthood. Behavioral changes have saved many adult lives in the past two decades. For example, the declines, by more than 40 percent and 50

percent, respectively, in coronary heart disease and stroke death rates since 1970, are associated with reduced rates of cigarette smoking, lower mean blood cholesterol, and improved control of high blood pressure. In the same period, deaths from motor vehicle crashes declined by almost 30 percent, due to lower rates of alcohol use, increased seatbelt use, and changes in speed limits. Cancer, heart disease, and the other top causes of death between the ages of 25 and 65-unintentional injuries, stroke, and chronic liver disease and cirrhosis-have all been associated with risk factors related to lifestyle.

HEALTHY PEOPLE 2000 OBJECTIVES AND SCHOOL HEALTH

The health of children must be of prime importance to the Nation. Reflecting this principle, over 170 of the 300 Healthy People 2000: National Health Promotion and Disease Prevention Objectives, developed under the leadership of the Public Health Service, are related to the health of mothers, infants, children, adolescents, and youth. At least 15 of the Healthy People 2000 objectives are directly achievable by school health education, physical education, nutritious school lunches and breakfasts, and other components of health programs through the schools. Schools can play an important role in achieving nearly 100 other Healthy People 2000 objectives. The Healthy People 2000 objectives related to school health have been compiled in a special edition of the Journal of School Health which I ask be submitted for the record. Through this publication, the Healthy People 2000 objectives relevant to school health programs will reach some 9,000 school health professionals and others interested in health promotion through the schools.

FEDERAL ACTIVITIES RELATED TO SCHOOL HEALTH

Since 1983, the Public Health Service has coordinated and chaired a Federal Interagency Ad Hoc Committee on Health Promotion through the Schools. This committee meets bimonthly and has served as an ongoing forum for sharing information among Federal agencies about programs and activities related to school health. In 1983, the U.S. Department of Health and Human Services and the U.S. Department of Education co-sponsored an “Interagency Meeting on Health Promotion Through the Schools." In preparation for this meeting, an informal survey was carried out which noted that school health-related activities were going on in numerous offices and agencies of the Federal Government. Participants in this interagency meeting expressed the need for an ongoing forum to discuss Federal school health initiatives.

The Ad Hoc Committee continues to meet regularly. In July 1990, a member of the staff of the Department of Education's Program on Comprehensive School Health Education began co-chairing the Committee along with the Office of Disease Prevention and Health Promotion's Coordinator of Children and School Programs. The committee has recently conducted an update of the 1983 survey to ascertain the extent of Federal programs and activities applicable to health promotion through the schools. This information will be published soon as Healthy Schools: A Directory of Federal Activities Related to Health Promotion Through the Schools. Your staff has been given a draft of this publication and will receive a final version when it becomes available.

Agencies and offices from seven different Federal departments participate on the Ad Hoc Committee, including the Departments of Agriculture, Defense, Education, Health and Human Services, Justice and Transportation. HHS agencies represented include the Centers for Disease Control; the Alcohol, Drug Abuse, and Mental Heath Administration; Food and Drug Administration; Indian Health Service; Health Resources and Services Administration; Administration for Children and Families; National Institutes of Health; Office of the Surgeon General; President's Council on Physical Fitness and Sports; Office of Population Affairs; and the Office of Minority Health.

Under a 3-year cooperative agreement with the Office of Disease Prevention and Health Promotion, the American Medical Association's Department of Adolescent Health has developed a "Healthier Youth by the Year 2000" project to promote the development of effective programs and policies to promote the health and well-being of adolescents. This project includes the publication of Healthy Youth 2000, which includes the year 2000 objectives specific for adolescents, including a listing of school health-related objectives. This publication has been distributed to some 6,000 education and health professionals concerned with promoting the health of adolescents.

Under a cooperative agreement with the American Association of School Administrators, the ODPHP has worked with school administrators nationwide to increase