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DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, EDUCATION, AND RELATED AGENCIES APPROPRIATIONS FOR 1999
Wednesday, March 4, 1998.
AGENCY FOR HEALTH CARE POLICY AND RESEARCH
WITNESSES
JOHN M. EISENBERG, M.D., ADMINISTRATOR,
RITA KOCH, OFFICE OF MANAGEMENT, CHIEF, FINANCIAL MANAGEMENT STAFF
DENNIS P. WILLIAMS, DEPUTY ASSISTANT SECRETARY, BUDGET
Mr. PORTER. The subcommittee will come to order.
Continuing our hearings on the Department of Health and Human Services, we are pleased to welcome Dr. John Eisenberg, the Administrator of the Agency for Health Care Policy and Research. Dr. Eisenberg, this is your first appearance, is it not, before our subcommittee?
Dr. EISENBERG. It is, in this room.
Mr. PORTER. So, we definitely welcome you and hope you are challenged by your new job, which I imagine you are. Could you introduce Ms. Koch and then proceed with your testimony.
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Dr. EISENBERG. I would be happy to. I think you know Dennis Williams.
IMPORTANCE OF AHCPR
In some ways, this is not my first testimony. I testified before this committee for the Physician Payment Review Commission when I was chairing it. Ironically I was asked in the questions and answers what I thought about this agency, the Agency for Health Care Policy and Research, and how important it was for physician payment. And my response was that it was very important to guide the evidence that helps us to understand the way in which physicians practice. I still, obviously, feel that way or would not have left Georgetown to come and join the agency.
AHCPR RESEARCH AND DECISIONMAKING
I would like to talk today about AHCPR briefly and then talk about our budget. As you know, AHCPR focuses on research that moves biomedical discoveries like the ones generated at the National Institutes of Health into medical practice.
Our research bridges that gap between what our scientists know and what health care Americans receive. The decisions about health care in this country are very personal ones. Every one of us makes a personal decision but those decisions about health care are often made with help, maybe from a doctor or a nurse or a loved one, but they still remain very personal and individual decisions.
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What I want to emphasize today is that those decisions, those individual decisions, are made in the context of a very complex area, one of the most complex in modern life, the health care system. It is here that patients and clinicians usually do not have all the information that they need, sometimes do not have any of the information that they really need, to make the best choices among the alternatives that are available to them.
AHCPR'S MISSION AND CUSTOMERS
Our mission, as I see it, is to provide science-based information so that we can help with those decisions, so that we can improve decisionmaking by all the decision makers in health care. Those are AHCPR's customers, the people who are making those decisions.
They are patients, they are clinicians, they are health care system leaders, they are public policy makers in both the public and private sectors. They use this kind of information every single day to make decisions that have an impact on all levels in the health care industry, from an individual patient deciding on whether to have surgery, to the health plan deciding on what kind of new benefits it might offer. Our budget for Fiscal Year 1999 addresses these challenges that are faced by the agency's customers.
RESEARCH FINDINGS
Our research, as you know, is both conducted and sponsored by the agency and the vast majority of our funds go outside the agency to the best researchers in the country, people who compete for funds with grant applications and undergo peer review in the same way that NIH does.
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For example, one agency AHCPR-sponsored project found that we could cut the cost for antibiotics for people with pneumonia by two-thirds with no adverse effect on patient's health by a simple change in the way in which antibiotics are used. It is that kind of research that I think is so useful.
And ironically, before I joined the agency, I was chairman of the Department of Medicine at Georgetown. And, so, my name is still listed on a number of managed care plans in Washington, in which I participated. I still get their mail. A few weeks ago, I got a brochure from four health plans in the Washington area who had put together an educational program for physicians. This brochure was about this very AHCPR research that showed how better care can cost less. And that, I thought, was very satisfying for an agency which generates research that we want to see translated into practice in the private sector.
TRANSLATION OF RESEARCH
A very important component of the research that we do on outcomes and on effectiveness is not only sponsoring that research, but also being sure that the research gets translated to clinicians and to patients for their decisions about treatment, and also gets translated to plans so that they can make decisions about what they are going to cover.
One of our new programs deals with the evidence for what works and what does not work for a variety of different treatments and interventions.
EVIDENCE-BASED PRACTICE CENTERS
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Last Fall we named 12 evidence-based practice centers located around the country and we assigned the first round of topics to those organizations. We are expecting reports from the EPCS within a few months.
We expect the reports to be used by our partners. Each of those topics was nominated by either a public or a private sector organization who said, we need a public sector review of this material, an assessment of this material.
These are organizations in health care and medical societies. They nominated the topics because of their need to develop quality improvement tools, practice recommendations and educational programs to improve health care.
COLORECTAL CANCER EVIDENCE REPORT
One example of that is a sponsored project that we did on colorectal cancer. This project developed an evidence report that contributed to the Congress' decision to cover colorectal cancer screening as part of the Balanced Budget Act, and also contributed to HCFA's decision about how it would pay for colorectal cancer screening, another way in which this research gets translated into action.
PARTNERSHIPS
We recognize that need to get this information, this research information, out to our customers. One of the ways we do this is through formal partnerships.
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NATIONAL GUIDELINE CLEARINGHOUSE
For example, we have a partnership with the American Medical Association and the American Association of Health Plans to establish a National Guideline Clearinghouse. The NGC will provide one-stop shopping to Americans about the best practices in clinical care.
This is a clearinghouse that will be available on the Internet in the Fall. It will make existing practice guidelines developed by public and private sector organizations available to every doctor, every nurse, every patient, and every health plan who can use a computer.
In addition to the research that we do on this level, the clinical level, to help doctors and nurses and patients make decisions, I think it is very important for us to remember that there are health plans, system leaders in health plans and health care organizations, who are making similar decisions and need similar kinds of information.
CONSUMER ASSESSMENT OF HEALTH PLANS SURVEY
For example, last month, Secretary Shalala released the AHCPR Consumer Assessment of Health Plans Survey. This survey will help not only consumers, but also employer benefits managers, and those who are making decisions for group purchasers about health plans, choose the plans that are most satisfactory to the people who are in them.
I was very pleased when HCFA announced last week that it would use this survey, CAHPS, to survey Medicare beneficiaries. You, your staff, and all of us will soon have a chance to use CAHPS as well; the Office of Personnel Management announced that it will be using the survey, and we are looking forward to it spreading even further.
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Already several States and several private corporations are using CAHPS as a way of getting information to their people about the differences among the plans.
GOVERNMENT PERFORMANCE AND RESULTS ACT
We have developed a budget request for this year, for Fiscal Year 1999, under the framework of the Government Performance and Results Act, GPRA.
And let me say, that we have developed an internal evaluation strategy as well that will allow us to assess our progress in meeting the annual objectives so that we will know the impact of our research initiatives on the health care system. That is very important for our translation efforts.
We are pleased that we met our Fiscal Year 1997 GPRA goal in improving the timeliness of data that we collect in our Medical Expenditure Panel Survey.
The first release of this data for 1996 came out in April of 1997, a remarkably quick turn around for this kind of data and we have kept up that pace.
FISCAL YEAR 1999 REQUEST
In Fiscal Year 1999, AHCPR requests a total of $171,435,000. That is an increase of $25,000,000 over the Fiscal Year 1998 Appropriation.
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The additional $25,000,000 will allow AHCPR to expand our emphasis on research to measure and improve quality, and to collaborate, as I have already mentioned, with other public sector agencies and the private sector to improve health care in this country.
Our research is going to emphasize improving the quality of care for all Americans especially for those who are at the greatest need.
For example, we will devote $5,000,000 to concentrate on the cost, quality and outcomes of care for people who have chronic diseases and disabilities. We will devote funds for research and demonstrations to improve the quality of care for children, as well as evaluations of the effectiveness of State and local approaches to implementing the CHIP legislation.
We will support major new assessments of preventive services to provide information that will help all of the agencies customers that I enumerated earlier to make decisions about preventive services.
In addition, the Food and Drug Administration Moderization and Accountability Act gave our agency a new responsibility to support two Centers for Education and Research in Therapeutics.
These so-called CERTS will increase our knowledge about the new uses and risks of medical products through research, and will also help to prevent adverse effects of medical products and the consequences of those effects.
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CONCLUSION
Mr. Chairman, approval of AHCPR's budget request for Fiscal Year 1999 will ensure that we continue to have unbiased, reliable information. It will allow us to provide more and better unbiased and reliable information on cost-effectiveness and effectiveness of treatments for specific conditions, as well as strategies that will help us to translate the best science into routine practice, into every day medical practice in this country.
That will give us high quality care at an affordable cost. My colleagues and I will, obviously, be happy to answer any questions that you have.
Thank you very much.
[The prepared statement follows:]
"The Official Committee record contains additional material here."
Mr. PORTER. Thank you, Dr. Eisenberg, we appreciate your fine statement. Ms. Koch, I thought that Dr. Eisenberg was going to introduce you. I just want to welcome you as well. We appreciate both of you being here to testify.
INITIATIVE TO IMPROVE HEALTH CARE QUALITY
Dr. Eisenberg, $15 million of the $25 million you are requesting as an increase in Fiscal Year 1999 is to support a Secretarial initiative to improve health care quality. We thought that was already what you were doing. Isn't this just the status quo in a different wrapping? Tell me how this is different from what you do now and what are the outcome measurements for this initiative?
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Dr. EISENBERG. The theme is similar, of course, to what we are currently doing because we are already devoted to trying to develop better ways of understanding and improving quality. What we want to do is to devote this agency to generating better quality measures, which are in great demand by this country, as well as to understand better what works and what does not work in trying to improve the quality of care that Americans get.
Unfortunately, because of our budgetary constraints last year, Fiscal Year 1997, we were only able to award ten new grants. This year it looks as if we will be fortunate to be able to get to the 15th percentile on applications.
There are a number of talented American investigators in this area who, I think, have a tremendous amount to contribute to what we know about quality and what we know about ways of measuring it and improving it. Our request is formulated to take advantage of the talent among the investigators in this country to apply the science to better quality of care.
That is why we have asked for additional funding. Because of the passion that the Congress feels and the commitment that the Administration feels to improving quality of care research, we have asked for an additional $15 million in this area.
Mr. PORTER. So, you are just giving the request for an increase in funding a name because you are already doing the quality research in any case.
Dr. EISENBERG. Well, we are doing some of it. What we have done by giving it a name is to transmit the message as clearly as we can that this is a high priority for the agency, and that this is the area in which additional funding would be dedicated.
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NATIONAL OUTCOMES RESEARCH CONFERENCE
Mr. PORTER. All right. Your agency sponsored a national conference to chart the course for the next 10 years for investment in outcomes research. It was anticipated that the results of this conference would be published in the spring of this year. What is the status of the report and how will the information be used?
NATIONAL OUTCOMES CONFERENCE REPORT
Dr. EISENBERG. Well, the report is being finished now. We had the conference in the fall. The report, what we call the ''outcomes squared initiative'' or the outcomes of outcomes research, will be used in two ways. One way will be to help us target the areas in which we commit our resources to further research about outcomes and to understand where the research pays off the best. What kinds of outcomes research needs to be done?
That could be the measurement of outcomes. For example, how individual patients value various outcomes. Or the content areas, those diseases in which they need to measure outcomes.
But, in addition to that, one of the concerns that we all have is that this research be translated into improved health care. And, so, one of the other outputs of the outcomes initiative is to look at how we can take this research and get it translated into improved practices through education, through changes in health care organizations, through better information to patients, and through better information to physicians. I anticipate that the report will be ready within a couple of months.
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USE OF AHCPR RESEARCH FINDINGS
Mr. PORTER. This will, I think, help to pin down what you are talking about by perhaps your giving us some examples.
Your agency has invested in 14 original Patient Outcomes Research Team (PORT) projects and 11 PORT II Projects. These projects have generated numerous findings. For example, the diabetes PORT has demonstrated that for Type II diabetes, insulin treatment is significantly more costly and not always more effective than oral agents.
Like other PORT findings, the teams are working closely with professional organizations to get these results widely disseminated. Once these findings are made available, how do you know if, in fact, they are being used? And, in your response could you tell us first, if they are being used how do you measure the impact they are having, and second, if they are not being used, why they not being used?
Dr. EISENBERG. Well, first, are the outcomes of these patient outcome research teams useful and what are the outcomes? Let me give you a few examples of some of the reports that have come out recently. The Patient Outcome Research Team at Johns Hopkins, which focused on cataract disease, developed a measure for understanding the impact of cataract disease on individuals who have cataracts. It has been described as the best method of understanding both who will likely benefit from cataract extraction, as well as understanding the outcome and what the contribution of those outcomes has been. That measure is already beginning to be used.
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The second example is an outcomes assessment that was done at the Massachusetts General Hospital on prostate disease, in which the outcomes of benign prostatic hypertrophy were evaluated. A videodisc was developed to help patients to understand their decisions. We have already seen the impact of this study for example, with the urology community picking up on that measure of outcomes such that that article has now become the most quoted article, I am told, in the urologic literature. This is a new measure of the outcomes of prostate disease.
And we also understand that this videodisc, which is a way of translating the outcomes to patients so that it can help with their decision making, is being adopted by individuals who want to help their patients understand what the options are for them with prostate disease.
MEASURING THE USE OF RESEARCH FINDINGS
Mr. PORTER. But you are not actually measuring who is using it. You are saying it is out there, we put it out and we hear people are using it or talking about it, at least. How do you know if it is actually being used?
Dr. EISENBERG. Well, we have asked the investigators in each of those Patient Outcome Research Teams to monitor the degree to which their work is getting disseminated and is being used by people in the community. And so far, that is the best way that we have of tracking that, other than watching some findings become commercial products, which some of them have, of course, as they appear to have value to those who would like to translate them and make a commercial product out of some of those findings.
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But the process is really using the investigators because they are the ones who are most likely to understand the way in which this is being disseminated.
Mr. PORTER. See, this is the point at which we really want to provide some focus because in the past, and not necessarily applying to this agency, the measurement might be how many ports did you do how many reports were generated? Well, it does not matter how many reports are out there if nobody ever reads them or does anything with them. Right?
Dr. EISENBERG. Right.
RESEARCH'S IMPACT ON PEOPLE
Mr. PORTER. What we really want to get at is not how many reports have been done, but how many people's lives are being bettered by what has been accomplished. In other words, is it being used, is it being followed, is it actually being given to patients?
Dr. EISENBERG. Well, let me respond to that in two ways, because I could not agree with you more. In the several months that I have been at the agency that has been one of my own personal campaigns. We need to tell the story, to understand the story about what this agency's products have meant, not only getting the research published, but also doing something with it.
I keep reminding our researchers that when they have their articles accepted that is not the end of their obligation to the public sector. It is in some ways the beginning of their obligation to the public sector that they need to get that research translated into action.
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Mr. PORTER. And you need to determine whether it has been.
PARTNERS AND USE OF RESEARCH FINDINGS
Dr. EISENBERG. Yes. We need to determine whether it has been translated. I would go a step beyond that actually, and say that we are looking now to develop partners who promise us that the research, once we have funded it, will be used. So, that for example, with the Evidence-based Practice Centers, we have partners who have assured us that when the report comes out they will adopt and they will use the results. For example, the American Psychiatric Association and the Academy of Pediatrics, have said that when our report on attention deficit disorder comes out, they will use it.
We are also going to have the report from the schizophrenia PORT come out within a few weeks, and we have a commitment from the psychiatric community that it will be used. My sense is that we cannot just let it get out into the published literature——
Mr. PORTER. I would go a step beyond that and if it is used, is it efficacious in directing at the disease or syndrome that we are attempting to do something about.
Dr. EISENBERG. Right, right.
Mr. PORTER. In other words, what effect is it having on people? Not how many reports are out or how many people have read it or how many people are actually using it, but is it working?
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Dr. EISENBERG. Right.
Mr. PORTER. You need an evaluation all the way to the end.
NATIONAL GUIDELINE CLEARINGHOUSE
Dr. EISENBERG. I agree with you.
Mr. PORTER. Okay. At last year's hearing, your predecessor, Dr. Gaus, testified that the agency would soon be signing a partnership agreement with the American Medical Association and the American Association of Health Plans to jointly sponsor a National Clearinghouse of Clinical Practice Guidelines.
This clearinghouse is intended to provide an electronically-based catalog of every guideline in the country as well as a comparison of the guidelines. What is the status on this initiative?
Dr. EISENBERG. It is going right on schedule, in fact, a little bit ahead of schedule. The National Guideline Clearinghouse has contracted with an organization that is expert in putting these Web Sites together and in gathering the information.
We have had several meetings of a planning group, which includes the AAHP and the AMA, to design the site, to decide on what the criteria ought to be for entry into the site, and to be sure that we are following the schedule as it has been laid out and we are right on schedule. We expect that it will be available on the Internet in the Fall.
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USE OF THE NATIONAL GUIDELINE CLEARINGHOUSE
Mr. PORTER. Again, how do we determine whether professional societies and other groups will actually use the site and are they willing to finance any portion of its cost?
Dr. EISENBERG. Well, I am pleased to say that the AMA the AAHP have already begun to finance part of its cost. They are partners with us in this project. As for use, we have the usual way of measuring whether or not a Web Site is being used, of looking at hits. But that really does not tell us whether or not it has been translated into action.
We have met with a variety of specialty societies as recently, in fact, as last week in Chicago, to talk with specialty societies about the National Guideline Clearinghouse. We are letting them know it is coming and have begun to talk with them about ways in which they can enable their members to use it most effectively.
We started to anticipate the concern that you have, that we have as well, because we do not want this to just sit on the Web, we want it to get used. We will follow that up with measures of how satisfied people are with the Web, and what their impression is of how much they have been able to use it. We are looking now for ways in which we can look at its impact on actual practice patterns, as well.
NGC AND THE NATIONAL LIBRARY OF MEDICINE
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Mr. PORTER. How does this differ from what, say, the National Library of Medicine does?
Dr. EISENBERG. It differs substantially in that our role as a research agency is to generate the evidence reports and then to put them on the Web. We bring the guidelines together in a way that evaluates the degree to which they meet certain standards of evidence, of being evidence-based, and then collaborate with other organizations to make them available.
We have collaborated with the NLM because of their expertise in using Web Sites and getting informaiton to users. They have been enthusiastic about working with us in this area. But the content of the National Guideline Clearinghouse is an area in which we have, I think it is probably fair to say, unique expertise within the Federal Government. The Library of Medicine's expertise in using the Internet and using the Web dovetails nicely with ours. And, so, we are seeing it very much as a partnership where we bring the expertise, the content, and the medical practice area, and they contribute expertise in how the Web can be used.
Let me just say in addition, that one can get into this Web Site through NLM's site. We wanted to be sure that no matter how people come into the Web that they had ease in getting into the National Guideline Clearinghouse's Web Site.
CURRENT AVAILABILITY OF GUIDELINES
Mr. PORTER. If I go down, as I did, to a Community Health Center in inner-city Chicago, they have sitting there a television set or a monitor that's hooked into the National Library of Medicine. Do they not have these practice guidelines already available?
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Dr. EISENBERG. They do not have the guidelines available. They only have access to a small sample of guidelines. You have to know how to go to the various sites for each of these guidelines.
What the NGC will do that is different from what you just described is two things in particular. One is that the individual who wants to gain information about a particular problem that they, he or she faces, has to go to only one place on the Web, instead of having to be an expert and finding all of the different sites that they might have to find anywhere on the Web. That is one contribution.
But I think the most important contribution is that—and this really gets to your previous question about what value-added we bring to this—is that because of our expertise in evaluation of medical services and using the evidence-based approach, we are putting together a side-by-side analysis of the guidelines that are available. This analysis will show not only who put the guideline together and what the audience was, and who the patients were and how the study was done that generated the guideline; but also a side-by-side analysis that compares the content of the guidelines, so that if you wanted to know about a particular area, like colon cancer, you could do a side-by-side analysis of each of those and compare what every organization said about that particular question. You cannot get that by yourself.
DUPLICATION OF RESEARCH
Mr. PORTER. Well, we are going to have Dr. Lindberg here and I am going to ask him the same question because it seems to me there is a potential at least for some duplication there and if there is then we have got to make certain that one of you is doing what needs to be done and not both of you doing exactly the same thing.
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Dr. EISENBERG. Well, you are absolutely right. That is why Dr. Lindberg and I meet every month to talk about what our two agencies are doing.
Mr. PORTER. You know what his answer will be.
Dr. EISENBERG. Well, we believe that we ought to cooperate and collaborate because we have a lot to learn from each other, I think.
Mr. PORTER. Mrs. Northup, let me apologize. The last time I looked over in that direction, you were not there. So, please, proceed.
PATIENT SATISFACTION
Mrs. NORTHUP. I understand that you are doing the work we talked about last year of assessing different plans and the efficacy of them and the efficiency of them and patient satisfaction. I assume you are doing that for managed care firms?
Dr. EISENBERG. Well, we are not doing it for managed care firms so much as about them.
Mrs. NORTHUP. Assess them.
Dr. EISENBERG. Yes, yes.
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CONSUMER SATISFACTION
Mrs. NORTHUP. Well, I wonder if you know there are several consumer protection bills regarding HMOs that have been proposed in the Congress and in fact, the President has endorsed certain proposals, but I wonder if it does not make more sense to see what your research shows both in consumer satisfaction and price control before we begin enacting new legislation that affects these plans?
Dr. EISENBERG. Well, I agree with you fully about the importance of being able to do those side-by-side comparisons. In fact, the Health Care Financing Administration has begun to use the CAHPS, the Consumer Assessment of Health Plans Survey. They announced this a couple of weeks ago. The Office of Personnel Management is also using CAHPS and a number of programs around the country, States and private organizations are using it, as well.
What it offers us is a way of providing one of the things that many of the people who are concerned about consumer protection believe is the first step—that is more information, better information so that we can compare what people think about the different health plans.
I am pleased to say that between the time we answered this question last year and now, that the CAHPS survey is available. The State of Maryland, the State of Washington and others already have booklets developed using CAHPS that allow people to make choices about their health plans.
To the degree that CAHPS addresses one part of the consumer protection agenda, which is getting good information to people so that they can make choices, I think that it is a very important part of that agenda and your bringing them together, I think, is an important and correct way to link them.
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CONSUMER PROTECTION INFORMATION
Mrs. NORTHUP. Of course, when we talk about in enacting anything like consumer protection information it is as though it is going to affect the private sector insurance market only. However, many of the Medicare and Medicaid plans, Medicaid in particular, in Kentucky, have gone to HMOs processes and any sort of legislation that we pass that would profoundly affect the price of those is also going to affect the Federal budget and our ability to access more health care for people who are in those programs. Would you agree?
Dr. EISENBERG. Well, on the price, let me just say that the Consumer Assessment of Health Plans Survey deals more with satisfaction about the care that people receive than——
Mrs. NORTHUP. And outcomes?
Dr. EISENBERG [continuing]. And the outcomes that they receive, their perception of the outcomes that they receive, of course, which is an important part of outcomes. It does not focus as much on the price issues. What it does is to say we can measure the price. What we have had trouble measuring in the past is satisfaction and outcomes. This is a step towards balancing the measure of price so that we do not choose on price alone, but so we can choose on price and quality.
CONSUMER SATISFACTION
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Mrs. NORTHUP. Actually I think if we looked at the HMOs plans that are under state jurisdiction and we sort of proposed consumer health or consumer protection mandates, it is very easy to see what it does to the price.
Because the state plans have experienced what happens to the price. I think what is important for us to know before we do anything in Federal policy affecting any other policies is to find out whether, in fact, there is an outcome problem or a consumer satisfaction problem.
And that is why I am eager to know what your study showed.
Dr. EISENBERG. Well, that is obviously what this agency is all about—measuring those outcomes and trying to get that information to individuals. I would be happy to show you what the CAHPS survey shows. It is different, of course, State-by-State because the plans do differ State-by-State.
But what it looks like is sort of like what you are used to seeing when you buy a car. They have the various characteristics of the plan so that you can see how they do on the various aspects of delivery of care that are important to you.
Some users report it in stars, some report it as those circles that have different quadrants built in. But I agree with you that it is a very important part of being sure that people can make choices among their plans.
COORDINATION OF RESEARCH
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Mrs. NORTHUP. The Office of the Inspector General I know is also doing this type of work. Are you all coordinating your results?
Dr. EISENBERG. Not with the Office of the Inspector General. No, not with the Inspector General.
Mrs. NORTHUP. Well, I might suggest that, you know, if we have two agencies doing the same type of research it might be interesting to have some coordination, some idea.
CONGESTIVE HEART FAILURE
Let me ask you another question. Last year, this subcommittee included report language regarding congestive heart failure. I had specifically brought that up with my colleagues concerned about what we know as the ''stroke belt.''
This particularly effects Kentucky. We have a lot of rural health service and the availability of, for example, cardiology specialists in rural health is limited. And the suggestion by this subcommittee was that we link a teaching hospital on practice, a hospital that has a practice dedicated to that service and rural health care providers with cardiologists in these centers, so that the most advanced practice would be available to rural communities without the increasing cost of somehow attracting those practices.
I just wondered if you had been able to do any work related to this? I mean I know that you all have grants that support this type of work and I just wondered if you had concentrated any of that in the ''stroke belt''?
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STROKE BELT RESEARCH
Dr. EISENBERG. A number of the projects that we are doing relate to the topic that you have raised. One of them is a project that is designed to evaluate the recurrence of stroke, ways in which we can prevent the recurrence of stroke through the appropriate use of anticoagulant drugs, and getting physicians to do what we know they should be doing in terms of reducing recurrence of stroke in that way.
One of the major factors that leads to stroke is atrial fibrillation, irregular beat of one of the chambers of the heart. We have some projects that we funded in that area as well, which should reduce the incidence of stroke.
We also have a guideline that the agency has produced in the past that looks at what should be done in the area of congestive heart failure.
And I have had personal conversations with the American Heart Association and the American College of Cardiology about the need for us to collaborate with them to develop additional information that would be available to practitioners so that they can help to reduce the stroke.
DEMONSTRATION STUDY
Mrs. NORTHUP. I am hurrying because I have to chair the meeting across the hall. But I think I am specifically asking about something else.
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And that is the demonstration study or a grant that would be targeted to where we already have a high incidence and a under-served area.
And about trying to put together expertise in a very efficient, effective way to communicate either by telephone or computer or whatever the most advanced medicine. I think what you are talking about is practice parameters, practice practices that are good medicine.
What I think I am thinking of is that there are those patients that do not respond as you expect and so forth, and they are not in Louisville, Kentucky, they are in rural areas and general practitioners do not have the expertise to, even if they had followed what was in the guidebook, and trying to bring advanced medicine specific to the patient. I just wanted to bring that to your attention.
PEER REVIEW
If I could just ask you one more question. It is about your research and I know you are an outcome-based agency. And I just wondered if you use peer review on the studies that you have conducted and the importance of peer review?
Dr. EISENBERG. Yes, we do. Peer review is a critical part of what we do. All of our grants are reviewed by experts from around the country in exactly the same way this is done at the NIH.
Unfortunately, in Fiscal Year 1997 we were only able to fund down to about the 8th percentile.
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This year we are hoping we can do a little bit better than that. That is one of the reasons why we have asked for additional funding for this year—so that the peer review process can approve and fund some grants in the future.
Mrs. NORTHUP [presiding]. Thank you. I am sorry. We are adjourned until 10 o'clock tomorrow morning.
Thank you very much for your testimony.
[The following questions were submited to be answered for the record:]
"The Official Committee record contains additional material here."
Thursday, March 5, 1998.
CENTERS FOR DISEASE CONTROL AND PREVENTION
WITNESSES
DR. CLAIRE V. BROOME, M.D., ACTING DIRECTOR, CENTERS FOR DISEASE CONTROL AND PREVENTION
WILLIAM GIMSON, DIRECTOR, FINANCIAL MANAGEMENT OFFICE, CENTERS FOR DISEASE CONTROL AND PREVENTION
DENNIS P. WILLIAMS, DEPUTY ASSISTANT SECRETARY, BUDGET, DEPARTMENT OF HEALTH AND HUMAN SERVICES
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Introduction of Witnesses
Mr. PORTER. The committee will come to order.
We continue our hearings on the budget of the Department of Health and Human Services, and are pleased to welcome this morning Dr. Claire V. Broome, the Acting Director of the Centers for Disease Control and Prevention.
Dr. Broome, we're very pleased to have you with us here today. We're sorry to have lost Dr. Satcher to higher pursuits, perhaps, within the Department, but I know he'll continue his interest in CDC from his new position.
We appreciate your standing in today, pending the nomination of the new Director for CDC. And obviously, we on this committee appreciate very much the work that CDC does, and consider it a very high priority for our country.
I'd also like to welcome Jay Dickey to our subcommittee today. Nice to have you here, Mr. Dickey. [Laughter.]
Mr. DICKEY. Thank you, sir.
Mr. PORTER. Dr. Broome, why don't you proceed with your statement, and then we'll have questions.
Opening Statement
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Dr. BROOME. Thank you, Mr. Chairman and members of the committee.
It's a real pleasure to be here with you today to speak with you in support of the President's budget request for the Centers for Disease Control and Prevention for fiscal year 1999 in the amount of $2.45 billion. This represents an increase of $78.6 million, 3 percent over the fiscal year 1998 appropriation.
I also really want to thank you, Chairman Porter, and the subcommittee, for your ongoing support of the Nation's prevention agency.
I'm confident that each of you here today would agree that prevention is vitally important to the health of this Nation. Although it's crucial to be able to treat and cure sick people who become injured or disabled, we would all prefer to remain healthy in the first place. Public health activities are essential to the health, well-being and productivity of this Nation.
The fact is that as we approach the turn of the century, we could be doing more for the quality of the Nation's health. Millions of people are still dying prematurely or suffering unnecessarily from preventable disease, injury and disability.
What I want to emphasize today is what I call the prevention gap. In many instances, we already know what works to prevent diseases and injuries. And yet, there's a disconnect between knowing and doing. We're not always putting our knowledge into practice.
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Let me give you some examples of CDC's prevention strategies that work, and to point out what we still need to discover to close the prevention gap. We know how to protect our older citizens from the suffering and untimely deaths associated with influenza. Influenza vaccine works. It works not only to prevent deaths, but to help seniors maintain healthy function and quality of life.
Yet more than 18,000 died unnecessarily of flu-related causes last year. Over 40 percent of persons 65 and older, the fastest growing age group in this country, did not receive influenza vaccine in the past year. Even worse, more than 60 percent of African-Americans went unprotected. That's a prevention gap.
We also know how to protect our children and grandchildren from certain birth defects. Folic acid works. Each year, 4,000 babies are born with the life-threatening birth defects spina bifida and anencephaly. We've known since 1991 that at least half of these cases can be prevented if women of child-bearing age consume adequate amounts of the vitamin folic acid. But 75 percent of women of child-bearing age still do not get enough folic acid in their diet.
We know how to help prevent today's healthy young people from becoming tomorrow's victims of heart disease and stroke. Cardiovascular disease is the leading killer for men and women and across all racial and ethnic groups. Cardiovascular disease is responsible for over 960,000 deaths each year.
Physical activity and proper nutrition work. Research has shown that moderate physical activity and a healthy diet can help protect Americans of all ages, not only from heart attack and stroke, but also diabetes and even some cancers.
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Yet poor diet, coupled with lack of physical activity, remains the second leading preventable cause of death in this Nation.
Having the basic scientific knowledge about effective preventive measures is only half the battle. Scientific findings are worth little if they sit on a shelf. We must put our scientific knowledge to work for people if the public's health is to improve.
We believe that CDC is in a unique position to close the prevention gap. We have the ability to conduct prevention research to close the gap between knowing what works and knowing how to turn that scientific knowledge into effective programs.
We also have the scientific ability to answer new questions about how to prevent disease, injury and disability. Then, very importantly, we have strong long-term collaborations with State and local health departments, health care institutions, other community organizations and private practitioners, the people on the front lines who can deliver prevention programs and practices directly to your communities.
The President's budget request includes funding increases to CDC in five critical areas. These increases will help us move from knowing what works to putting that knowledge to work.
Food safety. The President's budget includes a $5 million increase to support activities under the Food Safety Initiative. Each year, an estimated 6 to 33 million Americans develop a food-borne illness, and 9,000 persons die as a result. The annual cost attributed to food-borne illness is $5 billion to $6 billion.
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This increase will enable CDC to expand the National Early Warning System for detecting food-borne illnesses, and enhance links between Federal and State laboratories with sophisticated computer technology so that we can identify organisms which may be causing food-borne disease in multiple different locations.
We know how to increase the safety of America's food supply. With your help, we can act.
Adolescent smoking and health. The President's budget includes a $46 million increase for our continuing struggle to keep the next generation of young people from starting to smoke. Smoking is the number one preventable cause of death in this country, resulting in 420,000 deaths each year.
In addition to this preventable loss of life, medical costs were estimated to total $50 billion in 1993. Studies show that over 80 percent of adult smokers became regular smokers before the age of 18. Each day, to our national shame, over 3,000 young people begin smoking.
The budget increase will allow CDC to significantly increase grants to States for their smoking control programs. This will include all States, both the States that participated in the National Iinstitutes of Health (NIH) American Stop and the States Smoking Interventin Study (ASSIST) supported through CDC's Initiative to Mobilize for Prevention program. Results from these and control of tobacco use (IMPACT) programs have defined the type of anti-tobacco public health program that will help us reduce youth tobacco use, exposure to second hand smoke, and help adults stop smoking.
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We know ways to help protect young people from addiction to nicotine. With your help, we can act.
Eliminating disparities. The President's budget includes a total of $80 million for the Department to support a major goal in his initiative on race. Of this amount, CDC would receive $55 million to address the President's ambitious goal to eliminate disparities in health status suffered by racial and ethnic minority populations by the year 2010.
One target of the initiative is HIV/AIDS. It is appalling that the rate of AIDS is more than seven times higher for African-Americans than for white Americans. We need serious attention to improving our prevention programs to eliminate this disparity.
Because of its experience in conducting prevention research and programs, CDC will play a major role in the President's race initiative. CDC will help conduct a series of research demonstration projects in communities to address six areas of identified health disparities. HIV infections, infant mortality, cancer, cardiovascular disease, diabetes and child and adult immunizations.
We know we can accomplish this challenge, as shown by the significant gains in childhood immunization rates of minority children, where we have essentially eliminated health disparities. We know that we can reduce the extra burden of disease borne by minority populations. With your help, we can act.
Emerging infectious diseases. The President's budget contains $79 million, an increase of $20 million, to help combat emerging infectious disease. You've only to listen to the nightly news to know that the Nation remains vulnerable to deadly infectious diseases. Terms such as hepatitis C, Ebola virus, avian flu, and antimicrobial resistance have become household words.
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Hepatitis C, only recently identified, accounts for 8,000 to 10,000 deaths per year. And yet most of the 3.9 million Americans chronically infected with hepatitis C virus are unaware of their infections.
The requested budget increase will be used to expand the Nation's emerging infectious disease early warning system in as many as three additional States, for a total of 33 States. These efforts will strengthen the surveillance network and capacity of State and local health departments to respond to infectious diseases by increasing the speed at which outbreaks can be detected, investigated and controlled.
With your help, we can do it.
Prevention research. While we have many proven prevention strategies, such as the ones that I've mentioned, and are implementing successful programs based on these, there's still much that we don't know. We need prevention research to bridge the prevention gap. We need research that can help transform findings from bench level research into prevention programs that reach people, and research that can tell us about the effectiveness and the cost effectiveness of those programs.
The President's budget contains $25 million for a new prevention research program at CDC as part of the Research Fund for America. With this funding, CDC will support extramural research in academic health centers, such as schools of public health and medical schools, local and State health departments, and other community organizations.
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As illustrated by chart one, which is the only chart I'll be using in my presentation, we thought it would be helpful to look at the kinds of questions we feel prevention research is needed to answer. There are very pragmatic questions.
How do we keep organisms such as cryptosporidia and E. coli from invading our water and food supply? What factors motivate workers and employers to adopt protective work practices? How is hepatitis C virus transmitted among adults with no history of injection drug use or blood transfusions?
How can we use what we know about the health consequences of smoking, obesity and unsafe sex to help people choose healthy lifestyles? Can we prevent the chronic disease complications of infectious diseases, such as cervical cancer or ulcer disease, a fantastic new opportunity for prevention?
We know that prevention research is needed both to discover new ways to prevent health problems and to help us move knowledge into practice. With your help, we will do it.
Mr. Chairman, with your support for the President's budget request of $2,457,000,000 for CDC, you can help us close the prevention gap. CDC has the unique capacity to move from discovery to action. We can move research findings quickly to prevention programs located in communities throughout this country—programs that help people remain healthy.
With your help, we will be able to move more prevention know-how into practice.
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Thank you for this opportunity to appear before the committee. I'll be happy to answer any questions you may have.
Mr. PORTER. Dr. Broome, that was an excellent statement, and you organized it very well, and covered a lot of ground in a very short time.
''With your help, we can do it'' may be fairly close to lobbying. [Laughter.]
PREVENTION EFFORTS TARGETING CHILDREN AND YOUTH
But we got the message. [Laughter.]
I want to begin by asking a question, because much of, all of what you really said, how do we put our knowledge into practice, how do we gain additional knowledge, which was the last part, but how do we put the knowledge that we have into practice, and what you're saying, of course, is that many of our problems, certainly not all, but many of our problems in our country are problems of lifestyle that, if we can get our people to exercise more, use proper diet, have safe sex, not use tobacco and drugs, that people are going to be a lot healthier and a lot of lives are going to be saved.
In a free society, we can't make them do those things. We can narrow the use of tobacco in certain ways, we maybe can even outlaw that. But like drugs, even outlawing something doesn't necessarily change people's lifestyles, if they want to do it, they'll probably find a way to do it.
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Many people believe, and Dr. Ernst Wynder is certainly a leader in this area, that what we have to do is get to our kids at an early age in their lives with these kinds of messages, and attempt to change the kind of lifestyle that they may otherwise be led to engage in.
I wonder if you can lay out for the committee, what efforts do we have that reach children specifically, and are they being effective at all?
Dr. BROOME. We agree with you and Dr. Wynder that this is a very important approach. That is why we have been very active in supporting comprehensive school health education programs, which attempt to educate young people, but also make them able to understand the risks and benefits, to understand the messages that they get from society that smoking is cool, and evaluate whether it's really cool to choose something that will have such far-reaching health consequences.
We do have support for comprehensive school health education currently in 14 States, and we are working with all States in providing technical assistance on school health education programs.
[CLERK'S NOTE.—The witness clarified that the correct number is 13 States.]
We have also done very rigorous evaluations of the effectiveness of school health education programs, and have shown that these are effective in decreasing use of tobacco among seventh graders.
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I'd also like to make one more general comment. I think there is understandable skepticism about the difficulty of changing human behavior. Because we all know how hard that can be. That's why I think it's really important to look at our successes, and specifically in the area of tobacco use. Since Surgeon General Luther Terry's report came out, the United States has experienced a substantial decline in adult smoking, which is not seen in Europe or other countries where there has not been the same emphasis on the health impact of smoking.
Similarly, we have seen a dramatic decline in motor vehicle fatalities. Some of that is highway engineering, some of that is State laws regarding seat belt use, some of that is changes in cars. But some of it is changes in personal behavior, in terms of seat belt utilization.
So I think we do have some successful models.
Mr. PORTER. Excuse me, but a lot of that is related to drunk driving and the crackdown by States on drunk drivers across the country, I believe.
Dr. BROOME. I think that's correct, as well. It's again an example of how sustained, organized attention to educating people around these problems and thinking about creative solutions can be effective.
USE OF MASS MEDIA FOR HEALTH EDUCATION
Mr. PORTER. Okay, but let me ask a question. It seems to me that education programs in schools are fine. But the medium that really reaches young people in our country and reaches all people in our country is the medium of television. And let me ask you a question about how CDC uses television and radio to get messages out on public health. Do you have to pay for those?
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Dr. BROOME. We really have not had the budget capacity to support paid media advertising. However, we do think——
Mr. PORTER. So who does it? Because there are public service statements made on radio and occasionally on TV, coming from CDC. Is that the stations absorbing the cost? Is it the Ad Council? Who does these things?
Dr. BROOME. Let me make two points. One is that for example, in the tobacco area, we see advertising as part of a comprehensive campaign to educate the public, and particularly teenagers, about the risks of tobacco.
We have a clearinghouse where we obtain media announcements developed in California, Arizona and Massachusetts with funding from their excise tax. And we make those very professionally produced and tested messages available to anybody who would like to use them. So we do provide a distribution service, if you will.
We also do rely on donated public service announcement time.
Mr. PORTER. But we don't buy any time anywhere?
Dr. BROOME. My understanding is that to date, CDC has not purchased media counter-advertising. This would be part of our initiative for controlling youth tobacco smoking.
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Mr. PORTER. See, I believe, and I know a lot of my colleagues don't believe this, but I believe that the people who use our public airways and are licensed to do so have a responsibility to the public, and the least they can do for us is carry these announcements, if necessary, on a mandatory basis, so that we can reach people with a message on a medium that they are attuned to.
It seems to me that we do not do a very good job of combining your responsibility with the responsibility of our television and radio stations to help you get your message out to people, particularly to our young people. I think we have to have an initiative in that area, and I know some people say, ''well, you know, maybe we'll have to pay for all that time''. But it seems to me there ought to be a way of working it out with the networks and the media representatives to help you get this message out.
Influenza, you talked about, 40 percent I think you said of our seniors who would be at risk are not vaccinated. Is that right?
Dr. BROOME. Yes.
Mr. PORTER. That's incredible in a country like this. If you can prevent illness and death, people I think would, and reach people with the message that these things are available, I think we're doing a very bad job of getting from where we are in our knowledge base to getting people even information that they need to make a wise choice in respect to health issues, and particularly getting a message to our children.
Dr. BROOME. I can only agree with you. Although if you would permit me to make two other points. One is, in addition to advertising, there's a very innovative strategy for use of the media which we would like to explore further.
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Jay Winston at Harvard has worked with Hollywood producers to introduce messages about the importance of a designated driver into the actual content of TV shows. And therefore, it doesn't look as much like, here's an ad preaching to you. It looks like part of the standard norms. And we think this can be a very powerful approach to getting public health messages across. We are looking at that with other areas.
Mr. PORTER. Somehow we need a whole initiative, and I don't know whether it's Dr. Wynder's initiative, or one that would be brought forward by this Administration, but I think we need an initiative to reach young people in this country, and get at least their generation on the right track. I think we would save billions of dollars in health care costs over the long term and have a lot happier and healthier population if we did it.
Mr. Bonilla.
Mr. BONILLA. Thank you, Chairman.
Welcome, Dr. Broome. It's a little unusual to not see Dr. Satcher sitting there. I've worked with him for so many years now on so many projects on the good work you're doing at CDC. Bill's almost extended family in our office, I think we've done so much work with him over the years.
RACE AND HEALTH INITIATIVE
I want to say first of all that not just as a Congressman, but as a citizen of this country, I'm proud of what the CDC has done historically, and hope that the work can continue. On this subcommittee, we've had strong bipartisan support for what you do.
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I want to start out, however, on cautioning CDC on delving into areas that might stretch the dollars even thinner than what you're already facing. We want to make sure the dollars that go to CDC go for legitimate medical research and disease prevention and continue the success stories. We read stories about flu hunters that have combed the globe and are oftentimes, with support with everyone at CDC.
But when I hear initiatives like you outlined in your opening testimony about a race initiative, I'm concerned about that. Because CDC already does a lot of good work in economically depressed areas. I'm concerned that the Administration and others are split on this opinion, but I believe this is a great degree of bogus effort.
I can cite for hours if necessary good prevention programs that already exist in Hispanic and African-American communities. Mr. Stokes and I have worked on this aggressively on this committee. But I want to just be careful that it's not part of a political effort just to pander to minorities in this country that has little substance.
So let's be proud of what CDC is already doing and continue that, but be careful of political agendas that are occurring at a higher level. And I don't know if you want to respond to that or just accept that as a statement.
Dr. BROOME. Well, Mr. Bonilla, thank you for your comments and support of CDC. We really appreciate that.
I would like to say that the eliminating disparities initiative that Health and Human Services is proposing has very specific target goals, to have impact on health in minority communities. And yes, it very much builds on what we already are doing.
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But I see it as an accountability, a way of saying, it is unacceptable to have higher rates of disease in minority communities than in the community as a whole. And we need to challenge ourselves to eliminate those disparities.
Mr. BONILLA. Well, my contention, again, is that CDC is already doing this. So this new race initiative is just again a bogus effort to try to pander politically to minority groups in this country.
And let me tell you, I can speak from those neighborhoods. My Congressional district is almost 70 percent minority, when you combine my Hispanic and African-American populations. There are a lot of good programs going on down there, either directly related or indirectly related to CDC, because we have some outstanding medical research facilities in that area as well.
DIABETES CONTROL PROGRAM
Related to that, last year we discussed the implementation of CDC's diabetes control program. And as you know, Texas has applied for a diabetes control grant to serve the more than 850,000 Texans suffering from diabetes.
On page 86 of your budget justification, you state that about 14 to 15 States will be supported this year at the comprehensive level in their development of diabetes control programs. How many grants have been awarded so far?
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Dr. BROOME. The expertise of the chronic disease center informs me that we have some funding for all States to have at least core capacity in diabetes. Five States will be funded for comprehensive diabetes control and prevention programs.
Mr. BONILLA. Doctor, when do you expect the grant awarding process to be completed?
Dr. BROOME. For this year, the grants will be completed near the end of the fiscal year, so that would be September.
Mr. BONILLA. I understand that CDC and NIH, the Joint Diabetes Education Program, is now underway. Would you elaborate on the current status of this project?
Dr. BROOME. We are very enthusiastic about this joint effort with NIH to have a national diabetes education project, which mirrors the kind of success that has been had with education projects in other chronic disease areas. We have been jointly funding this, and it is well underway.
PREVENTION EFFECTIVENESS
Mr. BONILLA. I want to get into another area that you talked about. We all agree that prevention is so critical in this day and age. In fact, it's mind-boggling to me that with all the warnings about smoking, with all the warnings about diabetes prevention, with all the warnings about obesity, that people still choose to ignore this. If you teach a person something 10 times, 20 times, 30 times, over and over, do we reach a point where we're wasting our effort, where we're wasting money?
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In this day and age, with the media exposure we have to public service advertisements and the things that doctors, everyone who sees a doctor gets the advice from the authority face to face. And I'm just flabbergasted that more people in this country are not listening to what we're telling them. Every cigarette pack has a warning sign on it. In Texas, we have a law now that minors face if they buy cigarettes illegally. And I support that.
But I'm concerned now, again, that some of these initiatives like the additional anti-smoking initiatives are just throwing money away, again, for a politically correct agenda that really isn't going to make a difference.
Dr. BROOME. I think that there's a lot of difference between putting information out and having an effective prevention program. I'd like to point out several ways in which we think we can make a difference.
Let's take the example of physical activity. And I think we all are very aware of the couch potato image that unfortunately is all too prevalent in this country. The Surgeon General's first report on physical activity put together a lot of scientific information about the risks.
But the most important step forward was informing people that they didn't have to go out and run marathons in order to get the benefits of physical activity. Moderate physical activity also provides substantial health benefits. And that moderate activity can be very much part of your daily lives, taking the stairs instead of the elevator, walking the dog a little more actively.
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And we're trying to follow up on that report with messages that are appropriate for different groups. For example, arthritis sufferers can very much benefit from moderate activity. We have a randomized controlled trial of the arthritis self-help course in which we've shown a decrease in doctor visits and a decrease in pain with a comprehensive self-help education course which teaches arthritis sufferers what they can do to make their arthritis more manageable.
So I think we have some sort of specific instances where doing a better job of identifying the right messages, of working with groups, can produce benefits from that knowledge.
Mr. BONILLA. I know I'm out of time now, but just as a closing comment, again, related to what we're talking about, I'm picturing now someone that I know back in San Antonio who has, is a single person, has no children, lots of time, and understands clearly what some of the negative impacts are of, number one, smoking, which this person does, and lack of exercise, which this person is guilty of not doing.
Yet, in spite of being educated over and over and over again, she's now getting into her 40s, and still would rather be the couch potato.
So I wonder, at some point, what do you say, give up on that person, there is nothing you can do. Can you spend that dollar instead to develop a great vaccine for something else? It's a tough choice, but to put it into something else.
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I don't expect you to respond to that, because I'm out of time. [Laughter.]
Mr. PORTER. Thank you, Mr. Bonilla.
I want to advise members of the subcommittee that we're proceeding under the eight minute rule, and also that we are following the rule of the subcommittee that those who are here at the beginning of our hearing will be recognized first, and then those who arrive during the course of the hearing will be recognized in the order of arrival.
The problem I have is that all the people who were here at the beginning are Republicans, and all the people that arrived late are the Democrats. [Laughter.]
Mr. PORTER. So I guess perhaps—it's not usually that way. It's not usually that way, but let me say, maybe by enforcing the rule we'll change lifestyle here, and——
[Laughter.]
Mr. PORTER. Mr. Dickey.
Mr. DICKEY. Thank you, Mr. Chairman.
PREVENTION RESEARCH
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Hi, Dr. Broome. I've got an interest in prevention, and I note in your statement that we have only 1 percent of $1 trillion in our U.S. health care budget to spend on prevention. I'd like to talk about it in terms of it being an investment. And if I'm going to make an investment in something, I'd like to know if there's a return.
Can you tell me just generally, not specifically about anything, if we as a Nation double our investment in prevention, what type of return will we get?
Dr. BROOME. Well, I will avoid going into columns of numbers. But I would answer that we have two categories. First of all, we think it is very important to answer that question, to look at what is the cost effectiveness of our prevention activities. And in fact, we have a group which provides expert consultation to all of our programs in order to assess the cost effectiveness of those programs.
Prevention interventions, you could broadly divide into two groups. One actually saves money. For every dollar that we spend on immunizations, the country saves money. Between $6 and $20 per dollar spent. So that's a pretty good investment, I think anybody would agree.
There are other cost saving interventions, such as diabetes education for prevention of blindness and kidney disease, and treatment of chlamydia infection to prevent infertility and pelvic inflammatory disease. Those have been shown, with good documentation, to save money for every dollar invested.
But I think it's a mistake to hold prevention to a higher standard than medical care. We don't ask, does heart surgery save money? We say, this person needs heart surgery, and we're willing to invest, as a society, the money in that heart surgery.
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I would argue that prevention is a good investment, that people, I think, are willing to spend money to have a healthy life, to prevent the occurrence of that heart attack. What we are trying to do is provide the information about how much do you have to invest to get a year of healthy life for the different kinds of prevention interventions. And they compare very favorably to many health care interventions.
Mr. DICKEY. Mr. Bonilla, my colleague, was saying people know what they should do, and still don't do it. Now, I'm still looking at this thing from an investment standpoint. Whether or not we can spend the money to inform is one thing, and but it seems that we should then somehow encourage and give incentives to change behavior.
What we need to hear, or what I need to hear is, if we do that, can you say, looking at the whole picture, that we will in fact win the battle, or at least make some gains?
Dr. BROOME. Well, this is an excellent example of why we feel prevention research is so important, that we don't want to just keep telling people over and over and over in ways that do not result in a change in improvement in health. And let me give you an example in the injury area of how we've looked at different ways of trying to change behavior. In this case, use of bicycle helmets.
We have, first we supported the research that showed bicycle helmets are 85 percent effective in decreasing head injuries due to bicycle accidents. But then we said, well, it's not so easy to get kids to wear bike helmets. How can we encourage them to really use these helmets?
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And first we looked at education programs, at giving away bike helmets, to make no cost to actually having the helmet. But we also looked at the impact of States and localities who chose to pass legislation requiring bike helmet usage in children.
The State of Oregon did a very effective research project showing that not only did helmet usage go up after the State passed a bike helmet child use law, but head injuries went down. So we think it's important to look at the range of different ways we could use.
Mr. DICKEY. Let's talk about obesity. You mentioned diet and exercise. Now, I don't want you to make any personal references to me in this answer, if you don't mind. [Laughter.]
But there are numerous things, numerous diseases that you avoid by not having obesity in your life.
Now, how can we give incentives for people who know, speaking from personal experience, who know it's wrong to be obese? What type of incentives can we give to get people to lose weight, to lose fat content?
Dr. BROOME. We think the most effective strategies to reduce obesity are in fact the improved diet and physical activity, that those two strategies together have been, although it is a very difficult problem, it can be effective in reducing obesity.
The issue of how to effectively have people understand that and implement it is very difficult.
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Mr. DICKEY. Understanding is one thing. I'm not asking how we should inform.
Dr. BROOME. Exactly.
Mr. DICKEY. How do we give incentives to change behavior? How can we as a government give incentives? How can we as a Nation give incentives? Do you have any thoughts on that?
Dr. BROOME. I think that this is an area which we really only recently had substantial funding for. And we've actually reorganized in the chronic disease center to put an emphasis on this. So I guess my answer would be, we don't have the answers. We do think this is a high priority area where we'll be looking at what works. If you could ask us next year, we hope we'll have some answers.
MEASURING HEALTH STATUS
Mr. DICKEY. Okay, let me do this. Name me some measurable items of good health. I'm probably saying it wrong. That you can actually measure without going into the hospital and being admitted to measure your blood pressure for example.
Dr. BROOME. Blood pressure, you can take a history of physical activity, of use of immunizations——
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Mr. DICKEY. Physical activity is subjective, though, isn't it? It's the report of the patient?
Dr. BROOME. Right.
Mr. DICKEY. Okay, now, let's talk about things that are objective, if we can.
Dr. BROOME. Weight.
Mr. DICKEY. Weight. Thank you.
Dr. BROOME. Weight and height, which tell you together what the body mass index is.
Mr. DICKEY. Cholesterol.
Dr. BROOME. Well, cholesterol takes a lab measurement, but that's certainly one of——
Mr. DICKEY. It is objective, and that's not a real big cost, is it?
Dr. BROOME. No, and we think that's an important part of preventive health services.
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Mr. DICKEY. And what other items could we measure objectively without a great cost? Is there anything else?
Dr. BROOME. Dr. Gayle wants me to be sure and mention sexually transmitted diseases, which we can measure objectively.
Mr. DICKEY. No comment. [Laughter.]
Dr. BROOME. And I would argue that in fact, self-reporting, although not perfect, has been shown to be reasonably reliable. People, there's sort of a fudge factor, but you can——
Mr. DICKEY. That's the problem. Well, is my time up? I'll come back later. Thank you.
Mr. PORTER. Thank you, Mr. Dickey. Mr. Stokes, by reason of his being ranking on VA–HUD, has requested an exemption and is recognized next.
Mr. Stokes.
Mr. STOKES. Thank you, Mr. Chairman. For the record, that subcommittee starts at 9:00 o'clock in the morning. Therefore, I could not be here at 10:00. Otherwise I'd beat all those Republicans here. [Laughter.]
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RACE AND HEALTH INITIATIVE
Dr. Broome, let me start with the question that was posed to you by Mr. Bonilla. And, I'm sorry Mr. Bonilla's not here now, because I think he asked a very important question. I think it's one we should address appropriately, and you're the appropriate person to address it.
I've been sitting on this subcommittee for more than 20 years. For more than 20 years, I have had to, year after year, probe about the disparity between minority health and majority health in this country.
In 1985, the Department of Health, Education and Welfare, under Secretary Heckler, issued a report that said that there are 85 thousand excess deaths in the minority community, and cited six specific areas: heart attack, stroke, cardiovascular disease, suicide, homicide, and I believe diabetes was the other where we have these excess deaths.
Ten years, later in 1995, there was a ten year update. That report found that the country still had a serious health disparity between minorities and white Americans. The President's initiative, as I understand it, is designed to seriously attack this problem where African-Americans die seven years earlier than white Americans, in every category of disease from cancer, to cardiovascular diseases including heart attack and stroke. There's a very serious disparity between white Americans and black Americans. And the President is trying to attack these problems frontally with these types of initiatives.
Now, I see in your budget you address this. Would you explain for Mr. Bonilla's sake, for my sake, and for the Nation's sake why the President is doing this, and why this is not pandering. This is a President trying to be sensitive and responsive to the kind of disparity I've addressed.
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Dr. BROOME. Well, I think this goes back to something that we as an agency really believe that what gets measured gets done. And I think the difference is that we now have specific targets, both for the year 2000 and the year 2010, for decreasing and then eliminating the different, increased burdens of disease seen in minority populations.
As Mr. Bonilla noted, we already have a number of programs which address the disproportionate health impact in minority communities. And we have made progress, but not enough, as you point out. This is something that has been known for a long time.
We believe that having these very specific targets will help us work with our own programs and with our partners to measure our progress and to make those goals. So we feel that this really is raising this to a different level.
And I don't know, I assume you are familiar with the Year 2000 goals for the Nation. It's another example of having goal setting. We haven't met all of those. But by focusing attention on those programs, we have made progress. And we have influenced how our partners and State and local health departments and community organizations measure what they are doing.
The Year 2010 goals are under preparation. There will be no different goals for different ethnic and minority populations in the Year 2010 objectives. We will have a single objective for the country.
Mr. STOKES. A few moments ago, Ms. Pelosi, who sits next to me, showed me your chart.
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Dr. BROOME. We have a big one.
Mr. STOKES. Can we refer to it for a moment?
She was pointing out to me the disparity in terms of the AIDS case rate in persons 13 years of age, which is shown on this chart, where you can see the red block, which is marked white, and next to it the yellow block. I understand that in the next hour, seven Americans will become infected with AIDS. Three of the seven will be African-Americans. Is that correct?
Dr. BROOME. That's right.
Mr. STOKES. Talk about that chart a moment, so we can understand what the President's trying to do here.
Dr. BROOME. Okay. The occurrence of AIDS in African-Americans is seven times the rate in white Americans. And we consider this an indication of an urgent health crisis.
The prevention programs, there are two particular areas of activity that we're focusing on. One is prevention of new infections in the first place. And this obviously is a primary goal of CDC AIDS prevention activities.
In the minority community, we have targeted prevention activities toward minority communities in several ways. Most fundamentally, we use the community planning process, which tries to have local areas identify their priority groups and how they should be approached in terms of preventing AIDS.
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In addition to that, we have directly supported 94 community-based organizations to address minority AIDS and HIV issues. In addition to that, as has been noted in previous budget increases, it's very important for us to address the prevention of HIV/AIDS in populations who use drugs intravenously. And this has affected minority communities disproportionately.
We feel that it's very important, because of the increased rates of HIV/AIDS in minority communities, that we be sure our prevention programs are reaching those populations and having an effect.
The other major issue for minority communities is being sure that they have access to treatment. As you all know, we've had a very encouraging decline in AIDS deaths nationally. However, that decrease has been much more striking in white groups than it has been in minority populations, such as African-Americans. We're very interested in working with our colleagues in the health care area to be sure that treatment access is also addressed.
Mr. STOKES. But, would you say from your chart that AIDS has reached what we would describe as a disaster area in the United States as it relates to African-Americans?
Dr. BROOME. I think that it is a very serious crisis for the African-American community. Our surveillance data have identified this, and we are actively working with African-American organizations to address it.
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Mr. STOKES. My time has expired. Thank you, Mr. Chairman.
Mr. PORTER. Thank you, Mr. Stokes.
Mrs. Northup.
TOBACCO
Mrs. NORTHUP. Thank you, Doctor. I'd just like to respond, if I may, sort of in a statement form for a couple of minutes about some of the things that were discussed previously. And in emphasizing how important I think your education programs are.
I think changing behavior is enormously difficult. I think every single person can think of resolutions, to go to bed earlier, to lose weight, to exercise every day. And you do it incrementally—two steps forward, one step backwards.
I think it's very hard to measure change over three months as opposed to over three years. Do you, over three years, learn to eat less fat? Do you, over three years, start eating more vegetables? And those are the kinds of changes that humans can accomplish in the long term? But it's very difficult in a day to day basis.
But I do think that education is very clearly effective. Overall, we know that the more health education a person gets, generally they adhere to better health processes. It slowly makes a dent into our subconscious. Anybody who is a mom or a dad and tries to help a child change a habit knows that you don't wake up one morning and give your child a one page explanation about why they should start studying or be more organized. You help them every day for years become a more organized person.
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And that's why I think CDC's general effort to educate and target is so very important. I'd like to specifically apply that to tobacco.
We can say that everybody knows that it's not good to smoke. And if you go into probably any classroom where you have 7 or 8 year olds, you will see every child raise their hand and say they're not going to smoke. We're so involved in the class of 2000's effort to have a smoke-free class of 2000. Every seventh grader was so proud to be a part of that class.
Yet if you go to the graduating classes, the class of 2000 that are now sophomores, you find an enormous number of those children that smoke. So even though they get the information on health effects, they are also subject to $10 million of advertisements every day in this country, every day, $10 million of advertising, connecting being popular, being cute, being successful, being liked by everyone, related to smoking.
And when you become 11 years old, knowing that your mom and dad think you're great isn't your only objective. [Laughter.]
It was the most heartbreaking thing I learned when my oldest became 11. And when they're 12, they want to know in seventh grade, of course my mom thinks I'm handsome, does the kid that sits next to me in class think I'm neat. And the first time they show up at a mixer, they think, how am I ever going to stand out as a person? The shortcut of having a cigarette with their peers is something that is innate in them because of the years of advertising that exist in this country.
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That is why it is so important that we have an effective counter-advertising strategy.
Now, Mr. Chairman, I have to tell you I disagree, I don't know why the TV stations should bear the cost. I don't know why the tobacco companies shouldn't bear that cost. If they're the ones that have created this atmosphere that smoking is so neat, and they say they don't want 13 year olds to smoke, then why don't they also fund the program to effectively target 13 year olds.
Mr. PORTER. Okay, I agree with that. [Laughter.]
Mrs. NORTHUP. I just had to get that in. [Laughter.]
And I'd like to point out that it's not public service announcements. The neatest ad I ever saw was the one in California where it shows on a park bench two 13 year olds starting to kiss, getting closer and closer, and at the very last minute, the little girl says, ''Yuck, your breath smells like smoke.'' [Laughter.]
And you know, that message gets to kids in a way that a public service announcement doesn't.
So I just want to really encourage you to continue your efforts with the States that have incurred this cost themselves and to make it available to help direct public policy in that direction.
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You pointed out that adult smoking has declined. I think it's true, it's because of education. But you did not mention youth smoking, and the last time I saw, that was going up. Is it still going up?
Dr. BROOME. This is something that is of great, great concern to us. Youth smoking has increased. That increase tracks along very well with increasing advertising and promotional activities on the part of the tobacco companies.
The only somewhat hopeful sign is that in the States, California, Massachusetts and Arizona, that have had very well-funded, extensive tobacco prevention programs, the rate of increase is substantially less. It's not good enough. We want to prevent youth smoking. But it does appear that comprehensive tobacco prevention programs can be effective.
I couldn't do a better job of describing what those prevention programs might look like than you already have. I would just add two additional points. Those media campaigns don't just emerge. They need to be part of a well-designed health communication strategy which tests the message, which sees whether it's having the desired impact and alters the campaigns as needed. The materials that we are distributing have been through that kind of process.
Secondly, we're very optimistic about a campaign called Media Smart, where we try to educate teenagers about how they are essentially being manipulated and fooled by commercial advertising. Teenagers don't like to be fooled or to look stupid.
We think there is some opportunity to make them smarter targets of advertising, and better able to discern what the companies are really trying to do.
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Mrs. NORTHUP. Well, I'd like to also point out that we have heard so much from the people that have come before us this week in support of the Administration's position on the tobacco settlement that offsetting the tobacco companies advertising could be done cooperatively. That is by them agreeing not to do so much advertising, which has been so effective.
But we cannot do that by law. That has to be a cooperative effort that was part of a negotiated settlement.
Now, we all know, and they know, that we have to change that settlement. It doesn't have the support base it needs. But one of the ways of changing the atmosphere and the way kids think is by having them not bombarded, and by also quite frankly, having the tobacco companies have to incur a bigger penalty if youth smoking keeps going up.
And if we don't have some sort of negotiated settlement that includes a cooperative agreement to reduce advertising and to share in the burden if youth access goes up, we are going to find ourselves doing one thing and having very smart companies that haven't bought in find another way through the cracks. I'd really like to encourage the Administration to, rather than just sign on a unilateral bill, to put together a bill that has the cooperative effort, different maybe, but cooperative effort of what was proposed. Because we cannot negotiate that through 435 members of Congress.
Dr. BROOME. You made an absolutely crucial point, and that is our ability to monitor what's going on. CDC, particularly the National Center for Health Statistics, has developed in consultation with experts in the academic community a very specific proposal for how we could do effective monitoring of youth smoking, of youth starting to smoke. So we would know what effect our programs are having.
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Mrs. NORTHUP. Okay.
Mr. PORTER. Thank you, Mrs. Northup.
Mr. Miller.
Mr. MILLER. Welcome, Dr. Broome.
RACE AND HEALTH INITIATIVE
Before coming to Congress a number of years ago, I was a professor at Georgia State University in Atlanta. I taught statistics. My first lecture in statistics was always how to lie with statistics. It's an interesting lecture I used to do, because it was entertaining and it shows how you can prove any point using statistics.
There's no question there is a statistical disparity between blacks and whites, on, for example, AIDS. But is that really the best statistical measure? What about income, education, families? What do the statistics really show? what is the real cause?
So answer that question, if it's income, then we should target all low-income people.
Dr. BROOME. Well, I love to get these kinds of questions, because my background is actually as an epidemiologist. What I ask people all the time is have they separated out the effects of income, of particular geographic locations, or other variables?
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In this instance, and I think it's also important to point out that we use race as a variable which can be a marker for many different and complex risk factors. Being clear about what the particular problem is lets us tailor an intervention to that particular area. Having said that, when you look at income, there still is an increased risk among minority populations for HIV/AIDS.
There is also, and again, the issue of how to address that, you have to look at some of the different risk groups. Some of that is heterosexual transmission, some of that is transmission related to intravenous drug use. Some of that is transmission related to poverty. That means that it's not uniquely African-American or Hispanic. But we do need to look at the particular circumstances in a particular population.
That's again why community planning has been so important in trying to design prevention strategies that are appropriate for individual communities.
Mr. MILLER. I always have a concern about creating new programs, because I think we have too many programs in the Government right now. Are there not better variables than just race on these issues? Is that really the best variable to work with? What would be the best variable, for example, in AIDS?
Dr. BROOME. We look at it in many different ways. One of the most traditional has been the particular risk groups and means of transmission. That's where you divide sexually transmitted, transmitted in the early days by blood transfusions, transmitted by intravenous drug use. And those are important ways of looking at it, because they suggest what's the appropriate prevention strategy.
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But it's also important for us to understand the epidemiology which may be quite different. For example, in rural communities and in urban communities. There really isn't a one size fits all solution.
HEMOPHILIA AND BLOOD SAFETY
Mr. MILLER. We can talk some more about the issue of what is the best variable, and whether are we are just creating programs. But in my limited amount of time, let me switch to another subject. An area that I personally had an interest in over the past years, and I've brought it up with Dr. Satcher at hearings, is the issue of blood safety, of our blood system.
I have a special interest in hemophilia. In last year's report language, the committee encouraged CDC to enhance its support of a comprehensive blood safety surveillance and patient outreach effort to address the hemophilia product safety concerns, to ensure that these resources were available for broad implementation of this important public safety program. Additional funding was provided for this program in the conference agreement.
It is my understanding these funds have been allocated, but that a first-time internal charge for administrative costs was assessed at the same time, essentially leaving the effort at status quo. Could you tell me more about the administrative assessment and why the hematological unit has been charged with this assessment for the first time?
Dr. BROOME. Let me see if I can get the name of the bill right. The Federal Financial Accounting Improvement Act of 1996 required us to look at how we assess costs for our different activities, including grants and cooperative agreements. So we have had an outside consultant look at our accounting practices and recommend how the very real costs for administering grants are allocated.
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And the recommendation identified that historically, for various reasons, CDC had not been charging overhead on grants and cooperative agreements. This was judged quite inappropriate from correct accounting practices terms. The recommendation was that CDC should be charging 1.97 percent overhead on grants and cooperative agreements.
So not surprisingly, programs count on every dollar, and they would like to see that all dollars go directly into programs.
Mr. MILLER. Are we making any progress in this particular area?
Dr. BROOME. We are, actually. I would much rather focus on what we have been accomplishing. We have supported surveillance in federally funded treatment centers for hemophilia, and we're seeing decreased mortality in individuals enrolled in those treatment centers. We also are improving our ability to do surveillance on the blood supply for a range of organisms that might be risk factors. And the hemophilia population has been very collaborative and very anxious that we have effective and improved surveillance systems.
I think it's worth emphasizing that the blood supply in the United States is exceedingly safe. And we have learned from the kind of emerging infection crisis that AIDS caused with the blood supply and the hepatitis B and hepatitis C concerns to rapidly identify new threats, to get the screening tools which will let us keep infectious blood out of the blood supply system.
But we can't—this is a human product, so it's hard to guarantee absolute safety. But we have developed new diagnostic tools. We're looking very hard at Creutzfeld-Jakob disease to see whether there's any indication that this could pose a risk. We're looking at new tools for Chagas disease, for example.
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So I do think we are working very hard to be sure that we have the safest blood supply possible.
Mr. MILLER. Do you need any more resources to implement this safety program? I know everything needs resources, but is there something special?
Dr. BROOME. We have certainly used some of the emerging infections resources to address the blood safety issue, and also the support for the hemophilia program has been very key in monitoring the safety of the blood program. There's always more we could do. But we consider this a very high priority.
Mr. MILLER. Thank you, Dr. Broome. As I said, I look forward to getting some more information about the justification for statistically, that we're just not doing it for political purposes, but there is a real statistical validity to this method of creating new programs.
Dr. BROOME. We'd be delighted to get you all the cross-tabulations.
[The information follows:]
"The Official Committee record contains additional material here."
Mr. MILLER. Not too much.
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Thank you, Mr. Chairman.
Mr. PORTER. Thank you, Mr. Miller.
Ms. Pelosi.
Ms. PELOSI. Thank you very much, Mr. Chairman.
And thank you for the eight minutes. I hope it's the same eight minutes that my Republican colleagues have used. [Laughter.]
Dr. Broome, thank you for your excellent testimony. I join with our distinguished Chairman in commending you on that statement, but also for your excellent work.
HIV/AIDS PREVENTION AND SURVEILLANCE
As we all know, the charge of the CDC is promoting health, preventing disease, injury and premature death. So in the interest of promoting health, I think one of the issues before us that I hear my colleagues talking about is why do people not get the message. I think the answer is that we send mixed messages.
For example, as I said yesterday, we tell children education is important, yet we send them to schools that are falling apart. If it's important, then let's make it important across the board.
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We talk about health and we look at this chart, yes, we can probably extrapolate from that chart that many of the people in the yellow column are poor. But as you honor your charge in promoting health, preventing disease, injury and premature death, and we try to send a message to people to change their behavior, whether it's tobacco, which was appropriately emphasized here, or whether its unsafe sex practices, etc., we should also send a message to the communities of America, rich, poor or otherwise, that promoting health is important, and that we make it a priority by giving access to everyone to quality health care.
Until we do that, I think we're fooling ourselves. First of all, our message is a confused one. Health is important, but you can't afford to have it, or we can't make it accessible to you. And if you happen to be minority, then you will have all these increased instances of poor health as well as our distinguished colleague, Mr. Stokes, pointed out.
He emphasized that, as you will recall, in our visit to the CDC when some of our colleagues came down there, and you welcomed us and gave us a report on what you were doing. That was very beneficial.
But it was also very important for us, as far as Mr. Stokes was concerned, to convey in the area of HIV that our prevention efforts have to be much more specifically targeted. I appreciate your emphasis that you have made on community-based solutions. Certainly Dr. Helene Gayle is an expert in all of this, and I commend the CDC for the extremely important work on HIV prevention that you are doing.
Today that work is crucial, as we've discussed. At least one more American is infected every 13 minutes. With every passing day, the newly infected person is more likely to be a woman, a young person, or a minority.
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CDC has been on the front lines in the battle against HIV. And given your effort, I was disappointed that CDC HIV prevention activities were flat funded in the Administration's budget.
Mr. Chairman, with your leadership, and working with Mr. Obey, this committee has responded to the urgent need for more resources for care for people with HIV. That funding has made a tangible, real difference.
But we must also prevent disease. That's the best dollar spent.
So I would ask you, if you were able to find substantial additional funds over and above the Administration's request to help you respond to the epidemic, how would you use this additional funding to fight HIV?
Dr. BROOME. I couldn't agree with you more on the crucial importance of prevention. We still do not have a permanent cure for AIDS. So the best approach remains to prevent getting AIDS in the first place, getting HIV infection.
I think it's worth emphasizing that, there is some attention to prevention of AIDS in the President's budget request, specifically in the demonstration projects for eliminating disparities in health. Five million dollars is specifically directed to AIDS prevention.
In addition, we are hoping there will be an additional $10 million specifically for syphilis elimination, which as you know, can have a dramatic benefit also in AIDS prevention, HIV infection prevention.
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So there are two specific areas which will very much be targeted toward eliminating disparities.
In addition I think that there are a number of areas where there are new opportunities for improving our HIV prevention activities. As you know, we have a very good tool for markedly decreasing perinatal transmission. We want to be sure that every pregnant woman in this country gets counseled and tested.
We are already seeing over 50 percent declines in infant HIV infection. This is wonderful news related to the use of AZT. We also feel we've got very good levels of AZT treatment of pregnant women. But we want to be sure that's available.
Ms. PELOSI. Dr. Broome, I appreciate your response. And I want, before my Chairman leaves, not to neglect to say how pleased I am with other increases in funding that the Administration has put in the budget, for new ADAP drugs and Ryan White care and other priorities. It's just the prevention piece I was concerned about.
And in the interest of time, if I might just ask you about something you've mentioned a couple of times in relationship to the answer you're giving now, and that is, you've talked about the community prevention planning process as a model of local decision making, which allows each community to respond to its particular prevention needs in this diverse and dynamic epidemic.
As you know, we've had some concern about who's getting the grant money, especially in the minority community where the competition has been keen. Can you tell me about how the CDC helps community-planning groups get access to the latest science-based prevention research at CDC and NIH? Because we believe that the prevention must be science based. We believe, though, that has to be conveyed to these groups making application for grants.
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Dr. BROOME. Well, we agree with you as well, and we're doing that in several different ways. One is through the use of high quality surveillance data. We need to know where the epidemic is going, so that we can be sure our prevention messages are reaching the groups at highest risk. This is one of the reasons why we are putting forward a major consultative effort to be sure that we are tracking HIV infection, rather than AIDS cases.
With the new improved treatments, AIDS cases are markedly delayed and do not reflect where the epidemic is today. So we and our partners are generally agreed that HIV surveillance is an important tool.
There certainly are still ongoing discussions about exactly how that surveillance should be conducted. But we will be developing a guidance for State health departments for comments.
In addition, there is certainly specific technical assistance that's important both for community planning groups and for community-based organizations. We do provide support both within CDC and also specific technical assistance groups who have the latest research information and can make that available to community planning groups.
Ms. PELOSI. Thank you, if I may, on another subject——
Mr. DICKEY [assuming chair]. Ms. Pelosi, I want you to know that you're proceeding only because I don't have enough nerve to keep you quiet. [Laughter.]
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Ms. PELOSI. Well, anything that works. [Laughter.]
I'll be brief, Mr. Chairman.
BREAST AND CERVICAL CANCER
The Administration's budget would direct $145 million to maintain State-based programs as part of the National Breast Cancer and Cervical Cancer early detection program. Can you tell us about your successes there and what you see as the most crucial needs and best prevention methods, and opportunities in women's health?
Dr. BROOME. We think that this has been a very successful program, and we very much appreciate the support that it has received. Through 1997, we have screened over 1.3 million women for breast and cervical cancer. We have detected 23,000 early or pre-cancer lesions in the Pap tests. This kind of early detection directly saves lives. We believe cervical cancer should be a completely preventable disease.
Now, in addition to the screening program, you can ask, well, why haven't we completely prevented cervical cancer deaths in this country. And that's why we think the cancer registry program is very important. What we're doing is looking at where cancers are occurring.
The State of Rhode Island has done a very creative program which shows that in older women, the cancer deaths are occurring because they tend to see internists who don't think about doing Pap smears. So we can then tailor our screening programs to reach those women.
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Ms. PELOSI. I think they're doing them every five years or so for older women now.
The tyrant, the clock, not our Chairman, beckons us, Dr. Broome. But I want to thank you again for your extraordinary work. Certainly, we miss Dr. Satcher, but he's still there, in a new position. But he made a valuable contribution to CDC, we all agree on that.
I also want to commend the Clinton Administration for the demonstration projects to reduce health disparities in minority populations. I think that is a very, very important initiative, science-based, and that promoting your mandate at CDC in that context is the most appropriate approach for you to take. I commend the Administration and you for that.
Thank you for your testimony and your answer.
Mr. DICKEY. Dr. Broome, I am certainly supportive of the Federal dollars——
Ms. PELOSI. Are we having a second round?
Mr. DICKEY. No comment. [Laughter.]
PREVENTION RESEARCH
I am certainly supportive of the Federal dollars that have been pouring into medical research. However, I am concerned that we might be investing too much in research and too little in the dissemination of facts to the general public.
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In your opinion, are we bringing in the research in a fashion the public can use it? And then, as a second question, or do you believe we are investing in prevention at a rate that adequately complements our investment in research?
Dr. BROOME. Well, given my scientific background, I do believe that additional research yields additional benefits. What we would argue is that it's crucial that the public gets the benefit of those research results,