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Policy and Research, which would enable the Agency to expand research activities, including the promotion of a more effective system of primary care.

Within the NIH budget, AADS especially wants to note our concern about the Biomedical Research Support Grant (BRSG) program. The BRSG program is used to advance and strengthen the medical and health-related research programs of academic and scientific institutions by providing flexible funds for pilot research projects, central resources, support for new investigators, and interim funding for researchers who are awaiting funding of their research grants. For example, in my own state of Pennsylvania, BRSG funds were used by the Fox Chase Cancer Center in Philadelphia to support a pilot project on the effects of dietary iron on tumor growth. The results of the study indicated that iron, which is often administered to cancer patients undergoing chemotherapy, may counteract the tumor-suppressing effects of the treatment. BRSG funding permitted the development of these concepts, which are now being pursued further. AADS endorses the Ad Hoc Group for Biomedical Research Funding's recommendation to restore BRSG funding to its FY 1986 level of $56 million, and urges the Subcommittee to reject the Administration's proposed elimination of this important program.

AADS also is concerned about the Academic Research Enhancement Award and National Research Service Award programs. We urge the Subcommittee to provide sufficient funding so that recruitment of scientists and training of individuals in specified shortage areas can be continued.

Health Education Assistance Loans: AADS is very concerned that the Health Education Assistance Loan (HEAL) program remain a viable "loan of last resort" for dental students. Students pay the market rate for these unsubsidized loans and are assessed an insurance fee to offset defaults. Twenty-five percent of all dental students borrow through the HEAL program to finance a portion of their education. Without HEAL loans, many students would be forced to discontinue their training.

AADS urges Congress to not restrict access to HEAL borrowing, and requests that the Subcommittee lift the credit ceiling for the remainder of this fiscal year as well as for FY 1992. The HEAL program is being reauthorized this year, and we believe all parties are genuinely committed to significant program changes. The reasons for defaults must be carefully scrutinized so that the program can be modified to further reduce defaults and increase collections. We believe that it is unfair, however, to deny HEAL loans to today's health professions students, who have not caused the default problem and should not bear the brunt of previous inadequate program design.

National Health Service Corps: Congress in 1990 approved new legislation to revitalize the National Health Service Corps (NHSC). AADS acknowledges the important role that the NHSC can play in meeting the need for health care providers, including dentists, for underserved populations. We are requesting $60 million for this program in FY 1992, and urge the Subcommittee to specify a preference for scholarship awards rather than loan repayment in order to create a better balance between loans and grants for our students.

Minority Health Programs: Responding to the serious problems in the delivery of health care to our nation's disadvantaged minorities, Congress last year passed the "Disadvantaged Minority Health Improvement Act", which authorized programs to expand the recruitment and retention of underrepresented disadvantaged minority students and faculty in the health professions.

While AADS applauds the Administration's support for addressing the problem of inadequate health care for minority citizens, we urge that this Subcommittee not divert funds from other important health professions assistance programs to do so. Such a strategy would only exacerbate the problem of health care delivery to Blacks, Hispanics, Native Americans, and other minority groups.

We urge the Subcommittee to fund the Minority Scholarship program at $18 million, the Minority Loan program at $15 million, the Faculty Loan Repayment program at $2 million, and the Centers of Excellence program at $20 million (for all types of centers) in FY 1992.

Geriatric Education Centers and Geriatric Training: Needs in geriatric dental care and training continue to increase. For example, the new Federal Nursing Home Reform now being implemented has drawn attention to need for personnel trained to deliver care to special patient populations in long term care settings. Potential oral complications of the elderly include: the threat of oral infections compromising care of diabetes patients or of cancer patients receiving chemotherapy, and the effects on oral health of medications that many elderly take. Further, since more elderly patients are retaining their teeth, they are more susceptible to oral health problems.

The Geriatric Training program provides for one- and two-year postdoctoral fellowships for medical and dental faculty. In enacting this authority in 1987, Congress responded to the need for in-depth training of faculty in geriatrics. Previous funding supported the establishment of 23 Geriatric Training programs, including the development of curriculum, hiring faculty, and the provision of fellowship support. In FY 1991, only 16 Geriatric Training programs will receive funding. While the FY 1991 authorization level for this program is $13 million, AADS recognizes

budget constraints facing Congress and respectfully requests the provision of $5 million for Genatric Training, in FY 1992, which would allow full funding of the existing Geriatric Training programs.

Geriatric Education Centers (GECs) provide multi disciplinary short term faculty training. Curriculum and other educational resource development, technical assistance and outreach. In FY 1991 31 GECS located in 26 states will be supported by the $10 million appropriation. In FY 1992. AADS recommends that the Geriatric Education Center program be funded at the FY 1991 authorized level of $16 million to continue existing centers and allow funding for additional GECS.

We acknowledge that the General Dentistry. HEAL and Geriatric programs addressed in this testimony may not be reauthorized before this Subcommittee addresses their FY 1992 funding levels. in the past, this Subcommittee has been critical to the viability of our programs, as the House delers consideration of all unauthorized programs. We urge the Subcommittee to again make an appropriation so that these important student assistance programs and primary care training programs can continue without interruption.

We thank the Subcommittee for the opportunity to testify on FY 1992 appropriations and for the substantial efforts Members have undertaken to benefit the health of the American people.


Senator HARKIN. JoAnn Gurenlian. Did I pronounce that correctly?

Ms. GURENLIAN. That is right.
Senator HARKIN. Thank you.

Ms. GURENLIAN. Good afternoon, Senator Harkin and staff. On behalf of the American Dental Hygienists' Association, I would like to thank you for this opportunity to testify regarding fiscal year 1992 appropriations for the Department of Health and Human Services, especially the National Institute of Dental Research. My name is Dr. JoAnn Gurenlian, and I am president of ADHA. I will summarize the recommendations contained in our longer statement which we have submitted for the record.

The ADHA represents 30,000 members across the country dedicated to assuring the highest level of preventive dental care. ADHA serves as an advocate for dental hygienists at the Federal, State, and local levels.

Mr. Chairman, dental hygienists play a vital and cost effective role in the delivery of oral health care, performing numerous preventive and therapeutic services. ADHA firmly believes that continued research at NIH is critical to the future of prevention.

Indeed, in identifying the causes of preventable dental diseases and the appropriate strategies to combat these maladies, the National Institute of Dental Research has helped to revolutionize our knowledge and provision of dental health care. Thus, the ADHA endorses a budget of $247.5 million for NIDR, a budget which would allow NIDR to capitalize on scientific opportunity.

Within this appropriation for NIDR, ADHA joins other oral health groups in urging that $6 million be provided for research into the safety and efficacy of using amalgam restorative materials and that $5 million be provided for further research into the longterm effects of fluoride.

ADHA also recommends $9.7 billion for all of NIH as recommended by the ad hoc coalition for medical research funding.

In addition, ADHA recommends that the appropriation for the Centers for Disease Control include funds to allow the Center for Prevention Services to allocate $2.3 million for the dental disease

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prevention activity. The DDPA is currently playing a critical role in monitoring and tracing the tragic case of AIDS involving a dentist in Florida.

ADHA supports full funding of the Disadvantaged Minority Health Improvement Act of 1990, in particular funding for grants to help profession schools to assist them in providing scholarships to individuals from disadvantaged backgrounds. Current funding levels do not allow schools of allied health to participate in this important program which is critical to efforts to recruit more minorities into the allied health professions.

ADHA joins the American Society of Allied Health Professions in calling for reauthorization and amendment of title VII of the Public Health Service Act. Our recommendations for appropriations levels for various activities within title VII are contained in our statement for the record.

The 30,000 members of the American Dental Hygienists Association appreciate the important contributions this committee has made to improving the quality and availability of oral health services throughout the country. We sincerely hope that this committee will continue to support preventive health programs as the most responsible approach to a long-term reduction in national health care expenditures.

Thank you.

Senator HARKIN. Thank you very much, JoAnn.

I just got a note that we may have a vote very soon, and I want to finish this whole thing today so we will not have to come back. I had just one question about dental school enrollments having gone down recently. Is that still the case?

Dr. FONSECA. The enrollment is stabilized. The applicant pool went down from 1975 to 1989. In the last 2 years the applicant pool has gone up at a rate of approximately 7 percent per year. So the applicant pool is turning around. The enrollment is level now after concomitant decrease in the enrollment in that same period of time.

Senator HARKIN. Doctor, on the research end, what am I hearing about silver in the teeth may not be too good and some problems with that?

Dr. LISTGARTEN. Well, there has been some controversy, but every available piece of evidence thus far indicates that there are no real good reasons to run to your dentist to get your amalgams taken out. I certainly have not had mine taken out.

There is, however, an inkling that additional research might be indicated to find out what some long-term effects might be. So there is probably some good cause to do some additional work on it.

Senator HARKIN. This whole area that all three of you testified on, research schools and affiliated programs, as you know from last year, this subcommittee addressed those areas responsibly. I think we did a pretty good job last year, and I think you look forward to us doing a good job again this year. It is an area in which I am personally very interested. Even with the budget constraints, hopefully we can manage to at least keep ahead of the game on this. So I appreciate it very much.

Dr. LISTGARTEN. Thank you. We certainly appreciate your contribution.

Ms. GURENLIAN. Thank you.


Senator HARKIN. One more panel of two witnesses who will speak on sleep disorders: Dr. Charles Czeisler of the American Sleep Disorders Association; and Joe Piscopo, American Narcolepsy Association, Inc.

Just a second here.

Did I say Czeisler? Is that right.

Dr. CZEISLER. That is impressive, Mr. Chairman.

Senator HARKIN. Very good.

Well, Dr. Czeisler, welcome. Of course, Mr. Piscopo has been here before. Good to see you again.

Please proceed.

Dr. CZEISLER. Thank you, Mr. Chairman, for this opportunity to discuss sleep disorders research before this subcommittee. My name is Charles Czeisler. I am an associate professor of Medicine at the Harvard Medical School, and I am here to represent the American Sleep Disorders Association.

Sleep disorders interfere with the quality of life, the health, and the safety of most Americans. Disturbed sleep afflicts over one-half of the 30 million Americans over the age of 65. In addition, the sleep and biological rhythms of 20 million Americans are disrupted by shift work, leading to sleep deprivation, reduced industrial productivity, and increased risk of accidents and illness.

Another 20 million Americans suffer from the serious sleep-related breathing disorder known as sleep apnea. One-third of all Americans complain of insomnia, and narcolepsy disables yet another 200,000 Americans.

Despite such high prevalence, the national effort to combat these disorders has thus far been woefully inadequate.

In early 1990, the U.S. Congress established the National Commission on Sleep Disorders to assess the impact of sleep disorders on our society and develop a long-range plan for sleep disorders research in the United States. Thankfully, great progress has been made over the last 20 years in our understanding of both basic sleep mechanisms and the clinical treatment of patients with sleep disorders.

One striking example is in the area of sleep and biological rhythm research. In 1972, scientists discovered a tiny cluster of nerve cells at the base of the brain that controls the timing of the occurrence of sleep within the 24-hour day. It also controls the timing of hormone release and the timing of daily variations in alertness and in performance. Just this past year so much progress has been made that it has been learned how to transplant that little cluster of neurons that represents this internal clock in the brain from one animal to another, and it still keeps on ticking after that transplantation.

Within the past 10 years, researchers have discovered that this internal clock in humans can be reset by properly timed exposure to bright light and to darkness. This new technology has the poten

tial to treat successfully common sleep disorders in the elderly and to enhance the safety and productivity of shift workers and transmeridian travelers just as we have recently done with the astronaut crew of the space shuttle Columbia that launched in December 1990.

Yet public policy often lags far behind new developments like these. This month, after a 4-year battle, the city of Albany, NY is being forced to allow its paramedics to work 72-hour shifts. Why? Because there are no nationally accepted guidelines to support the Albany Fire Chief's contention that public safety would be jeopardized by allowing paramedics to work 72 hours in a row. That is why every day across America chronic sleep deprivation leads to errors, accidents, personal injuries, and disabilities that could easily have been avoided.


These are a few of the reasons why the work of the National Commission on Sleep Disorders is so essential. The American Sleep Disorders Association strongly supports the work of the National Commission and recommends the initiation of a nationwide public education campaign on the health and safety consequences of sleep disorders in America. The ASDA recommends that a basic and clinical sleep research program be established within the NIH and that the productive research programs initiated within the NIH and ADAMHA be further supported and strengthened so that we can build an existing momentum and not lose ground.

Thank you very much for the opportunity to present the views of the American Sleep Disorders Association. I would be pleased to answer any questions.

Senator HARKIN. Thank you, Doctor.

[The statement follows:]


Mr. Chairman and members of the subcommittee, I am extremely pleased to be here today to discuss the federal government's commitment to sleep disorders research. I am Charles Czeisler, Ph.D., M.D., a member of the Government Relations and Public Policy Committee of the American Sleep Disorders Association. The American Sleep Disorders Association represents approximately 3,000 specialists involved in basic sleep research and the practice of sleep disorders medicine. The ASDA is concerned with the millions of Americans who are affected by the various disorders of sleep, the majority of whom remain undiagnosed and untreated. Mr. Chairman, the point I would like to make today is that sleep disorders and sleep related phenomenon have significant implications for an individual's overall health and well being and continued focus and research in this area is essential if the problems of sleep are to be addressed.


Although there is still much research which needs to be done in order to fully understand the function and activity of the sleeping brain, there are three basic principles which accurately describe the true nature of sleep.

One, sleep is an dynamic and complex process. Although the body is at rest during sleep, the brain continues to be active. The brain is as active while we are asleep as it is while we are awake.

Two, the second point is that the activity of the sleeping brain differs significantly from that of the waking brain. This condition explains why a person may be perfectly healthy while awake, but desperately ill while asleep.

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