CDC Fiscal Year 2000 Budget Request

Witnesses appearing before the House Subcommittee on Labor-HHS-Education Appropriations

Jeffrey P. Koplan, M.D., M.P.H., Director, CDC

accompanied by

Mr. William Gimson, Director, Financial Management Office,

Centers for Disease Control and Prevention

Mr. Dennis P. Williams, Deputy Assistant Secretary, Budget,

Department of Health and Human Services

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Statement by: Dr. Jeffrey P. Koplan

Director, Centers for Disease Control and Prevention

on Fiscal Year 2000 President's Budget Request

for the Centers for Disease Control and Prevention

Introduction

Good morning Mr. Chairman and members of the Subcommittee. I am delighted to be here before you as the new Director of the Centers for Disease Control and Prevention (CDC). Before coming to CDC, I served as the President of the Prudential Center for Health Care Research in Atlanta. My experience there has confirmed my belief that the private and public sectors have a mutual interest in preventing disease and injury and that this interest represents a tremendous opportunity to improve the health of all Americans. I am enthusiastic about CDC's accomplishments---what it has done to improve the health of Americans and its potential for even greater achievements in the future. I would like to thank each member of the subcommittee, and you in particular Chairman Porter, for your support of CDC. I know you recognize the critical work done by this agency. Your commitment to CDC and its programs has gone far to protect and promote the health and well-being of all Americans.

Major Achievements of Public Health and Directions for the Future

As I come before you to discuss our budget for the Fiscal Year 2000, I cannot miss the unique opportunity to highlight the major achievements of public health in this century. Since 1900, the average lifespan of Americans has lengthened by more than 30 years. Twenty-five years of this remarkable gain are attributable to a public health system that has both protected the public from infectious and environmental threats as well as enabled people to adopt healthier behaviors. In the interest of time, I will select just a few achievements that exemplify not only what has been done, but what must be done in the future to build on the progress we've made and to protect our children and grandchildren.

Since the 1940's, we have witnessed the development and use of safe and effective vaccines for polio, measles, rubella, and Haemophilus influenzae type b---to name just a few of the once common and pervasive causes of childhood death and disability. Childhood immunization rates are at an all time high and improvements span all major racial and ethnic groups. Polio has been eliminated from the western hemisphere, and measles, tetanus, Haemophilus influenzae type b meningitis and other vaccine-preventable diseases are at record low levels. Smallpox was eradicated in 1977, a feat which has yielded a savings of over $150 million every year. We know from these experiences that immunizations are one of most effective means of controlling common and serious diseases. We must continue to develop new effective, safe vaccines, such as the vaccine for rotavirus (a common cause of diarrhea in children), licensed just last year, while working with providers to ensure that children get the immunizations they need.

Although the emergence of new infectious diseases, including organisms resistant to antibiotics proves that we cannot be complacent, we must recognize the dramatic improvements in infectious disease prevention and control. As examples, outbreaks of typhoid and cholera are now rare events in the U.S. due to safe drinking water and sanitary sewer systems; tuberculosis, the second leading cause of death at the turn of the century, has declined over the last six years and we are now back on track for TB elimination. Our successes push us to set equally important goals for the new century. While, we've made great strides in reducing syphilis, we must now seize the opportunity offered by today's historically low rates and advances in treatment to eliminate it in the U.S. We have a unique opportunity to do so because more than half of all syphilis cases are concentrated in just 1% of U.S. counties.

Some of our most publicized accomplishments involve detecting and investigating infectious disease outbreaks---toxic shock syndrome, Legionnaires' disease, AIDS, and hantavirus to name but a few. The early detection and identification of the causes and risk factors associated with these diseases have afforded an opportunity to slow their spread. For instance, the development of medications and protocols to prevent transmission of HIV from a mother to her newborn resulted in substantial reductions in perinatally acquired HIV/AIDS (down 66% since 1992). And while rates of HIV infection have not declined, HIV/AIDS is no longer the leading cause of death among adults aged 25-44. Skills and technologies used to identify these diseases are vital to detecting new emerging threats such as avian flu, and are the first line of defense against possible bioterrorist events.

Death rates from certain chronic diseases have declined. For example, fewer women are dying from breast cancer, in part due to identification of the disease at its earliest, most treatable stage. When localized breast cancer is diagnosed, the 5 year survival rate is 97%. Public health education efforts, including CDC's National Breast and Cervical Cancer Early Detection Program, have greatly contributed to the 20% increase in mammography utilization since 1991 among women over 50. This has been money well spent. Further, we have made striking progress in narrowing the gap in mammography screening among women in certain minority groups, namely African American women. Still, some minority women, in particular, Hispanic women, get screened less frequently and are more likely to die from breast cancer. There has also been a decline in the nation's leading cause of death---heart disease. But while the death rate for all persons from heart disease has declined by 11% since 1990, not all races have benefitted equally. Culturally sensitive, targeted programs are needed to reach high risk groups with the benefits of prevention.

Motor vehicle death rates (as measured by deaths per 10,000 registered vehicles) have declined substantially---from 33 deaths per 10,000 registered vehicles in 1912 to less than 2 today. In addition to safer vehicles and highways, this great success can be attributed to vigorous public health and safety education efforts combined with Federal and State legislation to increase safety belt, child seat, and motorcycle helmet usage and to decrease drinking and driving. Child safety seats are up to 70% effective in reducing injury and death. Despite their efficacy, child safety seats are still only used for 2/3 of young children and are often used incorrectly. We must work to extend to all the benefits of child safety seats and measures to prevent other injuries, including those caused by fires, drowning, poisonings, falls and firearms.

Workers are protected far better today than they were at the turn of the century. Asbestos has been virtually eliminated from new use. Brown lung (byssinosis) is essentially a disease of the past and deaths from silicosis and coal worker's pneumoconiosis (black lung) continue to fall. Fatal occupational injury rates have declined 41%, from 7.5 per 100,000 workers in 1980 to 4.4 per 100,000 workers in 1994. All these successes have been accomplished with new scientific understanding to guide prevention efforts. We must continue to conduct research to identify and resolve occupational threats to health. The National Occupational Research Agenda includes 21 priorities for health research including asthma and chronic obstructive pulmonary disease, fertility and pregnancy abnormalities, health risks to special populations and evaluating the impact of emerging technologies on the workforce. CDC is confident that this approach will result in achievement of our performance goals to reduce morbidity, injury, and mortality among workers in high risk sectors.

Many of public health's greatest successes are based on the use of health information derived from prevention research. For example, CDC data from the National Health and Nutrition Examination Survey and the environmental health lab convinced the EPA to more rapidly remove lead, which causes cognitive impairment, from gasoline, resulting in lower blood lead levels in the U.S. population. The Surgeon General's Report on Tobacco Use in 1964 clarified the role smoking played in disease and set the stage for a public health crusade against this leading cause of death; a crusade that has made substantial progress---smoking rates among adults have declined from 42.4% in 1965 to 24.7% thirty years later. CDC is committed to working with our partners to achieve meaningful reductions in youth smoking. We must now build modern data systems and be prepared to address the urgent problems they reveal, such as tobacco use among youth.

Contemporary Challenges and CDC Priorities

Despite these accomplishments, much remains to be done. Levels of preventable illness, disability, and death in this country are still unacceptably high, and pockets of desperate need exist where people haven't benefitted from the progress made during the last century. For instance, gains made in life expectancy have not benefitted all Americans equally; the gap in life expectancy between African Americans and whites has been increasing since the 1970s. We must continue to conduct prevention research to develop programs to improve the health of communities.

Let me present to you one health problem that is reaching epidemic proportions---obesity. Obesity has increased by over 50% among adults and 100% among children and adolescents in just the past 15 years. Obesity is associated with many of the leading causes of death and disability including heart disease, diabetes, certain forms of arthritis and cancer. The rising rates of obesity portend greater disease, disability, and early death, and concomitant rises in health care costs and lost wages and productivity.

The epidemic of obesity illustrates the need for action in four priority areas for CDC: strengthening science for public health action, promoting healthy living at every stage of life, collaborating with health care partners for prevention, and working with partners to improve health globally.

First, we invest time and resources in research and data collection on obesity. We have already identified the magnitude and extent of the problem using data from CDC's Behavioral Risk Factor Surveillance System and the National Health and Nutrition Examination Survey. CDC will continue to investigate factors that have contributed to the increase in obesity and factors that might play a role in prevention.

We also address obesity by promoting healthy living at every stage of life. Consumption of fast food and soft drinks has increased in recent years and physical activity among youth (as measured by daily participation in high school physical education) has decreased. Evidence indicates that even moderate amounts of physical activity (30 minutes per day) can benefit health. Regular physical activity can benefit even older adults by improving strength and reducing the risk of falls. By stimulating environmental and cultural changes to encourage people to engage in physical activity and to consume healthy diets, we can begin to deal with obesity. We have had success in changing behaviors such as seatbelt use and smoking among adults. We can apply strategies that have been successful in these areas to obesity. For instance, school health education can be used to promote physical activity among youth. Environments that enable people to be physically active, such as safe neighborhoods with sidewalks or bike trails, can be effective in promoting physical activity.

We will continue to work with health care partners to promote weight control and reduction. Managed care organizations and American businesses have a common interest in reducing health care costs. CDC has a role here to play that no single managed care organization or corporation can take on itself---identification of effective programs and techniques to help Americans achieve healthier lives. Clearly, CDC can help to make this happen by working with health professionals to counsel patients to prevent weight gain and increase physical activity. Finally, as with all health issues, there is much we can learn from other countries about effective public health strategies.

I have used obesity as an example to illustrate the approach CDC uses to tackle the myriad of health priorities. We use monitoring systems to identify health problems, conduct research to identify risk factors, develop and test innovative interventions, and implement prevention programs with our partners in State and local health agencies, health care, academia, business, and voluntary and professional organizations. I look forward to sharing with you similar opportunities for preventing other critical health problems---from hepatitis C to tobacco use to occupational hazards---as requested in the FY 2000 budget.

FY 2000 Request

To address CDC's priorities, we have requested $3.1 billion, a total increase of 7% over our 1999 appropriation of $2.9 billion. We request increases in the following areas:

Strengthening Science for Public Health Action.

CDC uses science to make real, measurable differences in people's lives. Unfortunately, the infrastructure supporting this science has weakened. To strengthen science and the infrastructure that sustains it, we request increases of:

$22 million to support one of my top priorities---completing the construction of a new infectious disease research laboratory. This critically important laboratory building will house research on foodborne diseases, influenza, tuberculosis and antibiotic-resistant diseases---research which is currently conducted in crowded and antiquated space that compromises safety;

$15 million to develop a health statistics system for the 21st century that is capable of meeting increased information needs and makes data more available to users;

$12 million to address gaps in occupational safety and health research;

$138 million to assure that state and local public health agencies, networked with CDC, will be able to recognize and respond rapidly to threats posed by terrorism; $40 million of these funds are part of a $65 million initiative to support the National Electronic Disease Surveillance Network which will coordinate the infectious disease, bioterrorism, and food safety surveillance activities and establish a communication link between the public health and medical communities. In addition to the $40 million for bioterrorism, this initiative includes:

$10 million to build the national and state capacity needed to respond quickly to the threats of emerging infectious diseases;

$10 million to increase our ability to more rapidly identify and control foodborne hazards; and

$5 million to develop and pilot test strategies to identify, test, and refer persons at risk for hepatitis C virus.

Promoting Healthy Living at Every Stage of Life

CDC promotes healthy living at every stage of life, and among all populations, particularly those most affected by preventable disease and disability. CDC works to make communities healthy and safe and reduces or eliminates racial and ethnic disparities in health. The following increases are requested:

$25 million for community-based demonstration programs to eliminate disparities in the health of racial and ethnic minorities. These programs focus on six areas: infant mortality, cancer, cardiovascular disease, diabetes, HIV infection and child and adult immunization;

$10 million to fund a public education campaign to promote HIV testing, particularly among populations at highest risk;

$5 million to further efforts to eliminate syphilis in this country;

$27 million to prevent and reduce tobacco use among youth and adults; and

$60 million to expand vaccinations to include all susceptible children through 18 years of age.

Collaborate with Health Care Partners for Prevention

No single agency has the resources or the expertise to do all that needs to be done to improve the public's health. This request supports programs conducted in collaboration with other organizations, including those which deliver health care. Specific initiatives include:

$2 million to establish a Center for Bioethics and Research at Tuskegee University;

$2 million to expand the National Electronic Injury Surveillance System to collect information on all traumatic injuries seen in a national sample of emergency departments; and

$11 million to use science-based approaches to prevent violence against women and to enhance services for survivors.

Work with Partners to Improve Global Health

Finally, CDC will work with our international partners, including the World Health Organization, to promote health globally. Efforts to improve global health will benefit large vulnerable populations overseas, while at the same time protecting the health of U.S. citizens. CDC is fortunate to be engaged in many global health efforts targeting areas such as tobacco use and emerging infections. We request $17 million to support one of our largest current global health efforts: the eradication of polio. Global polio eradication will save the U.S. over $230 million annually.

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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES