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QUESTIONS SUBMITTED BY THE SUBCOMMITTEE

FARM HEALTH AND SAFETY / EDUCATION IN SCHOOLS

Should Surveillance be expanded to more rural

Question. states?

Answer. CDC is currently supporting six states to conduct surveillance identifying hazards to which agricultural workers are exposed, the circumstances of exposures, and the health status of these workers and their families. On April 30-May 3, 1991, CDC is sponsoring the "Surgeon General's Conference: Agricultural Safety and Health" to discuss these topics.

SMOKING AND HEALTH

Question. The FY 1992 budget requests $6,842,000 for smoking cessation programs, an increase of $3,503,000 over FY 1991. Approximately 50 million, or nearly 1 of every 3 American adults smoke. Moreover, there are 300,000 smoking related deaths each year and economic losses of smoking this year will exceed $65 billion. Do you think that this increase is adequate to meet your goals of reducing the incidence of smoking by the Year 20007

Answer. This 105% increase in the 1992 budget request will enable activities to be undertaken in key areas that will substantially reduce the incidence of smoking by the Year 2000. These additional activities include:

Strengthening the public health infrastructure to take
action against tobacco use. This includes, but is not
limited to:

Intensifying work with the States, thereby
building their capacity to address tobacco
issues.

Developing guidelines for school health
education and smoke-free schools, to enable

schools to address tobacco issues.
Launching targeted health information/education
campaigns

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Initiating target group-specific studies--to identify
and promote effective tobacco control approaches for
high-risk populations, such as minorities, women,
children, and adolescents, and blue collar workers.
Publicizing critical and needed information about
tobacco control.

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As a society, we should be doing more to prevent tobacco use. Broad social and environmental changes are needed to reinforce the point that tobacco use is damaging to health--and for that reason, tobacco use is not acceptable in our society. Federal dollars alone will not achieve such change.

Question. This budget also includes $16,500,000 for infant mortality programs. One of the programs cited in your budget is technical assistance to reduce infant mortality rates associated with low birthweight. In as much as smoking doubles the risk of low-birth weight and increases the risk of still birth by up to 1002, would it not make sense to increase funding for smoking cessation programs to target women who smoke?

Answer. Smoking remains the single most preventable cause of death in the United States and causes 10 percent of infant mortality. In an attempt to reduce infant mortality rates associated with low birthweight, in FY 1991, we have increased our work in prenatal smoking cessation (PSC) activity by expanding the program to more states and providing technical assistance to others. In addition, HRSA is increasing its activities in this area. While smoking cessation programs can help in reducing infant mortality rates associated with low birthweight, we are also excited about the opportunity for our increased smoking cessation education activities to improve women's health as well as the health of low-income persons, teens, minorities, and others.

We believe these substantial increases indicate our high level of concern and intent in this area. The new monies available in the FY 1992 budget for CDC's infant mortality initiative are being targeted towards the other high priority activities of assisting the states to better understand the extent of their infant mortality problem, through improved surveillance. This is an area that has been highlighted as a need in both the White House Task Force report and the Interagency Committee on Infant Mortality recommendations for future activity.

IMMUNIZATION/INCENTIVE GRANTS

Question. Many state and local health departments have stated that they do not have the resources to improve immunization levels of children less than 24 months of age. Yet, the FY 1992 budget requests $20 million for Immunization Incentive Grants which will be awarded to those states that are doing a good job of immunization. Dr. Roper, do you think this is a good idea -- it would seem to me that $20 million would be better spent in either helping states improve their immunization program or in increasing support for additional doses. What is the primary need?

Answer. While investigating outbreaks of measles in 1989 and 1990, we found the principal cause for the measles epidemic was failure to deliver vaccinations to at-risk preschool-aged children at the appropriate age, particularly in inner cities. In 1990, the proportion of cases in preschool-aged children increased to almost half, the highest proportion since the start of national data collection in 1973. Most of these preschool children were unvaccinated. CDC believes a number of policy and resource barriers are disincentives to the immunization of preschool-aged children by age 2 and that these incentive grants will be successful in encouraging the removal of those barriers. The primary need is to make sure that vaccine can be delivered to the population most at need.

HEALTH OBJECTIVES 2000/DATA COLLECTION

Question. Dr. Roper, as you know, I sponsored the Year 2000 Health Objectives Planning Act (P.L. 101-582). This law authorizes funding to the States to help the States prepare to meet the Year 2000 Health Objectives. I sent you a letter requesting that monies be made available to begin this process in FY 1991, and you responded to my request that you are moving forward to implement this Act. Where are you at this point, and what do you plan for FY 1992?

Answer. Currently, we are proceeding with development of uniform health status indicators in conjunction with national public health organizations and with the official State health agencies. We plan to complete the design for the health status indicators by May 1991.

We are continuing our efforts to develop uniform data sets for the Year 2000 Health Objectives through a variety of activities including identification of sources of data for monitoring the objectives and through many technical assistance visits to States to develop their capabilities to collect the needed data. We are also continuing the development of data systems which permit the exchange of data between CDC and the States and which permits the rapid transfer of State data to CDC. Finally, we are continuing our activities in assisting States to develop State health plans.

During FY 1992, we intend to continue our efforts in developing uniform data sets and providing State health planning assistance. We plan to disseminate the results of our health status indicators development through the MMWR and through meetings of the varied public health organizations which are concerned with the indicators. We also intend to provide some funds to selected States to support their efforts to develop State health plans. The funds to the States will be FY 1991 funds -- about $35,000 per state. The number of States to receive these funds is not known at this point, but will probably be nine. We also intend to conduct workshops with the states to derive uniform data reporting systems consistent with the Year 2000 Health Objectives and to improve the accountability of the Preventive Health and Health Services Block Grant.

Furthermore, the FY 1992 President's budget requests an increase of $4 million within the additional $15 million proposed for the Preventive Health and Health Services Block Grant to improve the capacity of State health departments to conduct their own State health status assessments. This information can be used by the States to more efficiently target the director of disease prevention/health promotion programs and to monitor the progress of these public health programs in meeting their Year 2000 goals and objectives.

FARM HEALTH AND SAFETY

Question. The FY 1991 appropriation bill provided $19.8 million to continue farm health and safety initiatives and to provide for some expansion. In spite of the fact that agriculture is an extremely hazardous occupation, this is the first time that a

concerted effort has been made to directly deal with problems
affecting our nations' farmers and their families.

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Where do we currently stand on implementing these new initiatives?

Answer: CDC has initiated a comprehensive agricultural safety and health program in collaboration with universities, State health departments and other parties in 23 States. The objectives of the program are to identify and to prevent the causes of injury and disease among agricultural workers and their families through surveillance, research, and outreach and educational efforts. The following are major components of the program:

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Supported six States to conduct surveillance
identifying hazards to which agricultural workers are
exposed, the circumstances of exposures, and the health
status of these workers and their families.

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Supported eight State health departments to employ
nurses in rural areas to: promote safety and health
among rural families; assist in surveillance of
diseases and injuries; and provide safety and health
instruction in schools. We will support two additional
States this year.

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Established two Centers for Agricultural Research,
Education, and Disease and Injury Prevention. The
Centers are conducting prevention research and outreach
programs.

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Supported 15 land grant universities work with State and local health departments to increase dissemination of safety and health information to agricultural workers and to identify worker groups with special needs including minority and migrant workers. Funds will support an additional eight universities this year.

Conducted four programs in the upper mid-west to
provide cancer screening and early treatment for
agricultural workers and conducting research on
pulmonary health hazards and pesticide exposures to
farmers and their families.

Question. When can we expect to see some results from these initiatives?

Answer. Our various surveillance and intervention
activities, which were initiated last fall, should already be
beginning to improve health and safety conditions. It
several years before these activities are operating
but we should already be getting health and safety )
the hands of farmers, their families, and others in
assist these rural populations. We will be holding &
Generals' Conference on Agricultural Safety and Health
to begin building a national coalition of people and or
who will be instrumental in achieving effective national

and injury prevention in agriculture. We are also presently conducting research to improve the effectiveness of our recommendations and technology for preventing agriculture related injury and disease.

In 1993, we plan to evaluate the impact of our surveillance and intervention activities towards identifying and preventing the priority causes of injury and disease among people working in agriculture.

HEALTH OBJECTIVES / BLOCK GRANT

Question. During the FY 1990 oversight hearings on the budget, discussion centered around the Institute of Medicine Report that basically found that our public health system was suffering from a lack of national leadership and inadequate resources. What is your assessment of the ability of State, local and county health departments to meet the Health Objectives 2000 goals?

Answer. According to the IOM Report, the public health system of the United States presently suffers from fragmentation, a lack of clear objectives, and limited resources. While the problem of resources will continue to be problematic during the nineties, I firmly believe the direction provided by the Year 2000 Health Objectives and a national commitment to building the infrastructure of the public health system will do much to see that States meet their objectives. During my tenure as Director of the Centers for Disease Control, I intend to focus CDC's energy on enhancing the capability of State and local health agencies to meet the objectives.

Question. One program that provides support to State, county, and local public health departments is the Preventive Health Services Block Grant. Should funding for the block grant be increased as one mechanism for meeting the Health Objectives for the Year 2000 and to rebuild our State and local public health system?

Answer. I believe the Preventive Health and Health Services Block Grant is one of the most effective means we have for meeting the Health Objectives for the Year 2000. Consequently, the President's Budget has requested an additional $15 million in appropriations for the block grant for FY 1992 a 16% increase over FY 1991. Concurrently, we are developing a legislative proposal that directs the sole purpose of this grant should be to serve as a vehicle to achieve the Year 2000 Health Objectives.

FETAL ALCOHOL SYNDROME

Question: Dr. Roper, there are so many neonatal problems that are easily reduced through simple prevention activities. Fetal Alcohol Syndrome is one of these.

Over the past few years, we've learned a lot more about the enormous problem alcohol poses to the proper development of the fetus. A recent study by the University of California indicates that a large number of mentally disabled individuals in permanent

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