bowel disease, peptic ulcers, cancer, pancreatitis and the digestive complications of cystic fibrosis, the number one genetic killer of children. Digestive diseases are much more than gas and stomach problems: they are major, serious conditions that affect millions of people every year. The gastrointestinal disorders affecting our aged population are just being recognized but not understood or treated.

Building on knowledge gained from years of investment in basic research, NIHfunded clinical studies of digestive diseases have yielded tremendous strides in our ability to treat or cure these ailments:

-Earlier this year, researchers identified a gene that is linked to an early stage of colon cancer, which is diagnosed in 140,000 Americans and results in 60,000 deaths annually.

-Due to improvements in surgical techniques and the introduction of a powerful anti-rejection drug, the one-year survival rate for liver transplantation patients has increased from 30 percent in 1980 to approximately 70 percent today. -One out of 10 Americans has a peptic ulcer. The development of new drugs in the 1970's to treat peptic ulcers led to a 43 percent drop in the number of hospitalizations for this condition between 1970 and 1980.

Gallstones affect approximately 20 million Americans, and nearly 1 million cases develop each year. Recently, a nonsurgical treatment for this disorder was developed. Accordingly, less risky alternatives to surgery are now available in the United States.

Accomplishments such as these have greatly contributed toward improving health care and reducing the costs of illness. However, in order to continue these kinds of advances, research at NIH must be adequately funded.

For fiscal year 1992, the AGA supports the ad hoc group for medical research funding in recommending an NIH budget of $9.77 billion. Specifically for the NIDDK, we recommend an fiscal year 1992 budget of $763 million, a 23.6 percent increase over this year's funding. This would allow support for 30 percent of approved research project grants, a modest increase over this year's 27 percent rate. It would also support 55 research centers, 200 career development awards and 1,000 research trainees.

Funding at this level would enable the NIDDK to support research in several areas that we believe are in need of special attention in fiscal year 1992:

-Hepatitis. Findings of three clinical trials report that approximately 50 percent of treated patients with chronic hepatitis C responded positively to treatments with a genetically engineered form of interferon initially tested by NIDDK. Funds are needed to continue to exploit basic and clinical research opportunities in this area.

-Liver transplantation. Clinical trials with a new chemical solution have shown impressive results for prolonging the viability of harvested organs, preserving grafts to survive at a higher rate and reducing the cost of re-transplantation. A new drug, FK 506, has been successful in preventing the rejection of transplanted organs and in reducing side effects. Additional research on FK 506 should be pursued in order to assess the drug's effectiveness as a single agent to prevent organ rejection. In addition, basic research efforts should be expanded in the areas of transplantation biology and the immunology of GI organs. -Irritable bowel disease. Additional basic and clinical research is needed on irritable bowel diseases including Crohn's disease and ulcerate colitis.

-Peptic ulcers. Additional basic research is needed on the factors that cause stomach ulcers. Additional studies of new clinical treatments should be conducted as well.

Basic research and clinical studies in digestive diseases has led to many important accomplishments in the past several years, and many current efforts hold tremendous promise for uncovering cures and treatments for some particularly incapacitating diseases often life-threatening. We realize that this is a time of very difficult choices for Congress because of the severe funding constraints it must work within; however, the AGA believes that health research is one area where the investment of funds can yield enormous dividends in both human and economic terms. Thank you for the opportunity to present the views of the American Gastroenterological Association. I would be happy to answer any questions.

Senator INOUYE. Thank you very much, Dr. Cohen.

I would like to ask you whether you consider your relationship with NIH, the medical school's relationship, as a close and collaborative one, because we are spending billions of dollars in NIH doing great research. My question is is that product getting down to you?

Dr. COHEN. Yes, sir; the product of the NIH and the NIH-academic medical school relationship has been a very fruitful one over the past years. The NIH supports the faculty who perform the research. The faculty in turn not only do the research, but train our students. The faculty, the students together serve the community where they are located.

For example, in Philadelphia I have been at both the University of Pennsylvania and at Temple University, and both of these medical schools serve the community. They perform the research, they train the physicians who then locate throughout the country, especially in Philadelphia and Pennsylvania.

So the collaboration is a very strong one.

Senator INOUYE. Thank you, sir.

Senator Specter.

Senator SPECTER. Thank you very much for your testimony, Dr. Cohen. We appreciate your coming. We appreciate your good work and we will do our very best.

Dr. COHEN. Thank you.

Senator SPECTER. Thank you.

Senator INOUYE. Thank you very much, sir.

PRESIDENT,

STATEMENT OF C. WILLIAM KECK, M.D., M.P.H., DIRECTOR OF
HEALTH, AKRON CITY HEALTH DEPARTMENT,
AMERICAN PUBLIC HEALTH ASSOCIATION

Senator INOUYE. Our next witness is Dr. William Keck, representing the American Public Health Association.

Dr. KECK. Thank you very much, Mr. Chai an and Mr. Specter. My name is Dr. William Keck. I am pres lent of the American Public Health Association.

This year alone, the United States will have a huge burden of death and disability resulting from preventable causes. The tragedy of this really unfortunate reality is that we have the tools at hand to address many of these problems through proven public health strategies. Many of those strategies are represented in the budget of the Centers for Disease Control.

APHA believes that the Centers for Dis ase Control's annual budget should be at least $2 billion, but I am going to emphasize only a few of its many programs in my testimony today. We urge Congress then to fund the CDC's immunization activities, including things like grants to States, the vaccine stockpile, the national vaccine program, the adverse events reporting system, and surveillance research and technical assistance, at a level of $320 million. We would like also to ask you to fund the socially transmitted disease program at $127 million. The current resurgence of some STD's, as we call them, is a lesson relearned, unfortunately. There is a direct relationship between funding and STD control accomplishments.

Injury is the fourth leading cause of death among all Americans and the leading cause of death among children and young adults. We would like to urge you to fund CDC's injury prevention and control program at a level of $50 million for fiscal year 1992, to strengthen current programs and allow the establishment of a center for injury control within the Centers for Disease Control.

Lead poisoning is the most common and one of the most devastating environmental diseases among children, particularly poor

minority children in the United States. There is a new strategic plan for the elimination of childhood lead poisoning that has been developed, and APHA requests $39 million in fiscal year 1992 for CDC's lead poisoning prevention program in order to begin that plan's implementation.

Mortality from breast and cervical cancer can be dramatically reduced. The administration's budget proposal is, unfortunately, inadequate for the task of implementing very effective disease reduction efforts available for those two conditions, and we would like to urge funding of CDC's breast and cervical cancer initiative at a level of $80 million in fiscal year 1992.

We also ask that you fund CDC's tuberculosis program at $36 million next year in order to begin implementation of the strategic plan for the elimination of tuberculosis in the United States.

Of course, AIDS continues to tax our ingenuity and our resources. APHA hopes you will fund Federal AIDS activities at $2.93 billion overall, but funding specifically focused on preventing HIV transmission should be increased to a level of $350 million because, obviously, there is no cure for this disease.

The linkage between HIV transmission and illicit drug use compels us to also call for sufficient funding to expand the drug treatment system. Let me close by thanking you for this committee's very strong interest in prevention. It is very important to all of us who work in that area. Your support really is crucial in the struggle that we are engaged in to obtain adequate funding for public health programming that we know works. Thank you.

Senator INOUYE. Thank you very much, doctor. As I indicated earlier, like many of my colleagues on this committee, I am very much concerned about the lack of interest in prevention.

Dr. KECK. Yes.

Senator INOUYE. Dollarwise, do you think that we are spending enough on prevention?

Dr. KECK. No; I think my testimony indicates that I clearly do not believe that. We certainly do have some strategies that we know are effective in reducing death and disability. Unfortunately, we are not implementing them to the degree that we are capable of. To do that will require some additional funding and it will require attention being paid to this issue. It will require support for local efforts to apply these techniques to people who are at risk.

Senator INOUYE. Obviously, if we appropriated the sums that you have suggested, we would cut down the cost of health and curative medicine.

PREPARED STATEMENT

Dr. KECK. Well, I think that is certainly true in some areas, although not every mechanism of prevention is cost effective in that sense, although certainly many are. There is no doubt, I think, that we would reduce the level of disease and disability substantially. Senator INOUYE. I thank you very much, sir.

Dr. KECK. You are welcome, sir.

[The statement follows:]

STATEMENT OF DR. WILLIAM KECK

Mr. Chairman and distinguished members of the Subcommittee, my name is Dr. C. William Keck. I am the President of the American Public Health Association, the oldest and largest public health society in the world.

Earlier this year, the Administration testified before the Subcommittee and proudly announced that this was the first time any President's budget had devoted an entire chapter to prevention. We applaud this new federal emphasis on prevention. Those of us in public health who have long supported prevention activities are pleased by the Administration's agreement that prevention is a prime means of protecting the health of our citizens. And we are most grateful. Mr. Chairman, for your own interest in and commitment to this cause.

It is not enough, however, to elevate the "public profile of prevention activities, or even to make support for prevention a common and bipartisan- cause. We need to translate the nation's commitment into programs and services that are effective and will particularly help those segments of our population whose health needs are least served by the private sector.

This year alone ·

Approximately 140.000 Americans will die from Injuries: 50,000 of these deaths are homicides and suicides, over 40,000 are motor vehicle related, and at least 10.000 occur on the job.

About 1.8 million people in the U.S. will suffer head injuries. 50,000 of the survivors, most of them young, will experience severe long-term physical and mental difficulties.

More than 50,000 women will die from breast and cervical cancer.

More than 12 million Americans will contract a sexually transmitted disease such as syphilis, chlamydia or gonorrhea.

Over 1,000 bables will contract herpes at birth. Between one third to one half of them will die. and half of the survivors will have serious birth defects.

3,500 newborns will become Hepatitis B virus carriers and 1,000 of them will eventually die as adults from cirrhosis or primary liver cancer.

Thousands of children under six years of age will be hospitalized for treatment of lead poisoning, and at least a million will be exposed to lead to a degree that may impair their intellectual development.

The tragedy of these shocking statistics is that we have the tools to address many of these problems. We can dramatically reduce deaths and disabilities through the effective use of public health strategies. For example:

Most of the 6,000 cervical cancer deaths that occur each year could be prevented through screening and appropriate follow-up.

30% to 50% of all breast cancer deaths could be avoided through the widespread use of mammographies.

Most of the children born to women who are chronically Infected with hepatitis B virus could be immunized at birth and would not become HBV carriers.

Many cases of infant pneumonia, a common cause of Infant mortality, could be avoided by screening high risk pregnant women and treating those who test positive for chlamydial Infection.

The public health community is eager to tackle these problems, but we need adequate resources to do so.

In this testimony, APHA focuses on Immunization and the control or prevention of sexually transmitted diseases, injuries, lead poisoning, tuberculosis, breast and cervical cancer mortality. AIDS and drug abuse. Time constraints prevent us from discussing all the important programs funded through the Centers for Disease Control. At a minimum, however, the Centers for Disease Control should receive $2 billion.

Immunization Program

We urge Congress to fund the CDC's Immunization activities including grants to states, the vaccine stockpile, the National Vaccine Program, the Adverse Events Reporting System, and surveillance. research and technical assistance at $320 million.

The Administration argues that we have been 97-98% successful in our immunization efforts, but its budget request would provide Inadequate funding to complete the job. Unlike the Administration. APHA's funding request would allow the States to immunize more children next year than we did in FY1991. It would also fund hepatitis screening of pregnant women and Immunization of thousands of infants against this disease. And it would allow states to provide a second dose of MMR vaccine and deal with measles outbreaks.

It is impossible to overstate the importance of immunizing our youngsters. Vaccines are among the safest, cheapest and most effective ways to prevent infections and communicable diseases. Immunization returns as much as $90 for every dollar spent. The widespread use of vaccines has produced dramatic declines in the incidence of childhood Infectious diseases, and with that decline has come a drop in infant mortality. Immunizing children is far less expensive than paying the costs attributable to childhood Illnesses.

Sexually Transmitted Diseases (STD)

We ask you to fund the STD program at $127 million so that CDC can enhance its activities in the areas of syphilis, chlamydia, genital ulcer disease, and resistant gonorrhea prevention and control.

The current resurgence of primary/secondary syphilis, chancroid, and genital herpes among heterosexuals shows that we must again target STD control measures to key populations. In 1990 there were more than 7,000 cases of congenital syphilis. Two years earlier only 650 cases were reported. On average, 1 in 10 college students now has an STD. Neglect of traditional STDs has reversed the positive momentum of the 1970s.

The serious complications of STDs include pelvic inflammatory disease, Infertility, ectopic pregnancy. infant pneumonia, mental retardation, immune deficiencies, neoplasia, and fetal death. At least seven cancers are associated with different STDs, and STDs are a determinant of HIV acquisition and transmission.

Despite the emergence of chlamydia, herpes, human papilloma virus and the AIDS virus as priority STDs, the federal commitment to this area declined in real dollars in the 1980s. The reductions have been foolish; for every $1 invested in Interrupting transmission of gonorrhea, $3 is saved in health care costs. Injury Prevention

We urge you to fund the CDC's Injury Prevention and Control Program at $50 million for FY 1992.

Injury is the fourth leading cause of death among all Americans, and the leading cause of death among children and young adults. It causes almost half the deaths of children aged 1-4; more than half the deaths of children aged 5-14, and nearly four-fifths of the deaths of 15-24 year olds.

For those under 35, motor-vehicle crash injuries alone are actually the leading cause of death. The societal costs of such injuries are second only to those of cancer.

Although injuries are responsible for the loss of more economically productive years of life than heart disease and cancer combined, the federal expenditure for research in injury control is approximately onetenth of that for cancer and less than one-fifth of that for heart disease and strokes.

APHA believes that $50 million in FY 1992 will allow CDC to strengthen its integrated, multidisciplinary approach to injury prevention with the goal of reducing mortality, morbidity, disability and the costs of both intentional and unintentional injuries. Funding at this level will also allow establishment of a Center for Injury Control within the CDC, as recommended by the National Academy of Sciences.

Lead Poisoning Prevention

The APHA requests $39 million in FY 92 for CDC's lead poisoning prevention program in order to begin Implementation of the new Strategic Plan for the Elimination of Childhood Lead Poisoning.

Lead poisoning is the most common environmental disease among children. Almost 70% of poor. minority children in large, central-city urban areas have lead levels high enough to adversely affect their health.

Elevated lead levels in children can decrease intelligence, slow development, and produce behavioral problems. The effects on intelligence and behavior are especially harmful to children who are already disadvantaged by poor nutrition, and the other ills affecting inner city children.

We have made remarkable progress in removing lead from food and gasoline, but much more must be done to eliminate it from old house paint, dust, soll, and drinking water.

To prevent lead poisoning, we must ensure that all children with high lead levels receive appropriate evaluation and treatment. This program, if adequately funded, will screen children for elevated lead levels and assure medical referrals and environmental intervention.

Breast and Cervical Cancer Prevention

Our Association urges you to fund CDC's breast and cervical cancer initiative at $80 million in FY 92.

The Administration's budget proposal would only allow CDC to fund comprehensive programs in approximately 10 states. Given the enormous, acknowledged benefits of mammograms and pap smears, how can we explain that to women living in the remaining 40 states? Are their lives more expendable? Is their health worth so little that even a direct return of many dollars for each dollar invested can not Justify a modest outlay?

Among cancers, breast cancer is the leading cause of death for women under 65. Nearly two-thirds of the black women who dle from breast cancer are under age 65. Now that the "baby boomers" have reached the age of greater risk of breast and cervical cancer, we expect to see dramatic increases in mortality from these two cancers unless a systematic screening program is in place.

Mortality from breast and cervical cancer can be reduced. Most of the cervical cancer deaths could be prevented; and breast cancer mortality could be reduced 30% to 50%. CDC's cancer initiative therefore has the potential to dramatically reduce deaths from breast and cervical cancer.