thoughts about how to provide incentives to get schools to do this kind of thing whether they get the Federal money or not.

Dr. FIELDING. I think, Senator, that your discussion of the Malcolm Baldridge Award is really a good model. What is important about it-it certainly has some marketing benefit to corporationsbut I think what is more important, or equally important, is that it focuses on process. It says you have to have the internal processes in place that guarantee that you are going to be concerned about continually working to improve quality. That says another thing. It says you are internalizing that as part of your mission as an organization.

I think what Ms. Penfield said is very important. It legitimizes health and health status goals as an important part of the mission of schools as an important community resource. So I think that that's one way to incentivize it, by saying, look, it's important nationally that we view these as part of the schools' mission.

Second, what you can do is to critique what has been done. That is another incentive. You don't simply say people haven't wonyou don't win or lose-but you may get some feedback that can help you.

I do think that awards and recognition are very important, but oftentimes they don't fall equally on all those involved. I think one of the key things is to provide incentives in this, not just monetary, but in terms of self-esteem and external validation, for all the people involved, from the food service workers to the physical education teachers to the health education teachers to the school board. Unless all of them feel they have something to gain from this, I am afraid it will be difficult. But I think the analogy of the Malcolm Baldridge Award is a very good one.

Senator BINGAMAN. It strikes me that perhaps in section on "Outstanding Healthy American School Awards," maybe the legislation needs to be a little more explicit about the kinds of programs we are hoping to look to as criteria for determining awards, because I would not want anyone to get the impression that there is a necessary correlation between getting a Federal grant and getting an award. A lot of schools are probably not going to be able to get grants given the limited budgets that exist, and some schools may not get grants of any very substantial size, but any of these may well be entitled to an award if they do the things that need to be done. So I think that's something to look at.

Dr. FIELDING. Senator, you asked a question about evaluations, and I had one thought on that issue. That is, in the short-term, I think one could look at health effectiveness and educational effectiveness. The cost-benefit can take a long time; it is a modelling. There are a lot of issues among economists as to what are the right assumptions, discounting rates, and other things. But I think everybody understands that if you can reduce risk factors, you don't get kids to start smoking if there is a very substantial benefit there, or if you get somebody to adopt a lifetime exercise pattern, or to not start taking cocaine, or to not be killed in an auto accident. I think those are very clearcut things one can look at as well as the educational goals-if you can affect the dropout rate; if kids are present more, if there are fewer discipline problems. I think there are a

number of ways to look at this in ways that can be meaningful to the community, to the institution, and to the Nation.

Senator BINGAMAN. Well, I appreciate very much the testimony of all of you. I think it has been a useful hearing. We will continue to work away at this and try to get S. 2191 enacted into law. Thank you very much for coming.

[Additional statements submitted for the record follow:]

PREPARED STATEMENT OF THE AMERICAN ACADEMY OF PEDIATRICS

Mr. Chairman, members of the committee, the American Academy of Pediatrics represents 43,000 physician members who are dedicated to the health, safety and well-being of infants, adolescents and young adults. We appreciate the opportunity to discuss S. 2191, the "Healthy Students-Healthy Schools Act."

We would like to commend the author of this important legislation, Senator Bingaman, for his outstanding leadership in the area of school health. The state of our children's health has been overlooked for far too long, and the Academy is encouraged by the increasing amount of attention it is receiving. Children must learn early that the way they treat their bodies today will affect them the rest of their lives. It will affect their ability to learn, their ability to gain meaningful employment, and their ability to live a long life.

There are a number of components that the Academy views as critical to the success of any school health program. Many of these components have been incorporated into the "Healthy Students-Healthy Schools" legislation. First, we believe it is vital that health education programs be given the same priority as traditional school subjects, such as math and English. Health education, directed by a qualified health educator, should be taught as a part of a basic curriculum and should be a requirement for students from kindergarten through grade twelve. One coordinated comprehensive health course which incorporates all the necessary aspects of health education will reinforce the importance of positive health habits. This approach would be far more successful than addressing each aspect of health education separately. Presenting one unified health package teaches students how each separate aspect of health affects their overall well-being. Students would also have an opportunity to ask their teacher how each of the different aspects of health education affect their individual health.

Another valuable benefit of a single coordinated health program is the elimination of duplication of services. Currently, there are several local, State, and Federal public and private entities which provide some health education. This piecemeal approach is often expensive and does not ensure that students are receiving a comprehensive health education program. One coordinated program would reduce waste and ensure students get a comprehensive health education program. Therefore, the coordination among initiatives, outlined in the "Healthy Students-Healthy Schools" bill, is not only a fiscally responsible idea, but an educationally sound one as well. If health education courses are going to significantly impact a student's daily life, it is important for that student to understand the direct consequences to his or her health. We therefore recommend that teachers use a "hands-on" approach or laboratory experience to engage students. It is much more effective to teach students how to monitor their own health than to lecture them on the do's and don'ts of a healthy lifestyle. Teaching students what happens when alcohol or cigarette smoke enters the body provides them with the information needed to reach their own decisions on such practices. This method can help students use the facts and concepts discussed in class when making everyday decisions. Active participation of the students will result in the most effective learning of sound health concepts and practices.

If the Nation is going to have high quality health education courses, it must first have high quality teacher training programs. As we integrate health education into the basic school curricula it is imperative that it becomes a required part of the overall elementary school and secondary school teacher training programs. Colleges and universities need to establish high standards and requirements as exacting as those for other fields of instruction. While health education is currently available in many colleges and universities, it is not generally required for all postsecondary students in elementary and secondary education degree programs. This background would be useful for all educators, not just those who will be directly responsible for a health education program.

Although curriculum and teaching method are important to the viability of a program, equally important is its financial security. In order to develop a quality

health education_program, necessary funding must be available to set and reach long-term goals. For example, if the goal of a program is to increase the overall fitness and nutrition status of a group of students, funding for the duration of the program should be guaranteed at the outset to ensure maximum success.

Equally important to a program's success are parent and community involvement. A health education program should not be confined to the school building. Participation of parents and the community in the development and implementation of the program will strengthen its impact. The school environment should also support health education, including physical education programs that emphasize aerobic fitness and healthful school lunch and snack machines. Additionally, a non-smoking environment for schools and teacher health worksite wellness programs should be instituted. Students will not accept the taught behaviors if they are not reinforced in their lives outside the classroom and outside the school. Parents will and must play a decisive role in the program. Health education courses should be developed so that parents as a whole understand and approve of the curriculum. This can be enhanced by efforts of school districts, public agencies, the medical community, and other private agencies to intensify and coordinate the health education programs for adults. Coordinated community health education efforts will expose students to healthy behaviors in all aspects of their lives. We, as pediatricians, can aid in this aspect by making health education a regular component of our office visits.

While the Academy supports the overall goals of the legislation, we do have a concern about creating a health care system within or linked to school buildings. The legislation limits these to preventive health services, but this can result in the fragmentation of a child's health care. Ideally, every child in America should have a physician or physician group who serves as the primary source of health care and functions as the "medical home" of the child providing preventive care and treatment of acute and chronic illnesses. Both primary health care providers and schools should work together to ensure that all school-aged children have access to comprehensive health care. The physician or physician group should coordinate health care and be responsible for maintaining a complete medical record on the child. An important component of this model is parental involvement, which needs to be maintained.

School-linked or school-based health care clinics have been successful in areas where health care services have been unavailable. If school-based clinics are established, guidelines must be followed to avoid unnecessary fragmentation of care and ensure appropriate follow-up care. The school-based services should be provided or supervised by a physician who is trained in the health care of children and adolescents. Schools need to provide linkage to appropriate medical care resources, and an appropriate referral system should be established for the care of children with medical problems. Policies regarding confidentiality must be established. If school-based services are available only during school hours, arrangements should be made for services to be available when school is not in session. Lastly, school-linked or schoolbased services should be assured of sound and continuous financial support.

Parents, educators, and pediatricians all play an important role in health care education and delivery of services to children. The Academy feels strongly that we all should work together to develop successful school health programs. Children are extremely complex both emotionally and physically. Pediatricians bring a unique understanding of a child's health and well-being to the table and can be an important resource in any health program affecting children.

The American Academy of Pediatrics would again like to thank the Chairman and Senator Bingaman for their leadership on this issue. We look forward to working with Senator Bingaman, the Chairman, and Congressman Mike Andrews (DTX), the House sponsor, to develop legislation which will meet the health needs of our Nation's students.

PREPARED STATEMENT OF C. PETER MAGRATH

Mr. Chairman, I am C. Peter Magrath, president of the National Association of State Universities and Land Grant Colleges. I commend Senator Bingaman for his interest and involvement in providing for health education for America's students and for America's schools, and I applaud the Labor and Human Resources Committee's commitment to educational programs that will improve the health and well being of tomorrow's generations.

I am pleased to submit testimony on behalf of the Cooperative Extension System of the Nation's land-grant universities. As you know, Cooperative Extension was established by Congress as a partnership of the land-grant universities and the U.S. Department of Agriculture, and is a vital part of the mission of the land-grant uni

versities, translating the research and scholarship of the universities for use by the people. Cooperative Extension also is a network of university faculty and specialists who work in nearly every county of the country providing education on topics from animal husbandry to public policy, from waste water treatment to community development, from child care to nutrition and health. Significantly, Cooperative Extension has included programs for young people in its mission since its founding 75 years ago, and devotes a substantial amount of its effort and emphasis to promoting the health and well-being of America's youth. Most importantly, for your consideration of S. 2191, the Healthy Students-Healthy Schools Act, Cooperative Extension offers children and teenagers important health and nutrition education through inschool programs and in after-school activities.

A FEW EXAMPLES OF COOPERATIVE EXTENSION'S HEALTH AND NUTRITION ACTIVITIES FOR SCHOOLS

Since 1986, Cornell University Cooperative Extension has had major responsibility for developing a nutrition education curriculum, entitled "Nutrition for Life," for kindergarten through 12th grade students in New York State. Each year, the curriculum reaches 500,000 students, and is being used by 75 percent of the State's teachers. Cornell Cooperative Extension has developed a magazine for teens, called Alive!, that features articles on nutrition and athletic performance, emotional wellbeing, the dangers of junk food and other topics. Seven hundred thousand copies of Alive! have been distributed to New York State students.

West Virginia University Cooperative Extension has developed a program for use in schools that deals with the health problems created by use of smokeless tobacco, a major health concern for young people in the State.

New Mexico State University Cooperative Extension works with the schools across the State in health screening and nutritional analysis for students as part of a targeted program of nutrition and health for young people. Cooperative Extension is also working with pregnant teens in schools to help prepare them to care for their children, and to instruct them about their own diets during pregnancy. Afterschool day-care programs use extension-developed materials on excercise and nutrition, food choices and preparation, which supplement their school curriculum.

In many States, Cooperative Extension has developed videotapes and other materials for use in sex education classes and for parents to use in talking to their children about reproductive health issues.

Through Cooperative Extension's 4-H programs, which serve 5.4 million schoolage youth, young people learn self-esteem and decision-making skills that help them resist drugs and alcohol. Teens in 4-H programs are closely tied to the schools, and in urban, rural and suburban areas, the school systems support 4-H activities.

These programs are only representative of the work that Cooperative Extension is doing across the country to promote better health and nutrition in and for the schools. The point is that Cooperative Extension is working to promote the goals of "Healthy Students-Healthy Schools," and that collaboration should be noted more specifically in the legislation, S. 2191, now being considered by the Committee.

RECOMMENDED LANGUAGE CHANGES

ELIGIBILITY

In the application process outlined in Sec. 8(c), the following should be added to part (3): after non-profit public agencies, add, "Cooperative Extension System of land-grant universities,".

HEALTHY STUDENTS-HEALTHY SCHOOLS INTERAGENCY TASK FORCE

Cooperative Extension has provided programs for youth and families in nutrition and health education since it was established in 1914. Its history is replete with collaborative efforts with schools, and its activities on behalf of America's young people are_exemplified through the work of our Federal partner, the Extension Service, USDA, on the Federal Interagency Task Force on Child Abuse and Neglect. It is important, therefore, that the Extension Service, USDA, be included as a named member of the Interagency Task Force in the bill (Sec. 6(a)).

In the same part, the word nutrition should be added, following the phrase "school health." This addition would insure that nutrition, which is vitally important for the health of young people is recognized, and that agencies that provide nutrition education be included on the task force.

Senator BINGAMAN. Before concluding, there was an item I particularly wanted to get on the record, and that is that I want to thank Debra Egan, who is a Fellow from the National Institutes of Health in our office, for her work on this bill. Debra is here today, but she is not going to be able to stay here; she will be returning to the NIH soon. She has been working with Carrie Billy and Mary Jo Hoeksema, who are permanent staff, on this bill for me. Debra deserves some particular recognition for her contribution to our effort, and I know many of you have had dealings with her. So, I just wanted to mention, on the record, all the appreciation we have for Debra's good work.

With that, we will conclude the hearing.

[Whereupon, at 11:15 a.m., the committee was adjourned.]