<DOC>
[105th Congress House Hearings]
[From the U.S. Government Printing Office via GPO Access]
[DOCID: f:40482.wais]
THE HEALTHY START PROGRAM: IMPLEMENTATION LESSONS AND IMPACT ON INFANT
MORTALITY
=======================================================================
HEARING
before the
SUBCOMMITTEE ON HUMAN RESOURCES
of the
COMMITTEE ON GOVERNMENT
REFORM AND OVERSIGHT
HOUSE OF REPRESENTATIVES
ONE HUNDRED FIFTH CONGRESS
FIRST SESSION
__________
MARCH 13, 1997
__________
Serial No. 105-11
__________
Printed for the use of the Committee on Government Reform and Oversight
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40-482 WASHINGTON : 1997
________________________________________________________________________
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COMMITTEE ON GOVERNMENT REFORM AND OVERSIGHT
DAN BURTON, Indiana, Chairman
BENJAMIN A. GILMAN, New York HENRY A. WAXMAN, California
J. DENNIS HASTERT, Illinois TOM LANTOS, California
CONSTANCE A. MORELLA, Maryland ROBERT E. WISE, Jr., West Virginia
CHRISTOPHER SHAYS, Connecticut MAJOR R. OWENS, New York
STEVEN H. SCHIFF, New Mexico EDOLPHUS TOWNS, New York
CHRISTOPHER COX, California PAUL E. KANJORSKI, Pennsylvania
ILEANA ROS-LEHTINEN, Florida GARY A. CONDIT, California
JOHN M. McHUGH, New York CAROLYN B. MALONEY, New York
STEPHEN HORN, California THOMAS M. BARRETT, Wisconsin
JOHN L. MICA, Florida ELEANOR HOLMES NORTON, Washington,
THOMAS M. DAVIS, Virginia DC
DAVID M. McINTOSH, Indiana CHAKA FATTAH, Pennsylvania
MARK E. SOUDER, Indiana TIM HOLDEN, Pennsylvania
JOE SCARBOROUGH, Florida ELIJAH E. CUMMINGS, Maryland
JOHN SHADEGG, Arizona DENNIS KUCINICH, Ohio
STEVEN C. LaTOURETTE, Ohio ROD R. BLAGOJEVICH, Illinois
MARSHALL ``MARK'' SANFORD, South DANNY K. DAVIS, Illinois
Carolina JOHN F. TIERNEY, Massachusetts
JOHN E. SUNUNU, New Hampshire JIM TURNER, Texas
PETE SESSIONS, Texas THOMAS H. ALLEN, Maine
MIKE PAPPAS, New Jersey ------
VINCE SNOWBARGER, Kansas BERNARD SANDERS, Vermont
BOB BARR, Georgia (Independent)
------ ------
Kevin Binger, Staff Director
Daniel R. Moll, Deputy Staff Director
Judith McCoy, Chief Clerk
Phil Schiliro, Minority Staff Director
------
Subcommittee on Human Resources
CHRISTOPHER SHAYS, Connecticut, Chairman
VINCE SNOWBARGER, Kansas EDOLPHUS TOWNS, New York
BENJAMIN A. GILMAN, New York DENNIS KUCINICH, Ohio
DAVID M. McINTOSH, Indiana THOMAS H. ALLEN, Maine
MARK E. SOUDER, Indiana TOM LANTOS, California
MIKE PAPPAS, New Jersey BERNARD SANDERS, Vermont (Ind.)
STEVEN SCHIFF, New Mexico THOMAS M. BARRETT, Wisconsin
Ex Officio
DAN BURTON, Indiana, HENRY A. WAXMAN, California
Lawrence J. Halloran, Staff Director and Counsel
Doris F. Jacobs, Associate Counsel
Robert Newman, Professional Staff Member
R. Jared Carpenter, Clerk
Ron Stroman, Minority Professional Staff Member
C O N T E N T S
----------
Page
Hearing held on March 13, 1997................................... 1
Statement of:
Coyle, Thomas, assistant commissioner, Baltimore City Health
Department, Maternal and Infant Care and Special Projects,
accompanied by Bernard Guyer, chairman, Department of
Maternal and Child Health, Johns Hopkins School of Hygiene
and Public Health; Melanie Williams, project director,
Mississippi Delta Futures Healthy Start, accompanied by
Robert Pugh, executive director Mississippi Primary Health
Care Association; Barbara Hatcher, project director,
District of Columbia Healthy Start Program; and Juan Molina
Crespo, project director, Cleveland Department of Public
Health..................................................... 106
Nora, Audrey H., Director, Maternal and Child Health Bureau,
Health Resources and Services Administration, Department of
Health and Human Services, accompanied by Thurma McCann,
Director, Division of Healthy Start, Maternal and Child
Health Bureau; James S. Marks, Director, National Center
for Chronic Disease Prevention and Health Promotion,
Centers for Disease Control and Prevention, Department of
Health and Human Services, accompanied by Mary Anne
Freedman, Director, Division of Vital Statistics, National
Center for Health Statistics, Centers for Disease Control
and Prevention; Duane Alexander, Director, Institute of
Child Health and Human Development, National Institutes of
Health, Department of Health and Human Services; and Lisa
Simpson, Acting Administrator, Agency for Health Care
Policy and Research, Department of Health and Human
Services................................................... 12
Letters, statements, etc., submitted for the record by:
Alexander, Duane, Director, Institute of Child Health and
Human Development, National Institutes of Health,
Department of Health and Human Services, prepared statement
of......................................................... 76
Barrett, Hon. Thomas M., a Representative in Congress from
the State of Wisconsin:
Prepared statement of.................................... 9
Statement from the Milwaukee Healthy Women and Infants
Project................................................ 5
Coyle, Thomas, assistant commissioner, Baltimore City Health
Department, Maternal and Infant Care and Special Projects,
prepared statement of...................................... 107
Crespo, Juan Molina, project director, Cleveland Department
of Public Health, prepared statement of.................... 178
Guyer, Bernard, chairman, Department of Maternal and Child
Health, Johns Hopkins School of Hygiene and Public Health,
prepared statement of...................................... 117
Hatcher, Barbara, project director, District of Columbia
Healthy Start Program, prepared statement of............... 151
Marks, James S., Director, National Center for Chronic
Disease Prevention and Health Promotion, Centers for
Disease Control and Prevention, Department of Health and
Human Services, prepared statement of...................... 61
Nora, Audrey H., Director, Maternal and Child Health Bureau,
Health Resources and Services Administration, Department of
Health and Human Services, prepared statement of........... 17
Simpson, Lisa, Acting Administrator, Agency for Health Care
Policy and Research, Department of Health and Human
Services, prepared statement of............................ 84
Stokes, Hon. Louis, a Representative in Congress from the
State of Ohio, prepared statement of....................... 195
Williams, Melanie, project director, Mississippi Delta
Futures Healthy Start, prepared statement of............... 125
THE HEALTHY START PROGRAM: IMPLEMENTATION LESSONS AND IMPACT ON INFANT
MORTALITY
----------
THURSDAY, MARCH 13, 1997
House of Representatives,
Subcommittee on Human Resources,
Committee on Government Reform and Oversight,
Washington, DC.
The subcommittee met, pursuant to notice, at 10:10 a.m., in
room 2247, Rayburn House Office Building, Hon. Christopher
Shays (chairman of the subcommittee) presiding.
Present: Representatives Shays, Snowbarger, Towns,
Kucinich, and Barrett.
Also present: Representatives Cummings, Thompson, and
Stokes.
Staff present: Lawrence J. Halloran, staff director and
counsel; Doris F. Jacobs, associate counsel; Robert Newman,
professional staff member; R. Jared Carpenter, clerk; Ronald
Stroman, minority professional staff; and Ellen Rayner,
minority chief clerk.
Mr. Shays. Good morning. I would like to call this hearing
to order and welcome our witnesses and our guests to what is a
very important hearing.
Every child deserves a healthy start. That caring principle
motivated President Bush in 1989, to make the effort against
infant mortality a national priority. Part of that initiative
was the Healthy Start Program, a 5-year demonstration begun in
1991 to test innovative, locally driven approaches to reach
pregnant women and improve the health of their babies.
Since then, Healthy Start projects in 22 communities have
planned their strategies, formed their community organizations,
and provided a variety of services to expectant mothers.
Through this fiscal year, Congress appropriated and the
Department of Health and Human Services, HHS, spent more than
$500 million on Healthy Start.
Now the test is over, and it is time to find out what
worked and what did not. It is time to analyze as objectively
as possible, the impact of Healthy Start initiatives on the
leading causes of infant mortality: low birth weight, birth
defects, and Sudden Infant Death Syndrome. It is time to
determine what Healthy Start demonstrated about the
effectiveness and sustainability of community action to improve
the health of infants at risk.
Toward that end, HHS is conducting a formal evaluation of
the 15 original Healthy Start projects. The study will measure
the program's performance in terms of infant mortality data,
infant health records, maternal health records, and public
health statistics. The $5 million study will be completed in
late 1998 or early 1999.
But the Department believes that enough is already known to
justify expansion of the program to 30 more localities. The
President's fiscal year 1989 budget requests $96 million for
replication of nine successful Healthy Start infant mortality
reduction strategies.
The request raises important oversight questions: On what
basis did the Department declare the program a success? Can
reductions in infant mortality rates be linked directly to
Healthy Start initiatives prior to completion of a national
evaluation? On what empirical data can communities rely to
replicate the successes and avoid the missteps of Healthy
Start? Can HHS manage an expanded program effectively?
As much as anyone, I want the answers to confirm that we
have found locally supported approaches reduce infant
mortality. But the decisions affecting the lives of 30,000
babies each year should be based on facts, not hopes or
theories. Federal policies and programs to fight infant
mortality must be based on sound research and current data, not
anecdotal information and purely local evaluation. When it
comes to the care of vulnerable infants, good intentions are no
substitute for good health outcomes.
We ask the HHS public health agencies involved in the fight
against infant mortality to address these concerns. We also
invite Healthy Start project directors to describe their work,
to bring local solutions to a national problem.
Your testimony today is an important part of the
subcommittee's Healthy Start evaluation. We are very grateful
that you came, and we are eager to begin this hearing. And we
welcome all of you.
With that, I would like to call on Ed Towns, who is the
ranking member of this subcommittee, and I would say without
hesitation an equal partner in this process, in this hearing,
and in all of the other hearings that we have conducted. Mr.
Towns.
Mr. Towns. Thank you very much, Mr. Chairman.
Millions of our children are in grave risk because of
infant mortality and low birth weight, particularly in our
under-served and minority communities.
In 1992, the infant mortality rate was 8.5 deaths per 1,000
births, one of the highest rates of infant mortality among
industrialized nations. African-American infants die at a rate
more than twice the rate for white infants, with 17.6 infant
deaths per 1,000 births, a rate seen in some of the poorest
Third World countries.
We are, however, making progress. Since 1970, the infant
mortality rate has been cut in half. But the rate is still much
too high, particularly in economically disadvantaged
neighborhoods. That is why programs like Healthy Start are so
important.
Healthy Start was developed by Dr. Louis Sullivan, former
Bush administration Secretary for the Department of Health and
Human Services. Dr. Sullivan recognized that a one-size-fits-
all-approach to infant mortality and low birth weight would not
work in under-served areas. Dr. Sulllivan designed Healthy
Start to allow local health care providers and community
residents to develop individual programs that work best in
their communities.
For example, the Bedford Healthy Start Program in my
district provides prenatal care, substance abuse prevention,
treatment for adolescent drug abuse, a pregnancy program,
immunization, of course, nutrition education and counseling,
and primary medical care for children.
While a 5-year study to evaluate the success of Healthy
Start will not be complete until next year, data from the
Healthy Start target areas suggest that the program has helped
reduce infant mortality and other pregnancy problems.
According to information that I received from Healthy Start
in New York City from 1990 to 1995, infant mortality dropped 43
percent in the Bedford target area compared to a 24 percent
decline city-wide. The overall decrease in the other New York
Healthy Start target areas was 40 percent.
According to Senator Arlen Specter in testimony that he
provided last year in the Senate on the Healthy Start Program,
the results of Healthy Start have been extraordinary.
In Pittsburgh, infant mortality has declined 20 percent,
and an estimated 61 percent decline for women who have taken
advantage of the Healthy Start Program.
Additionally, Gen. Colin Powell has announced that Healthy
Start will be a major part of the Corporation of National
Service that Presidents Bush, Carter, and Ford will unveil in
the coming weeks.
Two days ago, members of my staff visited the Baltimore
Healthy Start Program, and talked to health care providers,
community leaders, and with women and men who are participating
in the program. Everyone they talked with said that the program
is well-run, and is dramatically improving pre- and post-natal
health care for the women and children in the program. They
came back excited.
Like any other program, Healthy Start can be improved. It
is my sense that HHS should exercise better oversight over the
operations of the program. But this federally-funded, locally-
administered program appears to be cost effective.
According to the Office of Technology Assessment, $8
billion was expended in 1987 for the care of low birth weight
babies. HHS has estimated that reducing the number of children
born of low birth weight by 82,000 births could save between
$1.1 million and $2.5 million a year. We are talking about
saving money.
If Healthy Start can continue to play a role in reducing
infant mortality and low birth weight babies, and help to
improve the quality of life for poor women and children in our
country, it deserves our strongest support.
The program witnesses that we will hear from today are on
the front lines battling infant mortality in communities across
this Nation, communities where Healthy Start has made the
difference between life and death for thousands of poor
American children.
I am hopeful that we will learn enough from their comments
to dramatically improve the life expectancy for our country's
poorest children.
Thank you very much, Mr. Chairman. And I yield back.
Mr. Shays. I thank the gentleman.
Mr. Snowbarger, vice chairman of the subcommittee.
Mr. Snowbarger. I have nothing at this time. Thank you.
Mr. Shays. Mr. Barrett.
Mr. Barrett. Thank you, Mr. Chairman. I do have a
statement, if I could, please.
Thank you for holding this hearing on the Healthy Start
demonstration program. I am a strong supporter of Healthy
Start. The program in my district is called the Milwaukee Women
and Infants Project. And it has achieved good and solid results
in my community by getting pregnant women into prenatal care.
Milwaukee was approved as a Healthy Start site, because we
were experiencing alarming infant mortality and low birth
weight baby rates. The problems that Healthy Start addresses
are typical in my community. And the problems are particularly
striking for our African-American community.
For example, in Milwaukee, the average low birth weight for
1988 through 1990 was 14.7 per 1,000 births, with the African-
American rate being 18.3. By 1994, the infant mortality rate
had decreased by 8 percent for white infants. However, the IMR
for non-white infants increased by 20 percent.
I am proud to say that our Milwaukee Healthy Start Program
currently reports zero infant deaths among its client
population. In addition, it reports a 22 percent increase in
the number of women enrolling in prenatal care during their
first trimester, and substantial increases in health,
immunization, and nutritional access for infants and their
mothers.
Mr. Chairman, with the subcommittee's consent, I would like
to enter a statement from the Milwaukee Healthy Women and
Infants Project into the subcommittee's record.
Mr. Shays. Without objection.
[The information referred to follows:]
[GRAPHIC] [TIFF OMITTED] T0482.001
[GRAPHIC] [TIFF OMITTED] T0482.002
[GRAPHIC] [TIFF OMITTED] T0482.003
Mr. Barrett. Again, I am a strong supporter of Healthy
Start. When you look at the babies, who could not be? Healthy
Start projects are the type of community-based, locally-
designed, and locally-controlled programs that many of my
colleagues assert all programs should be.
For that reason, I am puzzled as to why the effectiveness
of these projects would be called into question even before a
Federal study is completed.
Healthy Start is a good investment. Look at the communities
and talk to the clients. The results are evident.
I must also express puzzlement about portions of the
Department of Health and Human Service's current funding
decisions for the Healthy Start Program. The Healthy Start
Program in my district is in the category of projects termed
``special projects.'' It is my understanding that the
Department proposes to severely under-fund special project
sites.
When the Healthy Start demonstration began in the Bush
administration in 1991, Milwaukee was one of seven projects
deemed approved, but not funded. Milwaukee and six other
projects were federally funded beginning in 1994. Milwaukee has
been funded at a level of $1 million annually.
It is my understanding, however, that the seven special
project programs will be limited to a maximum of $500,000 under
phase II of Healthy Start. My community's Healthy Start project
is telling me it will not be able to operate at this funding
level, ending services for many of my constituents.
In fact, I have been informed that the so-called ``special
projects'' have always been restricted in access to funding,
and have never had the opportunity to apply for the higher
funding levels available for the original sites, and for the
proposed new sites.
Today, I hope to receive an explanation about the criteria
for such administrative funding decisions, because my district
needs Healthy Start. I do not want to close it down, because it
works.
Thank you.
[The prepared statement of Hon. Thomas M. Barrett follows:]
[GRAPHIC] [TIFF OMITTED] T0482.004
[GRAPHIC] [TIFF OMITTED] T0482.005
Mr. Shays. I thank the gentleman.
If I could, I would like to get some housekeeping out of
the way, if I can.
I ask unanimous consent that all members of the
subcommittee be permitted to place any opening statement in the
record, and that the record remain open for 3 days for that
purpose. Without objection, so ordered.
And I also ask unanimous consent that all witnesses be
permitted to include their written statements in the record.
Without objection, so ordered.
We have two panels that will be coming before us. The first
is comprised of officials from the U.S. Department of Health
and Human Services. And then we will be having providers in the
local communities who will come and testify about their
programs.
At this time, I would like to call Audrey Nora, Director of
Maternal and Child Health Bureau, Health Resources and Services
Administration, accompanied by Thurma McCann, Director of
Division of Healthy Start, Maternal and Child Health Bureau.
Also, I would call James Marks, Director of the Chronic Disease
Center, Centers for Disease Control and Prevention; Duane
Alexander, Director of the Institute of Child Health and Human
Development, National Institutes of Health; and Lisa Simpson,
Acting Administrator, Agency for Health Care Policy and
Research.
If you would all just come and stand, as we do swear our
witnesses in, even Members of Congress. This is a policy that
we have for everyone.
[Witnesses sworn.]
Mr. Shays. For the record, everyone has responded in the
affirmative. I hope we can fit you at that table. We probably
need a table a little wider. I am sorry for that. The important
thing is that you have enough space to put your documents down,
and have a mike that picks up your voice.
Let me from the outset just apologize and just state for
the record. I chair the task force on the Budget Committee on
Health Care, and we are making our preliminary decisions on
what we are going to report to the full House. And the meeting
is now.
I want to weigh in on the very issues that we are talking
about in a positive way. So that should give me some license to
leave.
I will say that one of the issues that I would like
responded to from all participants, is, although I will not be
here: it is my understanding that this program was intended to
be a program to see the effect of local initiatives. But it was
a local-based and local community effort, and that ultimately
we would see programs. And it was the expectation, I thought,
and the expectation of others, that they would ultimately be
self-financing, that we would then seed additional programs. I
would love, for the record, the responses. So I've really asked
a question up front that I hope others will address.
We are going to start in the order that I called you, which
would be Dr. Nora first and then Dr. Marks, then Dr. Alexander,
and then Dr. Simpson, in that order. This will be chaired by
Vince Snowbarger, who is the vice chairman of the subcommittee.
Mr. Snowbarger [presiding]. Dr. Nora.
STATEMENTS OF AUDREY H. NORA, DIRECTOR, MATERNAL AND CHILD
HEALTH BUREAU, HEALTH RESOURCES AND SERVICES ADMINISTRATION,
DEPARTMENT OF HEALTH AND HUMAN SERVICES, ACCOMPANIED BY THURMA
MCCANN, DIRECTOR, DIVISION OF HEALTHY START, MATERNAL AND CHILD
HEALTH BUREAU; JAMES S. MARKS, DIRECTOR, NATIONAL CENTER FOR
CHRONIC DISEASE PREVENTION AND HEALTH PROMOTION, CENTERS FOR
DISEASE CONTROL AND PREVENTION, DEPARTMENT OF HEALTH AND HUMAN
SERVICES, ACCOMPANIED BY MARY ANNE FREEDMAN, DIRECTOR, DIVISION
OF VITAL STATISTICS, NATIONAL CENTER FOR HEALTH STATISTICS,
CENTERS FOR DISEASE CONTROL AND PREVENTION; DUANE ALEXANDER,
DIRECTOR, INSTITUTE OF CHILD HEALTH AND HUMAN DEVELOPMENT,
NATIONAL INSTITUTES OF HEALTH, DEPARTMENT OF HEALTH AND HUMAN
SERVICES; AND LISA SIMPSON, ACTING ADMINISTRATOR, AGENCY FOR
HEALTH CARE POLICY AND RESEARCH, DEPARTMENT OF HEALTH AND HUMAN
SERVICES
Dr. Nora. Mr. Chairman and members of the subcommittee, I
am Dr. Audrey H. Nora, Director of the Maternal and Child
Health Bureau, Health Resources and Services Administration. I
am accompanied this morning by Dr. Thurma McCann, the Director
of the Maternal and Child Health Bureau's Division of Healthy
Start, who is sitting on my right.
Mr. Snowbarger. Dr. Nora, if I could interrupt, before we
get into the substance of the testimony, I want to point out,
both to the panel and to my colleagues up here, we don't have
lights this morning on the timing, and our timing is going to
be held over here by a flip chart.
We will try to be generous with the time and understand
that it is a little difficult to see that while you're
testifying, but I apologize for the inconvenience.
I'm sorry, Dr. Nora. Go ahead.
Dr. Nora. OK. Thank you. I am pleased to share with you our
efforts to reduce infant mortality in the United States through
Healthy Start. In my testimony today, I will highlight the
progress Healthy Start has made toward improving maternal and
infant health in 22 communities across the country, and
describe how the Department plans to buildupon what we have
learned.
In short, we are convinced that the Healthy Start Program
is having a positive impact on reduction of infant mortality
and morbidity in the areas where the program exists, and we are
now planning to replicate these successful efforts in other
parts of the country.
Infant mortality, which is defined as the death of babies
before their first birthday, is a public health tragedy. Thanks
to an intensified national commitment to babies, to giving
babies a healthy start in life, the preliminary estimate for
the U.S. infant mortality rate is at a historic low of 7.5
deaths per 1,000 live births in 1995, and the proportion of
mothers getting early prenatal care is at a record high of 80.2
percent in 1994.
We have also seen declines in some of the risk factors for
low birth weight and infant mortality. Teen births dropped for
the fourth straight year in 1995, and smoking among pregnant
women has been decreasing in recent years. Nevertheless, when
compared to other developed countries, the United States
continues to have unacceptably high infant mortality rates with
significant disparities among racial and ethnic groups.
In 1991, based on findings by a White House Task Force on
Infant Mortality, President Bush recommended that actions be
taken to address persistently high infant mortality rates in
this Nation, particularly those associated with ethnic and
racial populations.
Healthy Start began as a demonstration program in late
1991, with funds appropriated initially under Public Law 102-
27, ``the Dire Emergency Supplemental Appropriations Act of
Fiscal Year 1991,'' and has been renewed annually since then,
in Labor HHS appropriations bills.
The Healthy Start Program was built on the premise that
residents of local communities would best know how to overcome
these barriers. Thus, new, community-based strategies were
needed to attack the causes of infant mortality and low birth
weight, especially among high-risk populations.
The National Institutes of Health, the Centers for Disease
Control and Prevention, the Agency for Health Care Policy and
Research, and many other Federal agencies participated with
HRSA in the development of the Healthy Start conceptual
framework. They continue to be our allies in addressing health
issues affecting our Nation's mothers, infants, children, and
their families.
Applicants for Healthy Start grants were sought among both
urban and rural communities with infant mortality rates at
least one-and-a-half times the national average. In late 1991,
15 applicants--13 urban and 2 rural--were awarded planning
grants.
The initial grants supported year-long, comprehensive
planning activities through fiscal year 1992. The projects
began serving clients in fiscal year 1993.
The overall goal was to reduce infant mortality in the
project areas by 50 percent over a 5-year period, focusing on
five principles which would assure early prenatal care and
appropriate supports for families. These five principles
include: innovation, community commitment and involvement,
increased access to health care, service integration, and
personal responsibility.
In late 1994, seven additional communities--five urban and
two rural--received Healthy Start special project grants. These
communities also had infant mortality rates greater than one-
and-a-half times the national average for infant mortality. The
goal for these projects was to significantly reduce infant
mortality rates in the target areas over a 2-year period.
In 1993, HRSA entered into a contract with Mathematica
Policy Research to conduct an independent, extensive cross-site
evaluation of the 15 original Healthy Start projects. This
national evaluation, managed by HRSA's Office of Planning and
Evaluation, consists of both process and outcome analyses.
The process evaluation will detail the individual
characteristics of the 15 original projects, their health and
social service infrastructures, organizational characteristics,
and descriptive information about the type and scope of local
interventions.
The outcome evaluation entails a quantitative analysis of
the overall success of the Healthy Start Program through
assessment of multiple program outcomes, such as infant
mortality rates, low birth weight incidence, and improved
maternal and infant health, using client-specific data as well
as secondary data sources.
The national evaluation is a 5-year effort with a final
report due in 1998. Comparisonsites to the Healthy Start
communities will be selected in order to demonstrate the
comparative impact of Healthy Start interventions on
communities.
While we await the completion of the Mathematica
evaluation, results from similar national studies and the
impact of community-based service interventions and outcomes
from a number of local evaluations at current Healthy Start
demonstrationsites are providing useful information.
A recent cross-site successful program to reduce infant
mortality in the South was conducted by the School of Public
Health, University of North Carolina. The evaluative program,
called Healthy Futures/Healthy Generations, used interventions
similar to Healthy Start's. It was sponsored, from 1988 to
1993, by the Southern Governors Association, and was co-funded
by the Robert Wood Johnson Foundation and the Maternal and
Child Health Bureau.
The evaluation compared data from 11 Southern States
participating in the Healthy Futures/Healthy Generations
program with six States who were not participating, and it
attempted to determine if a broad set of perinatal
interventions had assisted participating States to reduce
infant mortality and expand access to health care services.
Many of the Healthy Futures/Healthy Generations
interventions were very like those developed by Healthy Start
projects, and included public awareness campaigns for prenatal
care services, risk screening protocols, increased obstetric
personnel and training of those personnel, improved management
of high-risk mothers and newborns, and improved identification
and followup of high-risk infants.
Major findings from this evaluation include: improved
health outcomes of mothers and infants; enhanced perinatal
health care systems; increased utilization of public and
private resources, and other efforts which served as a catalyst
for a wide range of infant mortality reduction activities.
Substantial decline in infant mortality in the South occurred
during the Healthy Futures/Healthy Generations period, compared
to the pre-program period. For example, at the conclusion, the
infant mortality rate was 10 compared to 11.3 infant deaths
prior to beginning the program and these infant mortality
declines were substantially greater for black populations in
the South. There were also increases in the percentage of women
who sought prenatal care during their first trimester. There
was an increase of .3 percent in the South compared to a .4
percent decrease in early prenatal care nationwide.
Our knowledge of successful community-driven approaches for
Healthy Start grantees has been greatly enriched by timely
information from 14 of the 15 original projects. Each of the
seven special projects has also been required to conduct a
local evaluation.
The local evaluations have looked at interventions, such as
outreach services, infant mortality reviews, prison
initiatives, post-partum surveys, community ethnographic
studies and studies of special populations, such as adolescents
and male partners.
The Healthy Start initiative also features an aggressive
national and local public information and education component
that raises awareness of infant mortality and promotes prenatal
care and other healthy behaviors. A new set of public service
advertisements, released in February, urges women to avoid
putting their babies' health ``on the line'' by seeking early
and regular prenatal care.
The campaign features toll-free numbers for English-
speaking callers and Spanish-speaking callers. For the first
time, just by calling the hotline, women can reach either their
own States' maternal and child health office or a local Healthy
Start site, whichever is closer.
Over the 4 operational years of fiscal year 1993 through
1996, information we have learned from the Healthy Start
projects has been distilled into nine models of infant
mortality reduction strategies which support the concept of
community-based service integration.
Mr. Snowbarger. Dr. Nora, we're going to have to ask you to
sum up quickly here. We have tried to be generous with the
time, and we're going to be running late if we allow everyone
the same amount of time. Thank you.
Dr. Nora. OK. Thank you. The Maternal and Child Health
Bureau and its Division of Healthy Start has provided guidance
and oversight to the 22 Healthy Start projects.
Our management of the Healthy Start initiative extends to
assisting the grantees in developing and implementing programs
and strategies to reduce infant mortality, closely monitoring
performance, providing and arranging for the provision of
technical assistance, facilitating community consortium
development, mediating conflicts, and promoting communication
with State Title V agencies.
While the overwhelming majority of Healthy Start sites have
experienced minimal problems in the development of consortia,
local conflicts have emerged in a few sites. Federal
regulations allow HRSA to take corrective action where grantees
exhibit serious deficiencies or, ``exceptions,'' in business
management or unsuccessful performance in administrative and
programmatic management.
Currently, three grantees fall into this ``exceptional''
category. They are Birmingham, Detroit, and Northwest Indiana.
The Mississippi Delta Futures Project was selected as one
of the seven special projects in late 1994. Its project area
covers eight counties in the Delta Region. Since inception, the
project has experienced difficulties in reaching cohesions
within the multi-faceted communities of the project area,
establishing effective communications among all stakeholders
and timely compliance with grant requirements.
Intensive technical assistance from both Federal staff and
private sector resources has been provided. In spite of these
efforts, it has been necessary to reduce funding to this
project during this fiscal year.
Mr. Snowbarger. Dr. Nora, could you conclude fairly quickly
here?
Dr. Nora. Yes. Yes. I will.
In conclusion, with encouragement from the Congress, HRSA
has established three objectives to operationalize the Healthy
Start initiative: No. 1, operationalize successful Healthy
Start models through replication; No. 2, establish a peer
mentoring program; and No. 3, disseminate nationally
information which we have learned.
In closing, I would like to emphasize that we are confident
that Healthy Start will continue to be a vital component of the
administration's comprehensive national strategy to increase
access to prenatal care and to help families care for their
infants.
We know that early and continuous prenatal care makes a
difference. If children are indeed our future, Healthy Start is
a strategic investment in that future.
This concludes my testimony.
[The prepared statement of Dr. Nora follows:]
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Mr. Snowbarger. Thank you, Dr. Nora. Dr. Marks.
Dr. Marks. Thank you, Mr. Chairman. Good morning. I am Dr.
James Marks from the National Center for Chronic Disease
Prevention and Health Promotion at the Centers for Disease
Control.
I am pleased to be here to discuss some of our agency's
activities related to infant mortality and prenatal care,
including the National Vital Statistics System. I will
summarize my written testimony on this work and also discuss
the timeliness and accuracy of the data, and some of our other
activities in this area.
As Dr. Nora has mentioned, the infant mortality rate in the
United States has declined steadily over the last quarter
century, reaching 7.5 deaths per 1,000 live births in 1995, the
lowest rate ever recorded. Slightly over 30,000 infants die in
the United States each year, with the leading causes of death
being birth defects, disorders related to prematurity and low
birth weight, Sudden Infant Death Syndrome, and Respiratory
Distress Syndrome.
However, the relatively poor international ranking of the
United States in infant mortality and the large differential in
infant mortality among the U.S. population subgroups presents
cause for concern.
The vital statistics system maintained by CDC's National
Center for Health Statistics is the source of the Nation's
official vital statistics. These statistics are provided
through State-operated registration systems and are based on
vital records filed in the State offices. Detailed annual birth
and death data are available for the United States as a whole,
for States, for counties, and cities of greater than 100,000.
CDC believes this State data on low birth weight and infant
mortality to be highly accurate. All of the States have adopted
laws requiring registration of live births and deaths, and CDC
relies on information provided by the States to complete the
national files. An example: the States were able to link about
98 percent of all infant death records to their corresponding
birth certificates, one of the ways that they are encouraged to
check on completeness of registration.
With regard to timelines, the vital statistics system is in
transition, with a shift toward electronic collection and
transmission of data. This is dramatically improving
timeliness. In 1995, almost 70 percent of births were
registered electronically, although most States were still
processing a paper legal record.
In October 1996, CDC released preliminary data for calendar
year 1995, including preliminary infant mortality rates, by
cause of death and race. This was an almost 12-month
improvement over previous data releases.
CDC is working further with the States to continue to
improve timeliness of vital statistics in general, and
especially timeliness of the linked birth and death data.
In addition to collecting the vital statistics, CDC
conducts epidemiologic research into the risks and causes of
infant mortality and supports the States to gather and better
use their data to assess their infant health problems and
target their resources. I will now describe some of this work
in a little detail.
For example, one measure that is of great importance is
that of early prenatal care, defined as having the initial
prenatal visit within the first 3 months of pregnancy.
In 1994, about 80 percent of all women received early
prenatal care, but there is substantial variation among our
largest cities, with the cities that have the lowest rates
averaging slightly over 50 percent, and those with the highest
rates having over 80 percent of women receiving early prenatal
care.
Another way that we use vital statistics is in examination
of ethnic and racial disparities in infant mortality. As you
have heard, African-American infants have over twice the rate
of infant mortality as do white infants.
It is found that this is principally due to the very low
birth weight rate, which contributes to almost two-thirds of
the disparity and the concomitive higher mortality of those
very small infants.
Although these very low birth weight infants represent only
a tiny fraction of all the births in the United States--about
2.3 percent of the births to African-Americans and only .8
percent among whites--because of their high mortality, they
account for this excess.
Further, when you look at the risk of death to college-
educated African-American women, compared with college-educated
white women, we find that the excess remains. We would assume,
for these college-educated groups, that access to quality care
would be much more nearly equal than for the population as a
whole, yet the excess remains.
Therefore, CDC has begun to examine the psychological,
social, cultural, and environmental factors that may contribute
to pre-term delivery, using a community participatory approach
in Harlem and Los Angeles. We are working with the communities
to understand how they view the infant mortality and the risks
and protective factors influencing maternal health and
pregnancy outcomes.
CDC also works heavily in the area of birth defects, the
leading cause of infant mortality, where it is surveillance and
epidemiologic capabilities have enabled us to conduct research
that has led, for example, to show that the consumption of the
vitamin, folic acid, could prevent 50 to 70 percent of cases of
neural tube defects, a very serious birth defect.
Our efforts, along with those of others, contributed to the
FDA's decision to require fortification of the food supply with
low levels of folic acid.
I would now like to just briefly mention our work with the
States and communities.
The Maternal and Child Health Epidemiology Program is
collaborative between CDC and HRSA. We support about 15 States
to increase their analytic capability through the assignment of
epidemiologists and support for specific analytic projects.
For example, Georgia evaluated the efficacy of prenatal
care case management funded by Medicaid and found that it does
get high-risk women into care earlier. This evaluation
influenced the State to continue to provide case management
services when it was an area under review.
The other is the Pregnancy Risk Assessment Monitoring
System, or PRAMS, which is an ongoing population-based
surveillance system designed to identify and monitor selected
material behaviors and experiences that occur before, during,
and after a pregnancy.
Again, in fiscal year 1996, we funded 15 States for this.
It is designed to supplement data from vital records and asks a
sample of women who have recently delivered about their
behaviors and experiences, such as access and use of care,
alcohol use, smoking, violence during pregnancy, et cetera.
An example of how this was used: in Oklahoma, they found
that half of all women with Medicaid coverage, who had their
first prenatal visit after the first trimester, indicated that
they began care as early as they wanted to. Thus, awareness of
the importance of prenatal care remains a barrier to receiving
early prenatal care, particularly among women with Medicaid
coverage.
In conclusion, continued progress in reducing the Nation's
infant mortality rate and eliminating the racial and ethnic
differences in pregnancy outcomes will occur if the national,
State, and local commitment to improving birth outcomes also
continues. It is increasingly clear that infant mortality is a
problem that needs broad community-based, as well as medical
interventions. The Healthy Start demonstration projects and the
complementary work that we are engaged in at CDC we hope will
contribute to reducing infant mortality in the future.
Thank you. I will be pleased to respond to any questions
you might have.
[The prepared statement of Dr. Marks follows:]
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Mr. Snowbarger. Thank you, Dr. Marks. Dr. Alexander.
Dr. Alexander. Mr. Vice Chairman, members of the
subcommittee, I thank you for the opportunity to testify here
today. I am Duane Alexander, Director of the National Institute
of Child Health and Human Development at the National
Institutes of Health.
The Congress charged my institute, the NICHD, with
supporting and conducting biomedical and behavioral research on
maternal and child health, the population sciences, and medical
rehabilitation. When my institute was founded in 1962, it was
given a special mandate to address the significant problem of
infant mortality in the United States, which was actually on
the rise at the time. Since then, the U.S. infant mortality
rate has declined by 70 percent.
NICHD-supported research advances have played a major role
in that reduction, particularly improvements in preventing and
treating Respiratory Distress Syndrome and the ``Back-to-
Sleep'' campaign aimed at reducing the risk of Sudden Infant
Death Syndrome.
Since 1990, three major research findings have
significantly affected and accelerated the continuing decline
in the U.S. infant mortality rate.
First is the development and use of surfactant to treat
newborns afflicted with Respiratory Distress Syndrome. Our
research had previously revealed that infants with RDS lacked
surfactant, a surface factor that keeps the insides of the
lungs from sticking together and makes breathing easier.
The development and administration of surfactant has
markedly reduced deaths due to RDS and saves almost $90 million
a year in medical costs.
To illustrate the significance of this advance, in 1963--
the year after NICHD was founded--President Kennedy's infant
son Patrick was born prematurely and died of Respiratory
Distress Syndrome. Despite all his advantages, his doctors and
his parents could only watch helplessly as Patrick struggled to
breathe, because the cause of RDS was not yet understood and
there was no treatment.
Now, with surfactant treatment, new respirators, better
isolettes, and advanced intravenous fluid therapy, all
developed through research, premature babies have a far better
chance to live. When Patrick was born, an infant with RDS, at
his weight and gestational age, had a 95 percent chance of
dying. Today, an infant at that weight and age has a 95 percent
chance of living.
Second, in 1994, an NICHD-supported Consensus Development
Conference concluded that use of antenatal steroids to treat
women in preterm labor would result in a 50 to 60 percent
reduction in the baby's risk of death or suffering
complications.
As a result of our targeted dissemination of the
recommendations from that consensus panel, the use of antenatal
steroids in high-risk women has increased from 15 percent of
such patients to about 60 percent, potentially saving the lives
of several thousand very low birth weight infants each year,
plus as much as $160 million annually in medical expenditures.
Further increases in the application of these
recommendations will result in additional savings in both
infant lives and costs.
The third and perhaps most dramatic research finding that
has reduced infant mortality in the United States in the 1990's
is the realization that placing infants on their backs to
sleep, rather than the common practice of on their stomachs,
reduces the risk of Sudden Infant Death Syndrome.
For many years, SIDS had been the leading cause of death in
infants from between 1 month and 1 year of age. Deaths due to
SIDS have fallen by more than 30 percent nationwide in the past
3 years. Some States are reporting reductions of over 60
percent in SIDS deaths.
Such declines can be traced to the success of the research-
based ``Back-to-Sleep'' campaign designed to encourage back
sleeping for infants.
The ``Back-to-Sleep'' campaign is led by NICHD with the
Maternal and Child Health Bureau and the American Academy of
Pediatrics, in collaboration with SIDS parents and professional
groups. Since the campaign began, it is estimated that 1,600
fewer babies a year die of SIDS.
Despite these major research advances and their direct
impact on reducing infant mortality, the rate of death during
the first year of life is still too high, and remains an
important public health problem for the Nation. We continue to
support a major research program on reducing infant mortality
and anticipate that our expenditures in this area during this
current fiscal year will exceed $94 million.
Recognizing that obstetric and neonatal practice was
hampered by a lack of clinical trials of sufficient size to
give clear indications rapidly of the effectiveness of various
treatment approaches, several years ago we established two
networks for multisite clinical trials in maternal-fetal
medicine and neonatology.
These networks develop common protocols, conduct the trial,
and present the results jointly. To date, these networks have
successfully identified both effective and ineffective
interventions and widely disseminated the results for
clinicians.
Our infant mortality research effort is placing special
emphasis on the leading cause of infant mortality, birth
defects, and the problems of prematurity, especially low birth
weight. For some time, we have explored questions about
possible links between maternal infections and premature birth.
Using the most promising lead we have at the present time
for reducing prematurity, our maternal-fetal medicine network
launched a clinical trial in August 1996 to determine whether
screening pregnant women for a marker of bacterial vaginosis
called fetal fibronectin, and treating them with an antibiotic
to eliminate this infection would reduce the rate of premature
delivery.
This large-scale clinical trial is based on evidence that
bacterial vaginosis triggers premature labor and on small
studies suggesting that antibiotic treatment markedly lowers
that risk.
Because large numbers of women, particularly African-
American women, have this common infection and are unaware of
it, the development of an inexpensive and easy means of
eliminating it could have a major impact on the incidence of
prematurity and infant mortality.
Mr. Vice Chairman, our Institute is proud of its record in
helping to reduce the rate of infant mortality in our country,
and remains committed to continuing to contribute to this
effort in the future.
I will be glad to respond to any questions that you or
members of the subcommittee have.
[The prepared statement of Dr. Alexander follows:]
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Mr. Snowbarger. Thank you, Dr. Alexander. Dr. Simpson.
Dr. Simpson. Good morning, Mr. Vice Chairman and members of
the subcommittee. It is my pleasure to be here. I'm Lisa
Simpson. I'm the Acting Administrator of the Agency for Health
Care Policy and Research.
I take particular pleasure in being able to testify here
this morning, both as a pediatrician, as my colleagues, but
also a former director of maternal and child health for the
State of Hawaii.
There are three major points that I would like to leave you
with today from our Agency's perspective.
First, that we share the Healthy Start Program's goal of
trying to reduce infant mortality and to do that through
research. However, our research programs have never directly
assessed the effectiveness of the Healthy Start Program.
The second point is that health services research, which is
the research that we sponsor, has contributed to our
understanding of the effectiveness and cost-effectiveness of
interventions to improve low birth weight outcomes.
Third, many clinical services today, whether used for
pregnant women, children, or adults, and are considered the
standard of practice, actually lack a strong evidence or
scientific base, and to create that scientific base and to use
it to promote evidence-based practice is a key strategy for
improving clinical care in this country.
The Agency's research emphasis, which stems from our
legislative mandate, has been on issues and conditions which
are common, costly, and for which there is substantial
variation in practice.
Perinatal care, which is the care of a mother before
delivery and of herself and her baby after delivery, is clearly
one of these issues. Let me give you some examples.
Each year in this country, the costs of hospital admission
for childbirth exceed $20 billion. Each year, the incremental
costs of low birth weight are close to $4 billion. To put this
in perspective, the annual direct costs of low birth weight
continue to exceed the cost of AIDS.
AHCPR has a series of studies underway on perinatal care.
Projects include studies of the management of childbirth and
patient outcomes, variations in practice related to prenatal
care, and strategies to improve the outcomes for very low birth
weight infants.
In 1992, the Agency funded a comprehensive 5-year research
project to investigate the components of obstetrical care. The
project, which is titled the Low Birth Weight Patient Outcomes
Research Team, or PORT, is headed by Dr. Robert Goldenberg, a
national authority on low birth weight at the University of
Alabama.
This project is now in its last year, and has already
yielded several key findings, and my written testimony includes
several highlights from this project, but let me just mention
one or two, because I think they exemplify how health services
research complements the biomedical and epidemiologic research
that are conducted by other agencies in the Department.
One of the most important and, frankly, controversial
findings of this study is the lack of evidence for the
effectiveness of prescribing bed rest for pregnant women
considered to be at risk for a number of adverse perinatal
outcomes.
In fact, there is not much consensus about when bed rest
should be used, for whom, or for how long, and yet a growing
body of research is showing that bed rest may, in some cases,
actually be harmful. Still, almost 20 percent of pregnancies
are recommended bed rest today.
So there is clearly a gap, a critical gap, between what we
know from research and what is going on day-to-day in clinical
practice.
Another important finding from this study is that high-risk
babies have an increased chance of survival, with no
significant increase in cost, if they are delivered in
hospitals with a high volume of deliveries in specialized
neonatal intensive care units, or NICUs.
This finding is from California, and it is my understanding
that the California Children's Service, which oversees neonatal
intensive care in that States's Medicaid population, is already
looking to these results to recommend revisions for their State
guidelines on neonatal intensive care.
Overall, this study has already produced 77 published
articles and abstracts in leading peer review journals on these
key findings. Mr. Vice Chairman, I respectfully request that a
cumulative bibliography of these articles be submitted for the
record.
Other findings from this study have influenced the practice
recommendations that have been disseminated by the Centers for
Disease Control and Prevention and the National Institutes of
Health.
For example, this study's findings on cost effectiveness of
the maternal screening and treatment for the prevention of a
disease neonatal Group B streptococcal sepsis were used by the
Centers for Disease Control in formulating their recently
released screening and treatment recommendations.
Other findings from Dr. Goldenberg's study were also used
by the National Institutes of Health in what Dr. Alexander just
mentioned, their consensus development conference on the use of
corticosteroids for fetal maturation and improving birth
outcomes.
But health services research also goes beyond looking at
the clinical services themselves to examine how you organize
and finance health care services and to determine which of
these approaches result in improved quality, better outcomes,
and lower costs.
For example, our researchers have estimated that, in 1987,
health care expenditures for infants totaled $12.6 billion and
were greater on a per capita basis than those of any other age
group younger than 65.
The source of this type of data is the agency's Medical
Expenditure Panel Survey, which collects detailed information
on the use and payment for health care services from a
nationally representative sample of Americans. Many questions
remain unanswered today about the many changes in the health
care system, such as the impact of managed care and what will
happen to the delivery of services at the community level.
This survey, or MEPS, is one source of information that
will be able to shed some light on these questions in the years
ahead. Because this survey is now an annual survey, we will be
able to provide you with much more current data on a yearly
basis, beginning in 1998.
To conclude, Mr. Vice Chairman, there are a number of
interventions being used today to reduce the rate of infant
mortality, and there is wide agreement that prenatal care is a
key strategy, but we need to continue to build the science base
behind these clinical interventions.
We need to give policymakers, physicians, patients and,
increasingly, purchasers and health plans information on which
specific interventions are the most effective and the most cost
effective in reducing low birth weight and infant mortality.
While our agency is helping to bridge some of the gaps in
this area, in other words, between what is known about
effective treatment and the use of these treatments in everyday
practice, a lot of work remains.
I am pleased to say that we are one of the Federal agencies
collaborating with the others at the table and private sector
groups in sponsoring a conference this fall that is going to
bring together national experts on preterm, and really try to
chart the course for research for the next decade in this area.
Thank you.
[The prepared statement of Dr. Simpson follows:]
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Mr. Snowbarger. Thank you very much. We will now go to
questioning for the panel, and I would like to begin by
reminding panelists--maybe that's the best way to do it--
reminding panelists of the chairman's question before he left.
This may really just be for Dr. Nora. I'm not sure. If others
want to respond, that's fine.
My understanding was his question was concerning the
legislation that was passed about the nature of the programs,
maybe beginning at the Federal level but, sooner or later,
becoming local programs that were self-financed.
Dr. Nora, could you respond to the chairman's concern?
Dr. Nora. Yes. I would be happy to. We refer to this as
sustainability. And, in the third year of the program, we
sponsored a national conference addressing this issue.
All of the grantees participated in it, as did some of our
other Federal partners. The private sector was involved. The
State Title V maternal and child health directors were
included, as well as local interest groups.
The grantees have been working on sustainability since that
time. We likewise anticipate that Federal funding will not
continue forever.
Mr. Snowbarger. Those of you who have been around the
committee before know that I like to take advantage of my
freshman status and claim ignorance on a lot of things.
Mr. Towns. Only this year. [Laughter.]
Mr. Snowbarger. I know. I know. Like I said before, I'm
going to take advantage of it.
I am not so sure we are concerned, necessarily, about
Federal funds running out, but it seems to me that there is a
need to expand this to other areas and, rather than expand the
program as a whole, I would think there would be a desire to
establish programs in certain geographic areas and then move on
to continue expanding the program nationwide.
Is that the course this is taking? Do we find any of the
programs that are anywhere near self-sustaining at this point?
Dr. Nora. Well, our intent is to expand the area into
approximately 30 other geographic areas, which would address
the criteria that have been identified. In addition, those
communities must have one-and-a-half times the national average
of infant mortality rates to be eligible.
We anticipate that many of the current existing Healthy
Start sites would serve as mentors to assist the new sites in
using the kinds of interventions that have been successful.
Mr. Snowbarger. I guess the question still is: is anybody
coming close to sustainability at this point? What steps have
been taken in that direction with any of the programs?
Dr. Nora. I would like to ask Dr. McCann to provide more
detail on the sustainability.
Mr. Snowbarger. That would be fine.
Dr. McCann. I guess as a result of the conference that Dr.
Nora mentioned, as well as many of the efforts that are going
on locally, there are several of the Healthy Start Programs
which have been able to find other funding for the currently
funded interventions.
As a result, when we are starting this next phase which we
are calling replication, and asking these current grantees to
mentor, we have given them the option of applying for whatever
model they wish to mentor, so that those that they have found
other funding for they would not be coming in to ask requests
for Federal funding.
In that way, we feel that they will be able to sustain many
of the existing interventions and models that are currently
going on, as well as getting support from us to help them with
those that they have not currently found funding for.
Mr. Snowbarger. So all of the programs that we currently
have in place will continue to receive funding?
Dr. McCann. Some funding.
Mr. Snowbarger. Some funding.
Dr. McCann. But not to the level that it will fund all of
the interventions that they currently have supported.
Mr. Snowbarger. OK. I'm not sure who to address this
question to, but one of the questions that came up as I was
listening to all of you speak is trying to get a handle on how
infant mortality, low birth weight, et cetera--it seems like it
has been going down nationwide.
Do we have some comparison between how programs in these
cities have fared versus the nationwide averages, as they have
gone down?
Dr. Nora. We have some results from the local evaluations
that would give us some information on that. Dr. McCann, do you
have the details?
Dr. McCann. Yes. We have trends that we have been following
among all of our grantees, in terms of what their infant
mortality rates are, but we are not attributing those infant
mortality rate drops entirely to the Healthy Start Program,
because we plan to wait for the outcomes of the national
evaluation to really point that out to us in a much more
technical manner.
However, through the local evaluations, many of our
grantees are reporting outcomes which suggest that they have
increasing enrollment in the first trimester, that they are
seeing more women during their pregnancy for prenatal care,
that low birth weight seems to be declining in many of the
sites and, you know, they have identified which clients have
received case management or outreach, and those clients whom
have been case-managed have reduced low birth weight rates.
So we are beginning to start to see some declining numbers
within the specific population that is affected through the
Healthy Start Program, but we cannot report that the decreases
are entirely due to the Healthy Start Program right now.
Mr. Snowbarger. You don't have any basis for saying that
the reductions are greater where the programs are in place than
they would be nationwide?
Dr. McCann. We can't say that, no.
Mr. Snowbarger. Dr. Marks, do you have any basis for
answering that question?
Dr. Marks. No. Really, the evaluation being done by
Mathematica will allow that to be looked at more thoroughly, in
that, in many of the cities, the Healthy Start has selected
certain areas of the cities so, overall city statistics might
not adequately reflect what is going on in the Healthy Start
areas. But the data that we have from Vital Statistics is being
made available for the evaluation, as they need it.
Mr. Snowbarger. If I can follow through on one question,
that has to do with the statistical analysis here by
Mathematica, apparently they were brought on board in 1993. I
understand that this is going to be a 5-year study and we'll
study the first full implementation here.
Is there any provision, though, in their contract or in
your arrangements with them, for interim reports, so that we
have some preliminary findings before the end of 1998? If I
understand this correctly, we're talking about this program
ending, in theory, in September 1997, and it's going to be a
full year, a year and 3 months later, before we can find out
whether or not the program has been successful.
Dr. Nora. Well, it's certainly true that the national
evaluation will not be available until 1998, but I think there
is some preliminary evidence in the local evaluations that are
showing changes in the communities where these programs are
located. I think you will hear about some of those from the
next panel.
Mr. Snowbarger. All right.
Dr. McCann. In addition, there are reports that are being
released that have begun earlier.
As Dr. Nora reported, there are not only outcome portions
for the national evaluation, but there is also process analysis
going on that some of these reports are being prepared at
present, they are undergoing the process that is set in place
for review by the grantees and other professionals prior to
being released. So some reports are available.
We also have what we refer to as special reports that have
been completed. One has been done on the outreach workers in
Healthy Start; another has been done on the adolescent services
in Healthy Start. Those reports are out and available at this
point in time.
Mr. Snowbarger. Thank you. Mr. Towns.
Mr. Towns. Thank you very much. Let me make certain I'm
hearing you right.
In your testimony, you indicated in Pittsburgh the rate of
infant deaths for pregnant women receiving case management and
home visiting is 7.8 per 1,000 birth rate, 50 percent lower
than the rate of 15.6 for women not participating in the
Healthy Start Program, but also living in the housing
development.
Now, what do you mean by that?
Dr. McCann. Well, what you're reading are data that are
reported by the grantees in their applications that they
present to us on an annual basis, which really provides an
opportunity for us to monitor the progress of the project.
There are other kinds of interventions going on in each of
the Healthy Start communities, other than the Healthy Start
interventions.
By looking at comparisonsites, which will be part of the
contract with Mathematica, we would be able to tell more
directly exactly what impact the Healthy Start Program has had
on these communities, and that's the part of the evaluation
that we are awaiting.
But, in the meantime, the grantees have taken a very close
look at their specific interventions, such as the one that
you're referring to in Pittsburgh, where they have taken a look
at their case managed population and just taken a look at
what's going on with infant mortality and low birth weight.
Mr. Towns. So, in other words--I mean, let me just make
sure I fully understand--you say there are reasons for me to be
excited about this?
Dr. McCann. There are reasons for you to be excited about
it. We are very happy about it.
Mr. Towns. OK.
Dr. McCann. We think that it's pointing in the right
direction, and we are awaiting the comparisonsite evaluation by
Mathematica to support what we've seen preliminarily.
Mr. Towns. OK. That's very clear. Let me just sort of ask a
general question to, I guess, all of you. If we were to
eliminate local community-based programs, like Healthy Start,
what would be the impact of the underserved communities
currently benefiting from the program? What would happen? We've
seen enough to be able to make a general assessment, haven't
we?
Dr. Nora. Well, we feel that Healthy Start was the glue
that pulls together the services that are existing within the
community, and we feel that it has strengthened the foundation
that is there and has made the community more aware of what
needs to be done; so we feel that it is important to be able to
bring this about.
In many of the projects, for example, there have been
efforts to integrate the services from across agencies, such as
WIC, the Infant Feeding Program, enrolling women in Medicaid,
and the outreach services that you mentioned earlier.
So it's an effort to pull all of these together to address
the problems of the entire woman and her pregnancy and the
baby.
Mr. Towns. Thank you. Dr. Marks, I think you mentioned in
terms of working with the community.
Dr. Marks. Yes.
Mr. Towns. I think I heard you say that. What do you mean
by that, when you say working with the community?
Dr. Marks. Sure. We've used the community approach in a lot
of areas, and not just in the infant mortality area, but we
have the projects that I mentioned in Harlem and in Los
Angeles.
One of the issues in working with the community is find out
how--as I mentioned before, we found that Medicaid women in
Oklahoma got care as early as they wanted. We need to find out
what are the sort of, the local issues that have people not
getting the care when it is available to them, what are the
issues that they see are important as barriers to care, whether
it's transportation, whether it's being encouraged and helped
to change behaviors that contribute to poor infant outcomes.
What we are doing in ours is to spend a lot of time with
focus groups and working with the community to see how they
frame the issues of infant and mothers' health, and then
whether we can, in fact, by what we learn by talking with them,
modify the systems that exist in their communities so that they
are more responsive and more specific for the kinds of concerns
that they have.
In those discussions, we spend time saying what we know
about the medical risks, what we know about the behavioral
risks, so that they understand what we do know, but especially
in the area of the gap between African-Americans and white
Americans infant health.
Whenever we do that analysis on just the medical factors,
we can explain some of that gap, but not all of it, so we have
to look for other interventions, and we think that some of that
may come from the community and what they perceive as the
issues and problems that they have to deal with.
Mr. Towns. Thank you very much, Mr. Chairman. I yield back.
Mr. Snowbarger. Thank you. Let me just try to close up this
panel with some questions about coordination between the
agencies that we have here.
We've heard research telling us new ways to deal with
problems, to what extent is Healthy Start, you know, monitoring
those changes and implementing those changes within their
communities, to what extent does the CDC monitor what Healthy
Start may be doing.
Is there any coordination or interfocus here between the
groups about how we're dealing with these infant problems in
high-risk areas, I guess is the best way to put it?
Dr. Nora. I think one very clear example is Sudden Infant
Death Syndrome and the ``Back-to-Sleep'' campaign. All of the
Federal agencies participated in this, and we continue to work
together on this campaign and share expenses; and I think it's
made a lot of difference as far as infants dying with sudden
infant death.
Maybe Dr. Alexander would like to add something else.
Dr. Alexander. Yes, I think that the SIDS experience is an
excellent example of agencies working together. The
epidemiologic findings clearly indicated that sleep position
was associated with Sudden Infant Death Syndrome and that back
was safer. All of us worked together in putting together the
``Back-to-Sleep'' campaign.
In addition, the Centers for Disease Control worked
together with us in the research community to develop a
protocol for a death scene evaluation that helps in
establishing the cause, that SIDS is, in fact, the attributable
cause of death or not.
All of us have worked cooperatively in developing materials
and getting the message out, and this message has been picked
up, it is my understanding, in the Healthy Start sites and
implemented very effectively in those communities where Healthy
Start exists.
Mr. Snowbarger. Thank you. Are there any more questions?
[No response.]
Mr. Snowbarger. If not, I thank the panel for coming this
morning and for presenting their testimony. And just to assure,
I can't remember who it was that asked, but all of your written
testimony will be included in the record. So thank you.
I think I would like to call the next panel forward: Thomas
Coyle, Melanie Williams, Barbara Hatcher, and Juan Molina
Crespo as well, by the way, as Dr. Guyer and Robert Pugh.
I apologize for letting you sit down first. We need to
swear you in, so if you could, all stand and raise your hand.
[Witnesses sworn.]
Mr. Snowbarger. I would like to recognize one of our
colleagues, Representative Cummings, at this time.
Mr. Cummings. Thank you very much, Mr. Chairman and our
ranking member. Thank you.
Mr. Chairman, I would like to introduce two esteemed guests
from my congressional district of Baltimore, and make some
brief remarks regarding the Healthy Start Program.
Historically, the 7th Congressional District of Baltimore
has experienced an exceedingly high rate of infant mortality.
Many high-risk areas in the city had twice the national average
of infant deaths. However, with the implementation of the
Healthy Start Program in 1993, Baltimore has drastically
reduced the number of babies born with low birth weights and
severely reduced the number of infant mortalities.
The Healthy Start staff, in conjunction with the Mayor's
Office and the surrounding community, are committed to ensuring
that all babies have a strong and healthy beginning, by
providing important prenatal care to high-risk mothers who need
it most.
Our city's infant mortality rate has dropped 31 percent
since the implementation of the Healthy Start Program. In the
two neighborhoods where Baltimore's Healthy Start Centers are
located, the infant mortality rate has been slashed by a
staggering 61 percent. The Baltimore example is truly a success
story.
We have targeted the program services to the poorest areas
of the city, which are at the highest risk. The staff is mostly
comprised of community residents who have been hired and
trained through the program, thereby providing important
employment opportunities to the community.
I might add, Mr. Chairman and members of the committee, I
have had an opportunity to meet many of those people who work
in the program. They are very dedicated. They give much of
their time and effort, going beyond the normal 8-hour day, to
assist people in lifting themselves up and lifting their
children up.
Mr. Chairman, this program is working, and I decry any
attempt to reduce its funding level.
I would now like to recognize Dr. Bernard Guyer and Mr.
Thomas Coyle. I am very pleased that they are able to testify
as to the merits of the Healthy Start Program in Baltimore.
Dr. Guyer is chair of the Maryland Commission on Infant
Mortality Prevention, and professor and chair of the Department
of Maternal and Child Health of the Johns Hopkins University
School of Public Health and Hygiene.
Mr. Coyle is currently the assistant commissioner for
maternal and infant care and special projects, of the Baltimore
City Health Department. He is responsible for all maternal and
infant programs managed by the Baltimore City Health
Department. He also serves as project director for the Federal
Healthy Start Program.
I am so proud of the work that these gentlemen do on behalf
of so many. Mr. Chairman, I thank you for the opportunity to be
here with them and I look forward to hearing their testimony.
Mr. Snowbarger. Thank you, Representative Cummings. And,
with that, Mr. Coyle, we will turn the microphone over to you.
STATEMENTS OF THOMAS COYLE, ASSISTANT COMMISSIONER, BALTIMORE
CITY HEALTH DEPARTMENT, MATERNAL AND INFANT CARE AND SPECIAL
PROJECTS, ACCOMPANIED BY BERNARD GUYER, CHAIRMAN, DEPARTMENT OF
MATERNAL AND CHILD HEALTH, JOHNS HOPKINS SCHOOL OF HYGIENE AND
PUBLIC HEALTH; MELANIE WILLIAMS, PROJECT DIRECTOR, MISSISSIPPI
DELTA FUTURES HEALTHY START, ACCOMPANIED BY ROBERT PUGH,
EXECUTIVE DIRECTOR MISSISSIPPI PRIMARY HEALTH CARE ASSOCIATION;
BARBARA HATCHER, PROJECT DIRECTOR, DISTRICT OF COLUMBIA HEALTHY
START PROGRAM; AND JUAN MOLINA CRESPO, PROJECT DIRECTOR,
CLEVELAND DEPARTMENT OF PUBLIC HEALTH
Mr. Coyle. Thank you, Congressman, and good morning, Mr.
Vice Chairman and members of the subcommittee.
We welcome the opportunity to be here today to testify
about the National Healthy Start Program. I have submitted my
testimony earlier this week, and we will try to summarize that
today.
I am joined here on my left by Dr. Bernard Guyer, who
Congressman Cummings has already introduced. I had listed out
all of Dr. Guyer's titles and several other things, but I'm
going to have to pass on this, since the Congressman has
already done that.
Because our time is limited, and because the focus of this
hearing is on evaluation, and because Baltimore City has
dramatic results in terms of the local evaluation, I am asking
Dr. Guyer, whose department has overseen this evaluation for
over 6 years, to do most of the testimony.
Bernie.
[The prepared statement of Mr. Coyle follows:]
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Mr. Snowbarger. Dr. Guyer.
Dr. Guyer. Thank you, Mr. Vice Chairman. I am pleased to be
asked to come here today by Tom Coyle and the Baltimore Healthy
Start Project. This is a wonderful collaboration between
faculty at Johns Hopkins and our colleagues in the Baltimore
City Health Department.
I have a handout that I put on the table with some of these
earlier results, for the committee. Let me just summarize
briefly the findings.
This committee is obviously very well-informed on issues of
infant mortality and low birth weight, and I won't go into any
of the background to that. What I want to provide you with is
some early evidence of the evaluation from the Baltimore
Healthy Start Project.
These data come from more than 600 women who participated
in the Baltimore Healthy Start Project during their
pregnancies, and they are compared to more than 500 women who
became known to the Baltimore Healthy Start Project, but only
after they delivered their babies.
In summary, the data show that the women who did not have
the Healthy Start services prenatally were more than twice as
likely to have a low birth weight baby, more than three times
as likely to have a very low birth weight baby, and more than
twice as likely to have a pre-term delivery.
Clearly, there is something going on with exposure to the
Healthy Start interventions during the pregnancy that gives
these women advantages over those who get to Healthy Start
after the baby is born.
The faculty at Johns Hopkins has been taking a careful look
at this data, trying to dissect it and understand what factors
account for these kinds of differences. But one thing that they
have done immediately was to look at women who are substance
abusers in both groups--those who get Healthy Start services
before the baby is born, during pregnancy, and those who only
become available afterwards. These findings hold up even among
women who are substance abusers.
I do not have hard answers for you on the causes and the
difference that Healthy Start makes, but I want to point you in
a particular direction that I think is important from the
Baltimore experience. Now, we know that low birth weight is an
important precursor of infant mortality.
It is influenced by a whole set of medical factors, but it
is also, as often is said, it is a social problem, and the
Healthy Start intervention in Baltimore, in particular,
provides social support, housing, job preparation, education,
case management to these women, and it may be that what we are
seeing among the Baltimore Healthy Start participants is the
added benefit of all those intensive services in reducing low
birth weight.
We have had very few studies in the past that have made
this level of intensive investment in these high-risk
pregnancies to try to see whether they could have these kinds
of effects on the difficult outcomes like very low birth weight
and low birth weight.
There are lots more analysis that need to be done with
these data to be able to come up with definitive findings, but
the early findings are very positive. Thank you.
[The prepared statement of Dr. Guyer follows:]
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Mr. Snowbarger. Thank you, Dr. Guyer. Mr. Coyle, does that
complete your testimony?
Mr. Coyle. Yes.
Mr. Snowbarger. Thank you. With that, I would like to call
on another of our colleagues, Representative Thompson, at this
time.
Mr. Thompson. Thank you, Mr. Chairman, and other members of
this subcommittee. I am happy to come and introduce someone to
you who is project director for our Delta Futures Healthy Start
Initiative in Mississippi and one of the few rural projects we
have across the country. But my support for this project is 100
percent. They operate presently in the 2d District of
Mississippi, which for the record is the State with the highest
infant-mortality rate. It ranks No. 1.
And I am honored to introduce Ms. Melanie Williams, the
distinguished project director of the Delta Futures Healthy
Start Initiative. Ms. Williams has done outstanding work
administering this program in Mississippi and is due much
credit for its success. A licensed, master-level social worker
of 10 years, she has demonstrated extensive leadership and
administrative ability through the development and
implementation of innovative programs dealing primarily with
maternal and child-health issues.
I also again want to say that my experience with this
project indicates that it is an excellent project, Mr.
Chairman, and I hope from the testimony that you will receive
from Ms. Williams and others here you will see that it is well
worth the investment.
And, once again, I would like to thank the committee for
allowing me to introduce Ms. Williams, and I present Ms.
Williams to you at this point.
Mr. Snowbarger. Thank you, Representative Thompson. Ms.
Williams.
Ms. Williams. Mr. Vice Chairman and members of the
subcommittee, thank you today for the opportunity to address
your organization about Delta Futures, and I bring you
greetings from the Mississippi Delta. Delta Futures was funded
in 1994 as one of the seven special projects added to the
Healthy Start Initiative. We began with an infant mortality
rate of 15.5 percent, which was a 3-year average over 1998 to
1990.
The project was formed around two primary goals: one, to
reduce the infant mortality rate by 20 percent; and the second,
to establish community-based groups and organizations that
could provide input and guidance into program planning and
implementation.
We attacked the infant mortality rate problem by developing
a number of strategies that we have implemented throughout our
eight-county project area. We have worked to develop programs
that enhance existing clinical services by providing prenatal
care providers to areas where those types of services did not
exist. We worked to reduce risk for pregnant and parenting
women by promoting healthy deliveries and enhancing parenting
skills.
We have also worked to provide facilitative services that
help to provide better access to prenatal care services by
providing transportation and child care for women who are
trying to access prenatal care services.
We have provided a great deal of training and education
that helps to raise public awareness. We have developed public
service announcements, brochures, and videotapes that are made
available to a wide variety of community groups and
organizations throughout the project area.
A lot of our efforts have focused on programs that target
adolescents and the gateway problem of teen pregnancy. We have
worked to develop efforts that boost self-esteem among young
people and encourage them to delay sexual activity until they
are ready for that responsibility.
Our infant mortality rate has dropped 10.6 percent in 1995,
which was a decline of 30 percent. I am not certain that we can
target Delta Futures with that full responsibility for that
decline. Our project has only been in existence for 2 years,
and many of our programming efforts focus on more long-term
outcomes.
The second component that we worked on was the development
of community-based groups and organizations that can help to
provide input into program planning and implementation; this
has been the most challenging and rewarding component of our
project. We believe that communities best know how to solve
their own problems, and it is simply our job to help them
determine what their needs might be and to help them craft
strategies that they think will work in their communities.
This has not been without its share of conflict. Sometimes
communities tell us things that we do not necessarily want to
hear, or want to implement strategies that we know cannot work
or cannot be done. They may come to the table with their own
agenda and their own ideas that may not necessarily relate to
infant mortality reduction.
We have worked very hard to increase the capacity of our
communities and to build infrastructure and to encourage
collaboration among existing groups and organizations. We have
been successful in developing an RFP process that has put over
$840,000 back into local community-based organizations for the
development of infant mortality reduction strategies.
We have worked to provide training in leadership
development, consortium building and maintenance, and conflict
resolution to these local groups and organizations.
The Division of Healthy Start has been very helpful to
Delta Futures with implementation of this initiative. Through
site visits and technical assistance during critical periods of
our implementation, the Division has demonstrated a commitment
to fostering successful achievement of project goals.
It should be noted, however, that while expansion of infant
mortality prevention initiatives to new communities is
important, it is equally important to assist currently funded
Healthy Start projects to sustain and continue effective
services as well.
Healthy Start should balance use of available funding for
both the maintenance of service levels for current projects and
seeding of new projects. Delta Futures is a unique Healthy
Start initiative, inasmuch as it is only one of three rural
projects. Our experience has been that expectations or
objectives oftentimes are somewhat ambitious for rural
communities.
Many systems and organizations that are readily available
in urban areas often do not exist in rural communities. Much of
Delta Futures' efforts have focused on building infrastructure
and strengthening communities' capacities to meet the
challenges of dealing with these complex issues. Because of
these challenges, our progress oftentimes seems slow or fraught
with conflict.
We are strengthened, however, by the ever increasing
commitment, enthusiasm, and willingness of the communities we
serve to reduce infant mortality, and as a result of our
efforts we believe that not only will we have successfully
reduced infant mortality in the Delta, but we will also improve
communities' ability to address many other issues that affect
the quality of life for its residents.
[The prepared statement of Ms. Williams follows:]
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Mr. Snowbarger. Thank you very much, Ms. Williams.
I apologize to the panel. We have been called to the floor
for a vote, so we will take a recess. Until we get back, we
would ask those that want to continue on the panel here, and,
Mr. Towns, if we can get back as quickly as possible so we do
not inconvenience these panelists any more than necessary. We
will stand in recess.
[Recess.]
Mr. Snowbarger. OK, we are ready to begin again. Mr. Towns.
Mr. Towns. Thank you, Mr. Chairman. I want to thank all of
the panel members for coming here today to present your
testimony. I would also like to introduce Dr. Barbara Hatcher,
who is the project director for the District of Columbia
Healthy Start Program. Dr. Hatcher, Representative Eleanor
Holmes Norton has asked me to commend you, on her behalf, for
your excellent service.
Ms. Hatcher. Thank you very much. Good morning, Mr. Vice
Chairman and other honorable members of the subcommittee. I am
Dr. Barbara J. Hatcher, project director for the District of
Columbia Healthy Start project. I am here today with Carol
Coleman, a resource mother in our project.
I am pleased to have this opportunity to share what we have
learned in the District of Columbia. There are many lessons
learned from our experience with Healthy Start. I would like to
take just a few minutes to summarize three major lessons
learned from this demonstration effort.
From a practical standpoint, we have learned about dealing
with communities and people in communities. We know the
importance of taking the services to the community and getting
community ``buy-in.'' For example, we have hired and trained
community residents and provided them with some marketable
skills.
This was not an easy or simple task. It is important to
note that some of our staff from Wards 7 and 8 are ex-
offenders, former substance abusers, and former welfare
recipients. We also have a cadre of community residents also
working on this problem. We have learned what it takes to
prepare those who have never worked or have not worked in a
long time.
Besides new skill development, we know we must help
individuals improve their self-esteem, self-worth, and life
skills. The hiring and training of community residents is a
small but important economic and community development effort.
It is important to the individual and the total community.
Because of efforts like Healthy Start, Wards 7 and 8 are
beginning to change. Given our practical and hands-on
experience, we can assist new communities to design appropriate
training programs. This not only has applicability for Healthy
Start but for new welfare reform efforts at the State level.
We have learned about working in communities and addressing
the infant mortality problem holistically. We have clearly
learned that Medicare alone cannot reduce infant mortality. We
are helping to redefine health care to be an inclusive concept
viewed within the community context and on a continuum.
Health care in depressed and low-income communities means
more than prenatal care. It includes what health professionals
call ``enabling services,'' such as social case management,
smoking cessation, substance abuse counseling and treatment,
and an array of preventive and educational services. We can
guide new communities as they attempt to redesign their system
of care.
While we must continue to validate our data scientifically,
we have also learned more about the association of substance
use with poor pregnancy outcomes. Our infant mortality review
and case management data strongly suggest that substance use is
a marker for poor pregnancy outcome. We believe that data such
as this from Healthy Start can help researchers pose and
examine new research questions.
However, the lack of scientific rigor does not diminish
what we have to share with others. We can help new communities
learn efficient and effective techniques for finding substance
abusers, screening for substance use, working with families
affected by substance use, and designing a system of care for
those very complex cases.
I would like to take a few minutes to address
sustainability. We are trying to sustain our efforts but must
compete with public safety, public works and welfare funding in
the District. As the total dollars decrease in the District and
we change to a system of managed care, sustainability is not
assured and will, of course, be more difficult. Infant
mortality is on the District's health policy agenda, and we
hope to be able to influence funding decisions.
In closing, these are only a few of the lessons we have
learned. We hope this is helpful and thank you for the
opportunity. I will be open for questions.
[The prepared statement of Ms. Hatcher follows:]
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Mr. Snowbarger. Thank you, Dr. Hatcher.
OK. I am going to call on Juan Molina Crespo, please.
Mr. Crespo. Good morning, Mr. Chairman, members of the
committee. My name is Juan Molina Crespo, and I am the project
director of the Greater Cleveland Healthy Family/Healthy Start
Project, which is the Healthy Start Initiative in Cleveland,
OH. On behalf of Michael R. White, mayor of the city of
Cleveland, I would like to thank this committee for the
opportunity to provide testimony regarding our project.
Mr. Chairman, with your permission, sir, I did bring a
poster that I would like to put on the easel.
Cleveland is 1 of the 15 original Healthy Start sites.
Healthy Start services have been available in 15 designated
neighborhoods in the city of Cleveland since October 1992, and
since that time we have seen steady progress. We have seen a
dramatic drop in infant deaths among the women who actively
participate in the Healthy Start Project, from a high of 20.2
deaths per 1,000 births in 1993 to 11.3 per 1,000 births in
1995.
In calendar year 1996 alone, 1,852 pregnant women were
enrolled in the Cleveland project. Each one of those women then
received the help and support they needed to ensure a healthy
birth. The rate of infant deaths for the population of women
who live in the project neighborhoods but who did not enroll in
the project rose from 21.5 in 1993 to 25.7 deaths per 1,000 in
1995.
We know that when we are able to find and enroll pregnant
women, outreach, indeed, works to reduce infant mortality.
Overall stats show that in 1990, the infant death rate in the
Project area was 22.4 deaths per every 1,000 live births. In
1995, that number was reduced to 20.8.
The impact of the program can also be seen in the decrease
in low birth weights among infants born in the Project area.
Low birth weight is defined as an infant who is born weighing
less than 2,500 grams. Low birth weight is often a precursor of
severe health problems for the baby, which can often lead to
death.
In 1990, the rate of babies born at this weight in the
Project area was 148 for every 1,000 live births. In 1995, in
the Project area, we have seen that rate drop to 121.3 for
every 1,000 live births. In order to reduce infant mortality
and address the problems leading to infant death, it is
imperative for a woman to enter prenatal care early in her
pregnancy and to continue that care on a prescribed schedule up
to delivery.
In 1991, the percentage of women living in the Project area
who delivered without having any prenatal care at all was 8.9
percent. By 1995, that figure had been reduced to 3.8 percent.
In 1990, 48 percent of women living in the project area who
delivered received an adequate level of prenatal care; that
figure was raised to 50.2 by 1995.
Our Project in Cleveland was carefully designed to achieve
these types of results, and began with a focus on four goals,
sir. The first, of course, was the reduction of infant
mortality in the city of Cleveland by 50 percent within 5
years.
Second, the Project was to create support for a system-wide
collaboration and integration among the social and medical
systems in the community.
Next, the Project sought to empower the community through
entry-level job opportunities, as well as volunteer leadership
development.
Finally, the Project was meant to test and refine new
strategies for addressing infant mortality, and identify those
which work and develop ways to sustain them and their effects.
The Healthy Start Initiative funding launched the creation
of a community-wide consortium to systemically address the
problem of infant deaths. Now well-established after 5 years,
the Healthy Start Consortium is made up of community residents,
project participants, medical and social service providers,
nonprofit agencies, community-based organizations, clergy, and
educators.
The Consortium has provided an unprecedented opportunity
for citizens and the public and private sectors to work
collaboratively to solve a major public health problem.
Healthy Start Initiative funding in Cleveland has also
allowed for the creation of a research team devoted solely to
investigating the causes of infant death in the city of
Cleveland. The results of this research have revealed that the
leading cause of death in our community is prematurity,
followed by Sudden Infant Death Syndrome, birth defects, and
infections, such as sexually transmitted diseases.
Taken together, these factors account for two-thirds of the
infant deaths in Cleveland. Armed with this information, the
Consortium began to focus its energies on the prevention of
these specific problems. The focal points of the Consortium's
educational programs were narrowed to the signs and symptoms of
preterm labor, the prevention of sexually transmitted diseases,
and appropriate sleep positioning for newborns to prevent SIDS.
These programs have been aimed at the general public
through a public information campaign. Outreach workers have
also received extensive training on these issues in order to
educate project participants one on one.
As the demonstration phase of the Healthy Start Initiative
draws to a close, we are in a position to analyze the public
health lessons learned. In Cleveland, our success rests largely
on the consortium structure, which has allowed a high level of
communication amongst providers and community to better address
the needs.
Also, we have learned that the causes of infant death in
our community may most often be traced to high-risk situations
in which a pregnant woman may find herself. You may remember
that in December 1994, there was a discovery of pulmonary
hemosiderosis that was found in Cleveland, and members of the
CDC dispatched a team to be able to do the appropriate
investigation of hemosiderosis.
The team that was dispatched by CDC from Atlanta was met by
our outreach workers. They were allowed into the homes where
the cases had been found, so we see that the outreach team
which has been developed in Cleveland has gone beyond the
Healthy Start box, and it has ramifications for other public
health initiatives in the city of Cleveland.
With these lessons in mind, the Greater Cleveland Healthy
Family/Healthy Start Consortium's vision for the future is the
provision of supportive services to the highest risk women in
the community: those who struggle with chemical dependency,
those who reside in homeless shelters, domestic violence
shelters, those who are incarcerated, as well as the teens and
the women who have fallen through the cracks of the health care
safety net in our communities.
Therefore, I would respectfully urge this committee to
recommend the continued funding of the Healthy Start Initiative
at the community level. Channeling this money through any other
agencies, either State or Federal, would dilute the effects of
the program and halt the real progress being made to reduce
infant deaths.
In Cleveland, we believe the people most qualified to
combat the issues of infant mortality are the people who face
those problems on a daily basis. Thank you.
[The prepared statement of Mr. Crespo follows:]
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Mr. Towns [presiding]. Thank you very much. At this point,
I would turn to a gentleman from Cleveland who knows a lot
about Cleveland. In fact, he was the mayor of Cleveland.
Mr. Kucinich. Thank you very much, Mr. Chairman, members of
the committee. I certainly want to welcome our visitors from
Cleveland and let Mr. Crespo know that I appreciate the work
that you are doing in our city on this program.
In my view, Healthy Start presents possibilities for saving
the next generation and for saving succeeding generations. It
is a part of our responsibility as lawmakers and as
policymakers to be sure that our policies are going to enable
babies to grow, to blossom in a healthy way, and I know this is
what this program is about.
And I have a few questions, if I may, with permission of
the Chair, to ask relative to the program in Cleveland, so that
perhaps you can help us understand precisely where those
benefits are and enable us to develop policies that will be
consistent with the needs of the people of not only our
community, but others who are affected by this program.
With respect to the data that has been provided to the
committee, one document cited Profiles, Attachment No. 1. It
says that Cleveland has seen a reduction of infant mortality
among women enrolled in Healthy Start from 22.4 out of 1,000
births in 1991 to 16.33. And in another document, which is the
Health and Human Services Fiscal Year 1998 Justification,
Attachment 3, it says there has been a reduction in infant
mortality from 22.4 to 13.5 per thousand. Still, in another
document provided by the city of Cleveland, as well as cited in
your testimony, it says that infant mortality among women
enrolled in the program is now at 11.3 deaths per 1,000 births.
Could you help to establish what is the correct infant
mortality rate per 1,000 births for women enrolled in the
Healthy Start Program today?
Mr. Crespo. Thank you, Congressman, yes. The data that you
referred to earlier is earlier data. The most current data that
we have, as of January 1997, for the women enrolled living in
the project area and enrolled in our Healthy Family/Health
Start Program is 11.3 deaths per every 1,000.
Mr. Kucinich. So, then, it would be fair to say, then, that
over the course of the program the infant mortality rate has
actually been cut in half, from 22.4?
Mr. Crespo. That is correct, for the women enrolled in the
project----
Mr. Kucinich. Right. I understand that----
Mr. Crespo [continuing]. The infant mortality rate has been
reduced by approximately 50 percent.
Mr. Kucinich. Mr. Chairman and members of the committee,
this is, I think, a striking testimony to the effectiveness of
a program when you can actually cut infant mortality rates by
one half. There are certain challenges, which, as you know, are
out there to the whole idea of Healthy Start, and some people
would say that the decrease in infant mortality rate could not
be directly attributed to Healthy Start. But even though let's
suppose for the sake of discussion that the decreases in the
IMR cannot be directly attributed to Healthy Start, aren't
there intangible benefits which are not measurable by the
statistics which accrue to the community?
Mr. Crespo. I think that in terms of the spillover effect
that we have that this project has been able to provide to the
community is one of dignity to a population where historically
we have not been able to do that. When we speak about
empowering the community and bringing them to the table to
develop the strategies and help us administer a project that is
going to save the babies in our community, I think that is
something that is very valid and certainly is something that
speaks to the future generations, like you indicated earlier.
So there are a lot of things. In terms of the job training,
the skills development, our outreach workers, for the most
cases, this was their first real job. I mean, they were one
step away themselves from being a participant in this project.
We have been able to not only bring them on as indigenous
outreach workers, those folks that are recognized by the
community as a leader in that community and to train them, but
also in many cases they have moved on to other jobs.
A good example of that, sir, is the recent flurry of HMO
activities all over this country. We have had our outreach
worker army raided, to some degree, by HMOs because they know
that the members that they are trying to reach are, for the
most part, the same participants that our outreach workers have
access to.
So we have developed a mechanism that is now being used by
at least three HMOs in Cleveland to be able to access those
difficult members. And as we all know, if we continue to get
them in prenatal care early, that means higher profit margins
for the HMOs.
Mr. Kucinich. Mr. Chairman, is there time for a couple of
more questions?
Mr. Snowbarger [presiding]. Well, let's see. Make them
short. Go ahead.
Mr. Kucinich. OK. According to Lolita McDavid, who I know
you are familiar with at Cleveland Rainbow Babies and
Children's hospital, says that for every $1 spent on prenatal
care, we save $3 in later cost for babies that are born too
soon or too small. And through this program, have you done any
studies which estimate how many dollars have been saved by
getting women, particularly high-risk women into early prenatal
care?
Mr. Crespo. Sir, I have not done that study, but let me try
to respond this way. I have taken a walk through the intensive
care, perinatal unit at Metro Health Hospital, and every baby--
those million-dollar babies that are lying there--and some of
them never get a chance to go home--we feel that those are our
babies, and if we can continue to reduce the number of babies,
the number of million-dollar babies that are in that intensive
care unit, then we think that all the dollars that are spent
with respect to Healthy Start are dollars well spent.
Mr. Kucinich. Thank you, Mr. Chairman. I want to thank you.
I just would like to conclude by saying this, that Cleveland
has this wonderful facility at Metropolitan General Hospital,
where we care for babies that are born prematurely for a number
of reasons, and this is what he is talking about. There are
babies that effectively require $1 million in care because they
have not received--their mothers perhaps have not received the
kind of care which this program can provide.
So I view life as a seamless web, and these newborn
children are certainly part of that, in the essence of it, and
so I am strongly in favor of this program, and I hope that we
will get support from members of the committee and the Congress
to continue. Thank you very much.
Mr. Snowbarger. Thank you. I do not know how many of you
were in the room before Chairman Shays left, but he left us
with a question that probably you can answer better than those
on the first panel. It was his understanding, as this Healthy
Start Program was put into place initially, that there were
really two hopes for these programs. One is that they would be
very much controlled locally, and the second is that they would
be at some point in time where they would be self-financed and
self-sustaining.
I believe that Dr. Hatcher addressed that, to some extent,
in her testimony, but could the others of you respond to the
sustainability question, please?
Mr. Coyle. Yes. I would like to. We, in Baltimore, never
understood that.
Mr. Snowbarger. Well, it is important for us to know that.
Mr. Coyle. We understood that that was supposed to be the
strategy. We did not understand how that would ever work. The
reverse would be true for us. We would think that the strategy
would be if you took 15 sites and did this kind of intensive
intervention, looking for real models that work, that you would
then continue a few of the best sites and let the rest of the
sites go--that is what our view of what a demonstration project
ought to be--so that those sites that have done this would
continue and be able to put that kind of information and
technical assistance and research out to the rest of the
country.
We are working very aggressively to find dollars to sustain
our program, and we hope to do that, but if anybody knows the
foundation situation these days and the whole other cutbacks in
State government, as well as the Federal level, where one would
think that you could sustain a program at $7 or $8 million is
hard to understand.
We are committed to sustaining our program, but I must say
we never understood the model to start with.
Mr. Guyer. Can I just make a quick response?
Mr. Snowbarger. Yes.
Mr. Guyer. I think sustainability is a really tough issue
for these programs. In part it is because I think the level of
investment that it takes to have the good outcomes is much
higher than any of us ever anticipated it would be. This is not
the level of investment that providing early prenatal care
takes. It is a level of investment that accounts for all of the
social issues related to these poor outcomes as well.
To the extent that there are savings to these programs,
those savings probably accrue to Medicaid, and you did not have
anyone from HCFA here today in your earlier panel. You might
want to think about using savings that accrue to the Medicaid
program to, in fact, sustain these preventive efforts at the
community level.
Ms. Williams. Mr. Vice Chairman, I neglected in my opening
remarks to introduce our executive director, Mr. Robert Pugh,
who is the executive director for the Mississippi Primary
Health Care Association, which is my organization's grantee,
and I believe he would like to address your question.
Mr. Snowbarger. Mr. Pugh.
Mr. Pugh. Thank you, Mr. Vice Chairman and other members of
the committee. Since I have not had the opportunity to say
``good morning,'' I will now say good morning or early
afternoon and will say that I am very delighted to have the
opportunity to be here today and to address you.
The issue of sustainability is one in which the Delta
Futures Project in Mississippi is currently developing a
strategy around. As Ms. Williams indicated during her
testimony, we are one of the seven supplemental projects that
were funded; therefore, we are just in our 3d year of Healthy
Start.
The issue of sustainability was not very clear at the
beginning; however, the division of Healthy Start has worked
very diligently with us to help begin the process of looking at
sustainability. I can tell you that that issue is a very
difficult one for a rural area and a very economically
depressed area like the Mississippi Delta.
Unfortunately, the Medicaid managed care picture in
Mississippi has not moved along as far as it has in some other
States. We do not have operating HMOs. We had hoped that we
would be able to develop a practical sustainability approach
through working with HMOs that would be developing in
Mississippi around Medicaid managed care. Unfortunately, this
has not happened.
Currently, however, we are working with our State health
department to look at ways in which we can identify a
sustaining and recurring source of revenue through providing
case management services to the Medicaid-eligible population
through our Medicaid Division, and we are very, very excited
about the possibility of getting that program under way during
this 0-3 year to continue not all of the efforts we are doing
under our Healthy Start Project, but some of the areas around
case management that are very important to us.
So it is going to be very difficult to undertake any real
sustainability for a program like we have in Mississippi in the
near future in the short run, but we are hopeful that some
success can be reached and can be started.
Mr. Snowbarger. Mr. Crespo, do you care to respond?
Mr. Crespo. Yes, if I may. Thank you. We looked at
components that we had nurtured, if you would, for the first
active 4 years of the project and saw where we were getting the
most bang for our buck, if you would pardon the pun.
We found that clearly outreach was something that needed to
be sustained. How we did that, we moved our outreach team in
terms of the management of that team from two, very good, sort
of traditional medical providers to an organization that is
called the Neighborhood Centers Association, which is an
umbrella organization of 22 settlement houses in the community.
So now the outreach is being managed by them.
They have been able to successfully enter into two
contracts with HMOs to deliver the outreach services that I
spoke of earlier. With respect to the school teams, we also had
outreach workers called ``specialized outreach workers'' that
work solely in the middle and high schools.
That was given also to the public school system because,
again, the cultures of the organizations where it was really
meant to manage could not really understand, I mean, the needs
of the kids effectively. So we gave the administration of that
over to the school system. We are expecting that they will be
able to sustain components of that within their own structure.
When we talked about the component of the high-risk teen,
we have a high-risk team that goes into the Justice Center for
Incarcerated Women in Cleveland. We have worked out a
memorandum of understanding with the Cuyahoga County Justice
Center so that they can again absorb those kinds of models that
we know are effective and working.
Last, I just want to bring up the issue of consortium. As
you know, the Consortium is sort of the whole infrastructure
that has to be maintained, and how do you do that? Well,
consortia activity, the community activity with the settlement
houses that are doing the outreach really validate those kinds
of efforts. Those are the kinds of things that bring together
community leadership.
Clearly, everyone that comes to the table is not concerned
about infant mortality, but the problems that come to the table
are directed and are involved and do have a causal effect on
the babies that are dying in our community. So everyone comes
with some solution, although in their mind they may not know
that the solution that they are providing is, indeed, a
solution to help combat infant mortality.
So those are the ways that we are attempting to sustain the
successful components that we have seen in Cleveland.
Mr. Snowbarger. Is it fair to say that you are sustaining
your program be delegating your outsourcing?
Mr. Crespo. I think it is fair to say that in Cleveland we
need to look at existing structures and prove to them that we
have a model, show them that we have a model that has had some
results, and we would like for them to help us sustain those,
yes.
Mr. Snowbarger. Just a real quick yes/no answer on this,
because I heard it a couple of places. Do you feel like you are
properly advised concerning the expectations on sustainability?
I have one yes, one no, obviously. You really kind of mention--
--
Mr. Coyle. I do not want to be misunderstood. What I was
saying is the Federal Government 2 or 3 years ago started
asking each of the sites to get ready for sustainability, so
there is no question that the Federal Government gave the
signal. In my mind, they did what they were supposed to do.
What I was saying to you is that it would seem to me if you
develop models that work, if you took a model in cancer or AIDS
and it was working, you would not come to the point where, OK,
it is working; now we are going to put it out of business.
I said I had trouble with the idea of how to do that. Let
me just make one important point here. Baltimore is committed
to raising significant dollars for sustainability, but what is
going to happen in Baltimore is if we do this, because people
believe in the infrastructure that we have, we are going to
move away from infant mortality because if you are dealing with
managed care organizations or foundations or others, a lot of
them want you to do something, but it is not infant mortality
driven.
So I have explained to the feds earlier that, yeah, we can
raise a lot of sustainability money, but it is not going to
help necessarily reducing infant mortality and low birth weight
because the dollars that we will get will not be targeted for
that. So there is a real dilemma here.
Mr. Snowbarger. Dr. Hatcher.
Ms. Hatcher. Yes. I would just like to add and supplement
what has been said. I think the Federal Government was very
clear with us regarding the sustainability, but what has
happened to us, there is a changing with health care reform,
welfare reform, and all these changing systems, it is just very
hard to begin to look at sustainability. I mean, to actually do
it, not to look at it. You can look at it, you can plan, but
you have a lot of people competing for a shrinking pot.
Mr. Snowbarger. Does anybody else care to respond? I
apologize.
Mr. Crespo. Mr. Chair, with my experience, I think that the
direction that we received from Washington in terms of
sustainability has been fairly clear.
Mr. Snowbarger. Thank you. Mr. Towns.
Mr. Towns. Thank you very much, Mr. Chairman. Mr. Chairman,
we have been joined by one of our senior, senior, senior
Members in Congress, and I am referring to his service.
[Laughter.]
An outstanding and highly respected Member, Congressman Lou
Stokes from Cleveland. At this time, Mr. Chairman, I would like
to yield to him.
Mr. Stokes. Thank you very much, Mr. Towns and Mr.
Chairman. It is a pleasure to be here, even if I have to
withstand these attacks on me. [Laughter.]
But I want to say for me it is a special pleasure to be
here, first, because this committee has been so instrumental in
terms of the promulgation of this particular legislation. I
have had occasion to come here before the subcommittee and
testify, and I really commend you for the interest and concern
that you have taken in this whole matter. I am pleased to see
these outstanding panelists who are here this morning and want
to extend a special welcome to Mr. Juan Crespo, who is our
Healthy Start Program director in Cleveland.
The Healthy Start Program is very important to me. As you
know, former Secretary of the Department of Health and Human
Services, Dr. Louis Sullivan was one of the initiators of this
legislation. We included it at the time we put forth the
Disadvantaged Minority Health Improvement Act, which I
sponsored in the House and Sen. Kennedy sponsored in the
Senate, historic legislation which Healthy Start became a part
of.
I serve on the Appropriations Subcommittee on Labor,
Health, and Human Services, and Education, Mr. Chairman, where
last year we put up an extensive fight to try and save this
program. At that time, it was felt that we had reached the 5-
year mark and perhaps we should move on and do other things.
And we had some pretty tough fights over on our committee
trying to get it funded because we realized that we could show
on graphs the kind of progress that has been made in 15 cities
around the country, major cities. We were able to show what was
happening in infant mortality prior to the initiation of this
legislation and how the graph would show in a very vivid way
how we had made some inroads on this whole infant mortality
problem.
So, I am hoping that we can get this program reauthorized
and funded, and let us continue making the progress that has
been made.
I have a statement which I will submit for the record, and
I appreciate the opportunity to be here with you, Mr. Chairman
and Mr. Towns.
[The prepared statement of Hon. Louis Stokes follows:]
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Mr. Snowbarger. Thank you, Representative Stokes.
Mr. Towns, do you want to do some questioning?
Mr. Towns. Yes. Thank you very much, and let me just say,
it is a pleasure to have you here with us, and we know, in
terms of the work that you have done in the area of health
period, and then, of course, in this particular issue as well,
so we are delighted to have you here.
Let me just move, first of all, to Mr. Coyle and to Dr.
Guyer. My staff had an opportunity to visit your program, and
they came back all excited, and, of course, I must admit, they
do not get excited too often. So evidently you must be doing
something very special over there.
Let me go to the question, though, of why do you think it
was important to include men as part of your Healthy Start
Project.
Mr. Coyle. We had a project that preceded Healthy Start,
and that is one of the reasons we were selected, because we had
a head start, something called the Baltimore Project, that had
been in place for 2 years before we started Healthy Start, and
so we had 2 years of experience in this business at a much
smaller level.
In the first year of Healthy Start, as we were getting to
some of the huge, risk-taking behaviors that our women have in
these poor communities, the realization came to us, which
should have come earlier, that many of these risk-taking
behaviors, particularly substance abuse, is directly related to
the male partner.
So a lot of their behaviors are affected dramatically by
the male partner they are with, either the father of the child
or a significant other, and we began to believe that if you are
going to change risk-taking behaviors which are at the heart of
reducing infant mortality and low birth weight, you have got to
bring the father into this. And so we created this very special
men's program.
Joe Jones, who is somewhere in the audience, he runs this
program. We have had great publicity on this, national
publicity on this men's program, and what it focuses on is
taking the highest risk men that you all know that are in your
communities and insisting that they pay attention to their
children.
And so the first focus, when we get these men, is that
their first responsibility is to their children. Once that
starts happening, then we deal with all the other social,
economic, and health issues dealing with the men, most of which
is around substance abuse, drug dealing, and those kinds of
things. And we have had tremendous success with getting the men
not only to take better care of their children, but also to
really turn their lives around.
But the answer to your question is, we believe you cannot
change the risk-taking behaviors of women if you do not deal
with their male partner simultaneously.
Mr. Towns. Thank you very much. Mr. Chairman, what I would
like to do is ask this question, let it go down the line, and
that will be it for me, but I wanted to get a response from all
of them on this issue.
I guess the best way to ask this would be, let's switch
roles, and thinking in terms of what Congressman Stokes said in
terms of the fights that we have had around here trying to
maintain programs such as this that we know are doing a great
job: what should I say to my colleagues that do not support
these programs in order to convince them to do so? Arm me. Give
me some material.
I tell you what, so I do not miss anybody, why don't we
start with you, Mr. Crespo, and then we will come right down
the line?
Mr. Crespo. Thank you, Congressman. I think probably the
most relevant thing is that we have seen, in the projects
represented here today among others, have seen that the process
objectives are being met; that is to say that we know that if
we enroll them early in their pregnancy, infant mortality,
indeed, is going to be reduced in that community.
And the spillover effect of that factor alone would have
very positive outcomes in terms of the overall makeup of that
community in terms of substance abuse, in terms of school
dropout rates, in terms of other activity that would lend
itself to putting together the community that we need in order
for babies to live in it.
So I think that the important thing, sir, is that we need
to look at this project, and we need to get out of the Healthy
Start box. Infant mortality reduction is much more
encompassing, and every facet of society has an impact on it,
so the dollars that are spent here are dollars that are well
spent.
Ms. Hatcher. I think that just by reducing low birth rate
and some of the problems that we know occur in our communities,
that costs a lot of money. Not only do you have to spend the
$200,000 for a low-birth-rate baby in the neonatal, intensive
care unit; that child is more likely to have other kinds of
developmental problems, so long term, we continue to pay for
this.
So in Healthy Start we can reduce the number to have
healthier children from the beginning, I think over the long
term there is a significant reduction in cost. It may cost us
$100 or $200--and that is probably low--I will say $2,000 per
case-managed woman, a woman that we case managed, but if you do
not have to spend $200,000 for that neonatal, intensive care
unit, right there you already have some health-care-dollar
savings.
I do not think we see it all in the short term; some of it
is a much more long-term effect, and so it is very hard for us
to give the kind of specific data that people may want, but I
think we have to see this as a long-term effect. There are some
short-term savings, but there is also the big long-term
savings.
Mr. Pugh. Congressman Towns, in response to your question,
we certainly recognize that there are a lot of competing
interests and priorities in this Nation and across the various
States and other communities. The idea of improving pregnancy
outcome certainly can be looked at in a cost-benefit way, just
as Dr. Hatcher has talked about some, but she also made another
profound statement a little bit earlier, when she said it takes
more than direct medical intervention to reduce infant
mortality and low birth weight.
The fact of it is, you can judge a nation by how it cares
for its children, and the fact of it is that nothing is more
important to our future in this Nation than raising healthy
children and giving every child that is coming into this
country, coming to life, a healthy start.
And one of the ways that we have known that we have done
that in Mississippi is by increasing community awareness and
bringing the community together around this issue to develop
strategies to help them solve their own problems in their
communities related to infant mortality, low birth weight, high
rates of teenage pregnancy. And we think it is very important
that resources be provided to do everything we can in this
Nation to raise a healthy, future population for this Nation's
sustainability, and I think that it is very important that this
be given top priority, regardless of the other competing
interests.
And I believe that the Congress can do much in helping to
foster the idea that this is a Nation who cares about its
children, that, indeed, this is a Nation that cares about its
future.
Mr. Towns. Thank you, Mr. Pugh. Ms. Williams. Oh, you want
to be identified with his statement. Dr. Guyer.
Mr. Guyer. I will just make a brief comment. It is
unfortunate that the timing of the evaluation of this project
is not exactly synchronous with the project itself. The
experiment is still in the middle, and it would be a shame if
what seem to be promising early results, in fact, are lost
because the level of support is not sustained. A few years
later we may find out that this was one of the most successful
efforts ever launched by the Federal Government in this area.
So I would make that argument for sustaining the level of
effort that currently exists.
Mr. Towns. Thank you very, very much. Thank all of you for
your testimony and for your comments. You have been extremely
helpful. I yield back to you, Mr. Chairman. I am sorry I went a
little over.
Mr. Snowbarger. That is fine, Mr. Towns. Let me ask two
final questions. One, Ms. Williams, specifically relates to the
Delta Futures Program. In her testimony, Dr. Nora indicated
that this project was one of the problem projects, maybe is the
best way to put it, and I suppose by raising the topic I give
you the opportunity to respond, but really what I was looking
for is, are there things that you have gone through that we can
learn how not to do things perhaps?
Ms. Williams. I would certainly hope so.
Mr. Snowbarger. Do you have any specifics that you can give
us at this point?
Ms. Williams. I think a lot of the struggles that we have
dealt with deal specifically with rural communities, inasmuch
as we are not always on the same learning curve as urban areas
might be, and we found that people often come--when you have
moneys that are available, everyone is struggling for their
share or their piece of the pie, and conflict is oftentimes
just an inherent part of that process.
And we certainly learned a great deal about how to deal
with and manage conflict and work with those communities and
deal with that, and I think that we have been very successful
in that area.
Mr. Snowbarger. One last question, however many of you want
to answer this. I asked the last panel about coordination and
cooperation between Federal programs. They were all very self-
congratulatory and actually had held a conference together, so
obviously they are coordinating their programs.
Do any of you care to respond to that? Do you find that all
of these child-health-care programs are working in synch and in
coordination, or are there problems there?
Mr. Crespo. Mr. Chairman, I think there is a need for
improvement on how that information gets to the community
level. That is not to say, of course, that we are not made
aware of certain conferences or funds that are available or
initiatives that we may be able to add our experience to, but
at the community level, those decisions are made here; and the
way they are brought down sometimes, I think, needs refining.
But, overall, I would say, yes, at least from Cleveland's
perspective, that we are made aware of those.
Mr. Snowbarger. All right. Does anybody else care to
respond? Dr. Hatcher.
Dr. Hatcher. Well, I think they are working together. In
the District of Columbia not only do we have the Healthy Start
Project; we have what is called the National Institutes of
Health D.C. Initiative, and that initiative is a research
project, but it is looking at this issue of infant mortality so
we can have a better understanding of what is impacting infant
mortality and what is unique about infant mortality here in the
District of Columbia.
I think it is particularly important because we are
primarily an African-American community. The disparity in
infant mortality is in our community, and so it provides a
unique opportunity for us to somewhat be a laboratory, even
though we do not want to be studied to death, but a laboratory
for what can really work. And those efforts from NIH are very
community based also. We hope the next level of funding will be
more intervention projects that will kind of support that some
of the Healthy Start models were actually very, very effective,
even though we believe our preliminary data says that.
Also, we are very fortunate to have from CDC an
epidemiologist assigned to our office so she can help us look
at our data and help me and other staff have a better
understanding of data and to use that data to really evaluate
and design other projects.
Mr. Snowbarger. Does anyone else care to respond? Dr.
Guyer.
Mr. Guyer. I think Healthy Start has been a somewhat
isolated program since its inception, and I think it would
actually benefit if the Federal agencies all spend some time
thinking about what have they learned from the Healthy Start
experience and how the different kinds of initiatives from the
different agencies could interact with each other at the
community level.
I think it is hard for community-level people to access all
of the different Federal initiatives. You hear that the
District of Columbia has lots of them. I suspect Mississippi
has few of them; so there is a real unevenness. And I think
HCFA also needs to be brought into that because they have the
money, and they are potentially the ones who will both fund the
failures and benefit from the savings.
Mr. Snowbarger. Representative Stokes.
Mr. Stokes. Thank you, Mr. Chairman. Once again, let me
thank both you, and your ranking member, Mr. Towns, for
inviting me to participate in this hearing this morning.
I have two quick questions. As we seek to reauthorize the
Healthy Start Program in its own right and having looked at
this program now for a period of 5 years, in your professional
judgment, are there certain provisions that we ought to put
into this legislation to strengthen it? And I hope I am not
covering something that you perhaps have already covered today.
Mr. Crespo. Congressman, I think that as we look at
expanding this project, the local initiatives, I think, have a
lot of experience and a lot of wherewithal to help shape the
future of how infant mortality reductions projects in this
country ought to be run.
I would respectfully recommend, suggest that project
directors be brought in on the discussion when it is about
expanding a project or funding a project, developing new
criteria for a project, so that the Federal Government, the
Federal entity charged with it, can benefit from our
experience. And I do not know that that has been the case. We
need to be at the table in terms of offering some direction and
some experience.
Mr. Stokes. Last, as directors, do you see any special
challenges facing either Healthy Start Program participants or
yourselves as directors of this program?
Mr. Crespo. The special challenges, sir, when we--I would
like to answer that by pointing to our young people, and by
``young,'' I mean middle school because, for the most part,
when we get them in high school, it is already too late. So we
need to start the prevention and the abstinence messages, we
need to start them earlier. We need to start them in middle
school.
So one of the challenges, sir, is that if this project is
not allowed to continue, we allow--because of it, the Cleveland
Public School System is for the first time beginning to track
incidents of sexual activity and pregnancy in these schools.
That has not been available before.
So I would again--that is going to be a big challenge for
that school system and for the Cleveland project to be able to
maintain that kind of information and that kind of data.
Mr. Snowbarger. Thank you, Mr. Crespo. Does anyone else
have any comment?
Mr. Coyle. Just two things.
Mr. Snowbarger. Sure.
Mr. Coyle. One is--Congressman Towns asked something about
this before--Congressman Stokes--the whole title of paternal
child health in some way needs to be relooked at and redefined.
Unless we can bring, especially in major cities, the African-
American male into this process in a real way, we are going to
make very little progress. And as long as we look at this--and
I understand all the history of maternal and child health, but
we have excluded African-American males from the whole family
process. The welfare system has done that. A whole range of
things have done that.
Until they are active participants in whatever Healthy
Start and whatever other similar projects happen in the United
States, we are not going to make a lot of progress.
Also, I just wanted to say that we did not have the
opportunity at the beginning, but several of our participants,
clients in Healthy Start, who are the heart of the matter, took
the time to come down here today to see what a hearing was like
because they are interested in that. I would like for them to
stand up so that you know that they came and they wanted to see
what this is all about. And they are the people that make our
program work.
[Applause.]
Mr. Stokes. Thank you very much. It is nice to see all of
them attending a hearing of this sort. I am sure it is edifying
for them and a comfort for them to listen to all of the experts
testify on something that is so near and dear to them.
Mr. Chairman, I think you have been very generous----
Mr. Snowbarger. Dr. Hatcher, did you care to respond?
Ms. Hatcher. I will just briefly say that I think that we
are going on the right track with trying to strengthen Healthy
Start. If we use the lessons that all of us have learned with
22 projects and we cannot only tell the next projects, but
their communities need to understand, this is, you know, kind
of the background of infant mortality, so they do not have to
start from the beginning. We can give them some information,
and they can go from that point forward.
Mr. Snowbarger. Thank you. I, too, want to thank all the
witnesses for their appearance. Mr. Crespo, it was pointed out
to me that you are at the table, but perhaps the table is a
little too small and the time too short to get into all the
detail that we need to.
There being no further business before the committee, the
subcommittee is adjourned. Thank you again.
[Whereupon, at 12:55 p.m., the subcommittee was adjourned.]
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