cocaine in the past month; increase the proportion of high school seniors who perceive social disapproval associated with the heavy use of alcohol, occasional use of marijuana, and experimentation with cocaine; and increase the proportion of high school seniors who associate risk of physical or psychological harm with heavy use of alcohol, regular use of marijuana, and experimentation with cocaine.

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The perception of social disapproval or risk of personal harm can be powerful in determining behavior. So I think promoting these perceptions about alcohol and drugs is very worthwhile. something's missing: tobacco is responsible for one out of every six deaths in America every year.

Why isn't tobacco included in these goals? (As background, the report has two tobacco goals: reduce from 30 percent to 15 percent the proportion of those who smoke regularly by age 20; and reduce smokeless tobacco use. However, there is no mention of educating kids about tobacco's risks or trying to reduce smoking by encouraging disapproval of it.)

Answer. The priority area that addresses reduction of tobacco use includes, as objective 3.10, an objective to establish tobaccofree environments and include tobacco use prevention in the curricula of all elementary, middle, and secondary schools. Although the work group developing the tobacco use objectives did not include levels of adolescent social disapproval as a measure of effectiveness in efforts to reduce smoking and use of smokeless tobacco (as was done for alcohol and drugs in the priority area on those forms of substance abuse), the survey that tracks perceptions of social disapproval for alcohol and drugs also asks high school seniors about perceptions regarding tobacco use as well. We will use the measure to evaluate the effectiveness of school-based and other anti-smoking health education directed at youth. You can be assured that prevention of the initiation of tobacco use will be a priority of the coming decade. In fact, one of Secretary Sullivan's nine major program directions specifically addresses this significant health promotion issue.

Question. The National Academy of Sciences stated in a recent report on health promotion and disease prevention that "Federal subsidies to tobacco growers should be eliminated," and that "cigarette advertising should be prohibited." Do you agree or disagree, and why?

Answer. We agree. Clearly, the Public Health Service is not the only voice with perspectives on the issues posed by tobacco use, and we do not have principal responsibility for agriculture or trade (advertising) policies. Our position on tobacco, however, is clear and uncompromising. Tobacco kills people--over 400,000 each year. From a health perspective, it has no redeeming qualities. While we understand that there are no longer any direct subsidies to tobacco growers, we advocate agriculture policy that shifts farming away from economic dependence on tobacco production and advertising policy that prohibits the glamorizing of a product that causes an immense amount of suffering and death.

PHYSICAL FITNESS AND SPORTS

Question. The budget request for the Office of Physical Fitness and Sports indicates that the Office supports "publication of research information". Please provide the Committee with details on this activity, including copies of such publications.

Answer. The President's Council on Physical Fitness and Sports publishes the Physical Fitness and Sports Medicine Bibliography on a quarterly basis in cooperation with the National Library of Medicine. This publication encompasses such areas as exercise and physiology, sports injuries, physical conditions and the medical aspects of exercise. It serves as a scientific resource for physicians,

physical educators, coaches, athletic trainers, physical therapists and others interested in the medical aspects of exercise and sport. A copy of this publication is being forwarded to the Committee under separate cover.

INDIVIDUAL RESPONSIBILITY FOR PERSONAL HEALTH

Question. Secretary Sullivan's speeches and much of the published material contained in your budget justifications seem to place major emphasis on individual responsibility for personal health. In your view, what is the appropriate federal role in promoting and protecting Americans' health?

Answer. First, let me point out that Secretary Sullivan and I have emphasized individual responsibility for personal health to redress the balance of emphasis in health and medicine. We believe that it is crucial that Americans understand that the medical care system is, in fact, not the most important determinant of their health status. The science backs up this point. The leading causes of death in this country today are largely outcomes of diseases that occur because of behaviors, such as smoking, alcohol and drug use, poor diet, sedentary lifestyles, unsafe sexual practices, and inattention to safety precautions like the use of seat belts in automobiles. We strongly endorse an emphasis on health promotion and disease prevention to prevent unnecessary disease, disability, and death.

That is not to say that health or even prevention is only a matter of behavior. As I pointed out in my opening statement, prevention involves personal behavior, environmental protection, and services. Each is crucial; none can be ignored if we are to take full advantage of opportunities available to improve the health of Americans. The Federal role must--and does--address all three of these elements of prevention. Our emphasis on individual responsibility is clearly not the only Federal response to America's health needs; but we believe that it is one that needs special emphasis because Americans have become too dependent on the health care system to take care of problems that could have been prevented.

Second, we should be reminded that, under the Constitution, States have the principal responsibility and authority for public health. The Federal government, through the Public Health Service, provides leadership (as in the Secretary's speeches that gain appropriate national attention), agenda-setting (as with Healthy People 2000), support for basic and applied research and development, protective regulation to ensure the safety of medications and the food supply, direct services to special population groups and support for services to underserved populations, national surveillance and monitoring, collaboration with the States to initiate and improve services (e.g., through block grant programs and special initiatives such as the breast and cervical cancer screening programs), and dissemination of health information.

Question. What education activities are your office undertaking, and how are these coordinated with the various clearinghouses of PHS agencies and the information dissemination activities of the Agency for Health Care Policy and Research?

Answer. Most of the health education initiatives of the Public Health Service are carried out as part of the ongoing programs of PHS agencies. Examples include high blood pressure and cholesterol education programs of the National Heart, Lung, and Blood Institute (NIH); cancer prevention and control initiatives of the National Cancer Institute (NIH); alcohol and drug abuse prevention initiatives of the Office of Substance Abuse Prevention (ADAMHA); anti-smoking initiatives of the Center for Chronic Disease Prevention and Health Promotion (CDC); and the Depression Awareness, Recognition, and Treatment Program (ADAMHA). From the Office of the Assistant

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Secretary for Health, we provide a forum to coordinate these health education programs. In addition, the ODPHP National Health Information Center provides a central one-stop resource for consumers and professionals with health questions that are referred directly to the appropriate Federal or private information resource for followup, as appropriate, or that are answered directly when no other information resource is available. In addition, the Office of Disease Prevention and Health Promotion is leading a Department-wide initiative to disseminate health messages on immunizations, smoking, alcohol, nutrition, and physical activity through all the Department's 25,000 grantees and regular contacts during 1991. are exploring joint activities and Information products with the Agency for Health Care Policy and Research (AHCPR) to educate consumers to be partners in a quality health care system and to take greater responsibility for self management of their health. Also, consumer oriented materials will be prepared for each of the AHCPR practice guidelines as they are released, and these will be coordinated with all PHS clearinghouses to ensure distribution. addition, AHCPR is actively working with other PHS components on the PHS Life Sciences Education and Sciences Board to increase public awareness and understanding of life sciences as it relates to the health care system and to enhance life science education programs and curriculum development at all levels, especially in grades K-12.

DESERT STORM

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Question. I am interested in your views on the impact of the Operation Desert Storm call-up of military reserve personnel. newspaper accounts of doctors, nurses, and other health professionals being called for Operation Desert Storm note that the call-up has further aggravated personnel shortages in underserved areas.

Happily, the war appears to be ending now. What is your view of proposed legislation granting funds to facilities experiencing warrelated personnel shortages?

Answer. The strategy I would suggest for dealing with any health staffing shortage problem would be to first rely upon DOD to exempt military reserve personnel from active duty in most serious cases of community hardship where loss of health care staff are involved. Second, I would count on the resourcefulness of state and local governments and professional organizations to solve temporary shortages with volunteers, retirees, staff sharing mechanisms, and other Innovations.

For serious problems after these efforts have been made, we would use the Commissioned Corps Ready Reserve to the extent possible to match personnel to the needs of the communities. This capacity would be augmented with those willing to volunteer from the roster of retired medical officers. Finally, If needs could not be filled using the reserves, we would detail some officers from the active Commissioned Corps to serve in temporary details in the underserved sector. I want to assure you that I would act quickly to temporarily deploy Commissioned Corps personnel, irrespective of possible voluntary solutions, if a true emergency situation is brought to my attention.

AIDS AMONG WOMEN

Question. As you know, there has been a lot of activity lately around women's health issues, especially with regard to research. As one of the people working on this issue, I am particularly concerned about the projected increased incidence of AIDS among women, now the fastest growing category of AIDS patients. Many of these women are pregnant or nursing mothers, who are likely to pass the virus on to their children. Tragically we know very little about the social and

behavioral issues that put women--and others for that matter--at risk for contracting AIDS.

In order to understand how to change high risk behaviors and to evaluate AIDS prevention programs, scientists have been telling us for years that they need to have some basic behavioral data that would be collected through the NIH's Survey of Health and AIDS Risk Prevalence, or the so-called SHARP study. Despite peer review and approval by a wide array of non-academics including several religious leaders, this study has been held up by your Department for over 3 years.

Last year in our Committee report we indicated our dismay with the Department that this survey continued to be delayed and we 'urge{d} the Department to approve the feasibility phase of SHARP promptly." (S. Rpt. 101-561 pp.215) We were delighted to learn that the Administration included $3 million dollars to launch the full scale version of this survey and applaud your commitment to this effort. We also understand, however, that the feasibility phase that the Committee urged the Department to approve last year, is still being held up in your office. Can you please explain this apparent inconsistency and tell the Committee when you plan to direct the NIH to proceed with this effort?

Answer. The proposed feasibility study for the National Survey of Health and AIDS Risk Prevalence (SHARP) is still under consideration in the Department. However, based on the results of the Dallas pre-test of the seroprevalence survey, we believe we can proceed with the study without further feasibility activities. However, this remains a sensitive issue. At this time it is not possible to provide a more definitive statement on the future of the project.

To preserve the option of proceeding with the national survey while the departmental review is underway, HHS has requested $3.0 million in the FY 1992 budget. This amount represents costs associated with initiating the national survey in that year.

AIDS FUNDING

Question. Dr. Mason, how much money did you request of the Secretary for HIV programs in your original presentation for FY 1992, as compared to the final level in the President's budget?

Answer. The FY 1992 HIV/AIDS request to the Secretary was $2,033,021,000 (including the Food and Drug Administration and the Indian Health Service). The FY 1992 President's Budget request for HIV/AIDS is $1,950,261,000.

DUPLICATION OF AIDS EFFORTS

Question. Dr. Mason, the natural history and transmission studies relating to HIV sponsored by PHS agencies are critical contributions to our understanding of this epidemic. I am concerned, however, by the number of different agencies involved in these studies. As I understand it, there are cohorts being studied at NIAID, NCI, NIDA, and CDC. Are any of these studies duplicative, so that they might be merged or possibly reduced in number to save on limited funds?

Answer. CDC and NIAID conduct studies of the natural history of HIV disease. While these studies are addressing some of the same issues, each study has unique qualities either in the study design, the study participants, or the major emphasis. Having independent studies also allows for prompt confirmation of results from one study by the other study.

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Question. Is the data collection in these studies such that they can be compared or merged in a meaningful way, so that together, larger cohorts could be formed?

Answer. CDC and NIAID staffs are in constant contact through review panels, scientific meetings, working groups, telephone consultation, etc. to look for ways to collaborate and to prevent duplication of efforts. As an example, a productive collaboration was recently established by combining CDC's heterosexual transmission study sites with NIAID sites into one multicenter study. addition, CDC has recently established a working group with colleagues at several other PHS agencies to develop a common protocol for studying the natural history of HIV disease in women.

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Question. What level of interaction is taking place among these agencies to assure that these studies are complementary and coordinated?

Answer. The data collection for the natural history studies in women will use a common protocol that will enable PHS agencies to collect comparable data for a single large cohort. The CDC and NIAID are in the process of combining their heterosexual transmission studies by adopting a similar protocol which will result in comparable data that will be merged resulting in a more meaningful analysis of research questions. NIDA has worked to assure that HIV natural history and transmission studies that are funded complement, rather than duplicate each other and also that, as much as possible, they complement work being done by other agencies or institutions. This has involved close coordination between NIDA program staff and both NIDA grantees and representatives from other agencies. ADAMHA and CDC have established a formal work group for facilitating coordination and collaboration between the two agencies.

AIDS AMONG WOMEN

Question. Dr. Mason, there has been growing interest in the course of HIV infection among women. There seems to be significant indication that the course of the disease is different for women, which calls for some investigation into the natural history of AIDS among women. Since 1984, the NIH and CDC have been following cohorts of gay men. These studies have provided invaluable information. While the PHS is funding several studies of transmission heterosexual and from mother to child-- I am not aware of any natural history studies of HIV in women. What plans does the PHS have to do similar natural history studies of HIV infection in women? Could resources be identified to begin such a study in FY 1991 so there will not be further delay in pulling such a cohort together?

Answer. The National Institute of Drug Abuse (NIDA), ADAMHA has sponsored a large-scale natural history and drug abuse prevention research program focusing on HIV infection in women and infants; subpopulations studied include women who are homeless or who live in rural areas, and those who engage in prostitution. NIDA also supports a study on the natural history of AIDS among female prisoners who are drug users.

CDC plans to fund several new studies in FY 1991 and to supplement existing studies to address several issues unique to women, including the natural history of HIV infection. The major objectives of these studies are to examine possible gender differences in disease manifestations, incubation period, and survival; to address the effects of pregnancy and contraception methods on the natural history of HIV disease in women; and to determine the effects of HIV disease and immunosuppression on other co-existing infections or conditions such as pelvic inflammatory disease and other sexually transmitted diseases (e.g., syphilis, herpes simplex, vaginal candidiasis, and human papilloma virus infection). Request for Proposals will be published in the Federal