Too many young people are joining the growing ranks of the marginally unemployable every year, constituting a direct threat to our Nation's productivity and competitiveness.

In the recent report "Code Blue," the American Medical Association declared an "adolescent health crisis," proclaiming that:

"For the first time in the history of this country, young people are less healthy and less prepared to take their places in society than were their parents. And this is happening at a time when our society is more complex, more challenging, and more competitive than ever before."

Witness after witness at the Oversight Subcommittee hearing emphasized the direct link between health and academic performance. A student who is sick, who is inadequately nourished, who abuses drugs or alcohol, who is pregnant, or who has an unintended child to raise is not in a good position to learn.

The Oversight Subcommittee's hearing revealed that there is much that the Federal Government can do to improve its efforts to promote child health through the schools. The Healthy Students-Healthy Schools Act we will be focusing on today will not only strengthen Federal efforts to promote child health education, but it will also provide the coordination necessary to avoid unnecessary fragmentation and duplication.

A recent survey identified almost 100 separate school health promotion and education programs administered by seven different Federal departments and two independent agencies. Unfortunately, there currently is little or no coordination among these programs. Among other provisions, the Healthy Students-Healthy Schools Act sets up an Interagency Task Force, to review and coordinate these Federal efforts. In addition, the legislation establishes a central office within the Department of Health and Human Services to help coordinate and assist States and local educational agencies to develop and maintain comprehensive school health education programs. It also establishes an Advisory Council of experts to review existing programs and curricula and establish realistic, achievable "Healthy Students-Healthy Schools Goals" for the Nation that are consistent with the Healthy People 2000 goals established by the Public Health Service.

Finally, the legislation authorizes the Secretary of Health and Human Services to award incentive grants to local educational agencies to encourage schools throughout the United States to grow into "Healthy American Schools."

Mr. Chairman, the success of our future economy will demand the full participation of our entire population. We must take action now to ensure that all young people, regardless of income, gender, or ethnic heritage, are prepared to be productive citizens.

Just as America's children must be healthy to be educated, they must also be educated to be healthy. Enactment of the "Healthy Students-Healthy Schools Act" will help us to further that objective.

You have called an excellent slate of witnesses this morning-some of whom I recognize from the Oversight Subcommittee's hearing last fall-and I look forward to the upcoming testimony.

Senator BINGAMAN. Thank you very much, Senator Cohen.

We'll go right ahead with testimony at this point. We will hear from our first panel, Dr. J. Michael McGinnis, who is the Deputy Assistant Secretary for Health and Human Services, and also the Director of the Office of Disease Prevention and Health Promotion.

Dr. McGinnis' leadership in "Healthy People 2000" is well-known to all of us, and I want to commend him. Healthy People 2000 is a tremendous effort that has benefited the country greatly. It really is a model for the kind of Federal leadership that we need to see in several areas.

Joining Dr. McGinnis is Dr. Lloyd Kolbe, who is the Director of the Center for Disease Control's Division of Adolescent and School Health within the Center for Chronic Disease Prevention and Health Promotion.

I understand, Dr. McGinnis, that you'd like to introduce some of your colleagues as well. Why don't I just turn it over to you for your introductions and testimony.

STATEMENT OF DR. J. MICHAEL MCGINNIS, DEPUTY ASSISTANT SECRETARY FOR HEALTH, AND DIRECTOR, OFFICE OF DISEASE PREVENTION AND HEALTH PROMOTION, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, WASHINGTON, DC., ACCOMPANIED BY LLOYD KOLBE, DIRECTOR, DIVISION OF ADOLESCENT AND SCHOOL HEALTH, CENTER FOR CHRONIC DISEASE PREVENTION AND HEALTH PROMOTION, CENTERS FOR DISEASE CONTROL; RHODA ABRAMS, HEALTH RESOURCES AND SERVICES ADMINISTRATION; MARY JANSEN, ALCOHOL, DRUG ABUSE AND MENTAL HEALTH ADMINISTRATION, AND ELAINE STONE, NATIONAL INSTITUTES OF HEALTH

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

It is really a privilege for all of us to be here to testify before you on this important issue. With me here, as you mentioned, is Dr. Lloyd Kolbe, who is director of our largest school health program, the program within the Centers for Disease Control, and we would like if we can to submit testimony of Dr. Kolbe for the record which reviews in some detail the important initiatives that the Centers for Disease Control has in this area.

Senator BINGAMAN. We'll be glad to put that in the record, and any other statements that any of the witnesses have. [The prepared statement of Mr. Kolbe follows:]

PREPARED STATEMENT OF LLOYD J. KOLBE, PH.D.

Much of the mortality and morbidity suffered today by Americans, young and old alike, is entirely preventable. All of us pay the resulting social and economic_costs. Among young people aged 1 through 24, almost 70 percent of all deaths is due to only four causes: motor vehicle crashes cause 33 percent of all deaths; other unintentional injuries (which we used to call accidents) cause 15 percent; homicides cause 10 percent; and suicides cause 10 percent.

These deaths 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. Further, 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.

Similarly, sexual behaviors established during youth often contribute to significant disease, social problems, and now (since the advent of the HIV epidemic) death. Cne million teenage females 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 dis

ease.

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. AIDS has become the sixth leading cause of death for 15 to 24 year olds. Nearly 20 percent of all AIDS cases have been reported among persons 20 to 29 years of age. Because of the lengthy period between infection with the human immunodeficiency virus (HIV) and the onset of AIDS, we know a significant proportion of those persons acquired their infection in their teenage years, and the majority of those infections are the result of risk behaviors practiced by teenagers.

Two health problems are most likely to plague our youth when they become adults: cardiovascular disease and cancer. Almost 60 percent of all deaths in the Nation are attributable to these two causes. Three behaviors contribute greatly to these diseases: tobacco use, improper diet (such as excessive consumption of fat), and inadequate physical activity. Patterns for these three behaviors usually are established during youth and continue into adulthood.

The Centers for Disease Control (CDC) is committed to enabling the young people of our Nation to avoid the risk behaviors described above and the health problems they cause. As evidence of this commitment, in 1988 CDC created a Division of Adolescent and School Health which now employs about 60 staff to identify priority health risks among youth, monitor the prevalence of these risks, support and implement national programs to prevent these risks, and evaluate the impact of national programs.

During the past 3 years, this division has established a coordinated national system that involves eight components specifically to help young people avoid behaviors that result in human immunodeficiency virus (HIV) infection. The eight components are: (1) epidemiological surveillance program; (2) national organizations; (3) State and city departments of education; (4) materials development and dissemination; (5) training and demonstration centers; (6) colleges and universities; (7) youth in high-risk situations; and (8) evaluation. Support for this national system totals $52.4 million in fiscal year 1992 and $52.1 million is proposed for fiscal year

1993.

These components enable CDC to work in collaboration with other Federal agencies and with many national, State, and local education and health agencies in the public and private-sector. Indeed, agencies that serve youth, especially health and education agencies, must work together if we are to be effective in preventing health risks.

Although these components initially were implemented to prevent categorical risks for HIV infection, in FY 1992, CDC began to use these components to help schools across the Nation prevent tobacco use, dietary patterns that cause disease, and sedentary lifestyles.

The first component of our national system is an epidemiological surveillance program to periodically assess the prevalence of youth risk behaviors that cause the most mortality and morbidity. These behaviors fall into six broad areas: (1) sexual behaviors that result in HIV infection, other sexually transmitted diseases, and unintended pregnancy; (2) drug and alcohol use; (3) tobacco use; (4) dietary patterns that contribute to disease; (5) insufficient physical activity; and (6) behaviors that result in unintentional and intentional injuries. CDC periodically conducts national surveys of these risk behaviors and also helps every interested State and 16 large cities to monitor the prevalence of these risk behaviors among their high school students.

In addition to risk behaviors we also monitor the extent to which the Nation's schools provide health education to prevent risk behaviors in each of the six categorical areas, as part of a planned and sequential, kindergarten through grade 12, comprehensive school health education program. CDC works with several national education organizations to implement this part of the surveillance system.

CDC collaborated with representatives from more than 18 other Federal agencies to develop this surveillance program. These agencies are located within the Department of Health and Human Services, Department of Education, Department of Agriculture, Department of Transportation, and Department of Justice. CDC continues to work with these agencies to monitor and report on 26 relevant National Health Objectives for the Year 2000, the Public Health Service Illicit Drug Demand Reduction Plan, and National Education Goal Six (i.e., safe, disciplined, and drug free schools).

The second component consists of support to 23 national organizations and the Indian Health Service. CDC provides fiscal and technical support for these agencies to help schools, and other agencies that serve youth, implement comprehensive school health education programs to prevent HIV infection and other important health problems. For example, CDC funds and works closely with the National Congress of Parents and Teachers, National Association of State Boards of Education, Council of Chief State School Officers, American Association of School Administrators, and many others.

The third component consists of fiscal and technical support to every State, four territorial, and the 16 large city departments of education, to help schools implement programs to prevent HIV infection and other important health problems. These departments of education work directly with CDC, and with the national organizations described above to: (1) develop prevention policies, curricula, and education materials; (2) train teachers to implement prevention education; and, (3) assess the extent to which schools provide prevention education and the extent to which students engage in behaviors that result in HIV infection and other related health problems.

The fourth component facilitates the development and dissemination of prevention education materials for youth. As one part of this component, CDC, in collabo

ration with other Federal agencies and 12 national education and health organizations, developed and disseminated "Guidelines for Effective School Health Education to Prevent the Spread of AIDS." CDC currently is working with various Federal agencies and national organizations to develop "Guidelines for Effective School Policies and Programs to Prevent Tobacco Use," and "Guidelines for Effective School Nutrition Education" respectively. CDC disseminates information about prevention education materials through the electronic Combined Health Information Database, and through an electronic Comprehensive Health Education Network.

The fifth component includes three national training and demonstration centers that help State and local officials learn how to implement state-of-the-art prevention education programs in their respective States and cities. This component also includes centers in 42 States that train teachers to implement comprehensive school health education curricula that include HIV education.

The sixth component is designed to enable the Nation's colleges and universities to prevent HIV infection and other important health problems among their students. In each of 5 States, CDC supports a lead university that provides technical assistance and training to enable other colleges and universities throughout the State to develop prevention education programs.

The seventh component is designed to help local health departments that serve the Nation's largest cities to prevent HIV infection and other important health problems among runaway and homeless youth, migrant youth, juvenile offenders, and other youth in high-risk situations. CDC has implemented this component in consultation with the Administration for Children and Families and the Alcohol, Drug Abuse, Mental Health Administration's Office of Substance Abuse Prevention. The eighth and final component is to evaluate, and consequently improve, the efforts I have described to prevent risks for HIV infection and other important health problems among youth. CDC is conducting research to evaluate the extent to which schools are implementing prevention education, and the extent to which students consequently reduce behaviors that result in HIV infection and other important health problems.

CDC conducts other programs and activities that influence the health of our young during childhood and adolescence. For example, since 1963, CDC has provided grants to State and local health departments to support childhood immunizations programs. Through these programs about 8.7 million children are immunized each year. CDC published guidelines (in collaboration with teachers, parents, community leaders, and law enforcement officials) for the control and prevention of suicide clusters. CDC also is developing guidelines for youth violence prevention programs. As a final example, to combat the alarming incidence of sexually transmitted diseases among youth, CDC provides fiscal and technical support to help State and local health departments prevent, diagnose, and treat sexually transmitted diseases. State and local health departments work with departments of education to help schools implement sexually transmitted diseases prevention education programs. CDC is committed to working closely with the Nation's schools to help implement planned and sequential, kindergarten through grade 12, comprehensive health education programs. To be effective, we believe these programs must focus on preventing risk behaviors in each of the six areas (i.e., tobacco use, drug and alcohol use, diet, physical activity, sexual behaviors, and behaviors that result in unintentional and intentional injuries). However, we believe these categorical efforts should be planned, implemented, and coordinated within a more comprehensive framework.

Indeed, schools can do much more than implement comprehensive school health education to improve the health of our youth, and their consequent educational achievement. As stated in Healthy People 2000: National Health Promotion and Disease Prevention Objectives:

Other aspects of the school environment can also be important to school health. State and local health departments can work with schools to provide a multidimensional program of school health that may include health education, school-linked or school-based health services designed to prevent, detect, and address health problems, a healthy and safe school environment, physical education, psychological assessment and counseling to promote child development and emotional health, schoolsite health promotion for faculty and staff, and integrated school and community health promotion efforts.

If our efforts to prevent these health risks among youth are to be effective and efficient, we must combine the various health expertise and health resources of health agencies with the necessary organizational capacity and policies of education agencies. Neither health nor education agencies can do the job alone. Both need

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