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Statement on Children's Health by Nicole Lurie, M.D., M.S.P.H.
Principal Deputy Assistant Secretary for Health
U.S. Public Health Service
U.S. Department of Health and Human Services

Mr. Chairman and Members of the Subcommittee, I am Dr. Nicole Lurie, Principal Deputy

Assistant Secretary for Health, U.S. Department of Health and Human Services (HHS). I am appearing today representing Dr. David Satcher, Assistant Secretary for Health and U.S. Surgeon General, who, because of a conflict in his schedule, regrets being unable to attend.

I want to thank you for the opportunity to appear before you today to discuss the status of children's health in America.

Let me say that the title of your hearing, "Children's Health: Protecting Our Most Precious Resources" could not be more appropriate. Indeed, as we look at the state of child health we are really looking into the future of our nation's health.

Current Status of Children<'s Health

With Labor Day now behind us, millions of this nation's children have returned to the familiar routine of exams, reports, pop quizzes, and projects. In just a few more weeks, children will be bringing home report cards that tell us something -- although not everything -- about how they are doing. With that in mind, I want to use my time today to describe how well we are doing as a nation as it relates to children's health.

As you well know, we are all here because we are concerned about the status of children's health in this country. This has been a concern for this Administration as well as for the Congress and for communities all across this country. It is important to set the context for our discussion by reviewing just how far we have come since the turn of the century.

In some respects, America's children are healthier than ever before. Infant mortality is down. Fewer teenagers are becoming parents. Childhood vaccinations are at the highest levels ever recorded in the United States. Marijuana use is heading in the right direction. And fewer children are being exposed to the hazards of lead poisoning. Indeed, a baby born today is expected to live 30 years longer than a baby born in 1900. We estimate that 25 of those years are due to public health efforts.

Indeed even since we were children, we have eliminated polio, and nearly eradicated measles and some forms of deadly meningitis. Thanks to vaccines -- which are among the 20^th century's most successful and cost-effective methods of disease prevention, we save nearly $15 dollars for each dollar spent. While we continue to be concerned and vigilant about the small but troubling number of vaccine-related injuries, we must be gratified that childhood vaccinations have reduced vaccine preventable diseases to record lows. No longer will vaccine preventable diseases shadow the lives of our children.

Fluoridation has sharply reduced the incidence of dental caries among children. The enactment of environmental health laws have led to cleaner air, while controls on lead in gasoline and paint have reduced the incidence of at least the most acute forms of lead poisoning in children, the use of safety belts and bicycle helmets have helped prevent thousands of serious injuries and death. Clearly reliance on Public Health tools to prevent disease, disability and death have helped to reduce the risks that children face. These are areas in which our Nation's report card is improving.

Mr. Chairman, there is cause for optimism. However, this is an incomplete picture.

Even though, for example, infant deaths are on the decline, African -American infants still are nearly 2.5 times more likely than white infants to die before their first birthday and Native American infants are more than 1.5 times as likely to die.

In other words, despite notable advances in child health, our nation's public health advances have not benefited all children and we see emerging public health threats that deserve attention and vigilance. Furthermore, unlike the communicable disease risks children faced at the beginning of this century, the threats faced by children today are in many cases challenges posed by lifestyle and environment in which they live and for which the solutions are more vexing.

We live in a time when it is not always safe for children to be in the classroom; a time when it is not always wise for children to play on the playground or to shoot a game of basketball on the court; (but neither is it healthy for them to sit at home snacking in front of the television or the computer screen); a time when making a wrong or careless decision can be deadly; and a time when many children are stressed, depressed and in overall bad health. And we live at a time when many of our young people lack the hope needed to inspire them to strive for high goals and a bright future. In fact, in terms of children navigating safely through the childhood and adolescent years, these are some of the toughest times our nation has ever seen for children. Ask any parent.

And as you know Mr. Chairman, the leading health risk for children is neither a disease nor a medical condition. It is poverty, which can contribute to poor nutrition, limit access to quality health care, and create living conditions that breed poor health. Nearly one fifth of children in this country still live in poverty.

Key Areas of Concern for Children's Health

If I were preparing a progress report on our children's health as a Nation now, I'd plan for some A's, but would send home an interim report, and request an urgent parent-teacher conference before the next report card. In this case the conference participants need to include parents but they also require the participation of all levels of government, and all sectors of community. In short, our entire society needs to be more involved in the health and well-being of our children; not just at birth, but throughout all stages of youth development..

As you know, one of the Surgeon General's top priorities is to move us toward a balanced community health system. This is a system that provides access to quality care and that balances health promotion and disease prevention along with early detection. Its a system that ensures a healthy start for every child and places mental health and wellbeing on a par with other health issues. We have estimated that half of all premature mortality in this country is preventable, because it is related to behaviors such as poor diet, physical inactivity, tobacco and alcohol use, drug abuse, and irresponsible sexual behavior. Many of these behaviors are set in childhood. We must re-focus our efforts so that we are as concerned about promoting health and preventing disease as we are about finding disease and treating it.

Lets take a look at the elements of a such a system, and examine how we are doing and its implications for the health of children.

First, access to care.

We believe that every child in America ought to be given an optimal opportunity for a healthy start in life. No investment could offer greater dividends for a nation. Children do not have the opportunity to choose their parents or choose the communities in which they are raised. Therefore it is vital that the community, supported by a strong and responsive public health system, provide the tools that can help prevent disease and unintended injury and provide access to quality, primary health care services.

Furthermore, a healthy start for any child begins in the womb. In fact, even before, with adequate amounts of folic acid we can prevent birth defects. Access to prenatal care is the single most critical factor in giving every child a healthy start. No less important is a child's access to health care services.

Access to high quality care is the bedrock on which a balanced community health system must be built: But right now, nearly 11 million children in the U.S. have no health insurance .Uninsured children are less likely to receive health care when they are sick than children who have some kind of health insurance. They also are less likely to receive medical care from a physician - even when they really need it. Uninsured children are 2 times less likely than insured children to get an annual check up, and preschoolers with no insurance are less likely than insured children to be fully immunized.

The Children's Health Insurance Program, (CHIP) provides funding to help states and U.S. territories expand health insurance to children whose families earn too much for traditional Medicaid, yet not enough to afford private health insurance. This historic, bipartisan achievement is an excellent example of how Congress, the Administration, and States can work together constructively to genuinely improve the lives and health of American children. Last week, CHIP plans were approved for Washington and Wyoming, so that now, uninsured children in all 56 states and territories have access to free or low-cost health insurance. This was an important step toward improving the health of the children of our nation.

But let's be realistic. Insurance, while critically important, is only part of the answer. Insurance doesn't guarantee kids access to care, and just as importantly, doesn't guarantee high quality care and finally, doesn't guarantee health. Our challenges don't stop with insurance.

A critical skill that children need to safely transition to adulthood is to develop healthy lifestyles. A balanced community health system would promote such healthy lifestyles. Here we have to recognize that, especially for kids, the choices we make as a society, and the kinds of investments communities make on behalf of kids, are critical to the kinds of healthy choices we want our youth to make. Lets look at a few critical areas, and to make this simple, I'll highlight the ones that are on the Surgeon General's prescription.

Physical activity: We know the many benefits that physical activity can bring to a child's development, such as enhanced growth and development, and improved mental and emotional health, yet no state in the Union requires the type of daily, school based physical activity science tells us is necessary to promote longterm health. After school opportunities for youth to be physically active are limited. Today American youth are the most sedentary generation in American history. Yet we have a number of opportunities to turn that around. We could choose to promote and support physical activity in schools - K-12. We could provide safe venues for kids to become involved in sports and physical activity after school. Our communities could build safe bike and walking paths.

The next part of the Surgeon General's prescription addresses nutrition. Our kids have poor diets and too many children spend their after school hours siting in front of the TV eating junk food and gaining weight. And kids are substituting soft drinks for milk - thus not only getting lots of sugar and caffeine, but not getting the important vitamins and calcium they need. We know that bone health starts early.

Mr. Chairman, obesity is a good example of an illness where health promotion and disease prevention could make a huge difference. It is clear that obesity is a major problem in this country. In fact, it has reached epidemic proportions in both children and adults. The percentage of young people who are overweight has more than doubled in the past 30 years. The prevalence of overweight among children ages 2-5 has increased steadily from 7% in 1989 to 8.6% in 1997. Approximately 4.7 million, or 11% of youths ages 6-17 years are seriously overweight. Obesity leads to other serious health problems, including diabetes, cardiovascular disease, stroke, and certain cancers. What's especially troubling, though, is that we are seeing increased incidences of Type 2 diabetes in children. Type 2 diabetes is also known as adult-onset diabetes and was traditionally unheard of in children.

The next part of the Surgeon General's prescription addresses Avoiding toxins, especially tobacco and alcohol. There are many problems associated with smoking and excessive use of alcohol, including cancer, SIDS deaths, cardiovascular disease, unintentional injuries, irresponsible behavior, liver disease, and asthma to name a few. Indeed, 23,000 new cases of asthma each year are associated with tobacco smoke. When we talk about school and report cards -- we emphasize that asthma is the #1 cause of avoidable missed days from school. Yet, we still tend to glamorize these behaviors through advertising and depiction in entertainment media increases their appeal to youth.

Tobacco. Smoking accounts for about 30 percent of all cancer deaths. And studies show that 3,000 teens become new, regular smokers every day. Of that number, nearly 1,000 will die prematurely from diseases related to tobacco. Beyond that, recent studies are showing that teens are now being attracted to cigar smoking, further exacerbating the tobacco problem. A single cigar can contain as much tobacco and nicotine as a full pack of cigarettes. Additionally, we are disturbed by reports of youth smoking of Bidis, a tobacco product imported from India and southeast Asian countries. There will be a report in tomorrow's MMWR suggesting that Bidis -- which come in flavors of cherry, chocolate and mango -- are gaining increased use among youth. In light of what we know about the addictive nature of nicotine and the longterm health consequences of smoking, the use of tobacco products by youth remains of great concern. There is no safe form of tobacco. The continued support of effective, research based tobacco control programs is an essential part of our public health strategy against tobacco-related disease.

Underage Drinking. It is estimated that there are over 9.5 million drinkers between the ages of 12 and 20. Of these, 4.4 million were binge drinkers. 3 million youth between the ages of 14-17 are regular drinkers who are considered to have a problem with alcohol. Alcohol is the number one drug choice among American teenagers. Alcohol is consumed more frequently than all other illicit drugs combined and is the drug most likely to be associated with injury or death. Alcohol is a drug that can affect judgement, coordination and long-term health. It is involved in teen automobile crashes, homicides, and suicides; the three leading causes of teen deaths. And it is a major etiology of unintentional injury, the #1 killer of our children.

Finally, responsible sexual behavior. Here I am pleased to report that we are making progress as a nation. Abstinence rates among youth are up and teen pregnancies are on the decline, although they are still higher than any other developed nations. In this area we continue to send our youth mixed messages-we glamorize irresponsible sexual behavior in the media, and at the same time have not made the commitment to assure our children have basic information with which to act responsibly.

We believe in promoting responsible sexual behavior, which means remaining abstinent until in a committed relationship and protecting yourself and others against disease and unwanted pregnancy.

The teen birth rate for women between 15 and 17 years of age in this country has been on the decline since the early 1990s, but it is still one of the highest in any industrialized nation. Serious disparities exist too. For example, the birth rate for young black women is still three times the rate for young white teens. The birth rate for young Hispanic women, also three times the white rate, has just recently started to turn down. In 1996, 7 percent of Hispanic and black young women and 2 percent of white young women of high school age gave birth to nearly 200,000 babies. Not only is the consequence of teenage pregnancy an impediment to the child's healthy start in life, it is also an impediment to the mother's own start at life as an adult.

Responsible sexual behavior also includes protecting oneself and others against disease. One of the major sexually transmitted diseases, chlamydia infection, has declined substantially between 1988 and 1996 for young women However, HIV/AIDS is increasingly a disease of women, of people of color and of the young.

Our goal is to let young people know that relationships do not begin with sex. Rather, relationships should begin with communication, understanding, and appreciation. That's what responsible sexual behavior is all about.

Achieving balance in a community health system requires solutions which cannot be found in one agency, or one department, or one program. They require collaborative efforts across Federal agencies and between government and communities. I'd like to highlight two areas, in different stages of development, which we hope will serve as a model of collaboration between Federal agencies and communities.

Safe Schools-Healthy Students

President Clinton announced Saturday the award of the Safe Schools-Healthy Students grants. This is the most mature of our program. Here, Department of Education, the Department of Justice and the U.S. Department of Health and Human Services collaborate to provide students, schools and communities with enhanced comprehensive educational, mental health, social service, law enforcement, and, as appropriate, juvenile justice system services that can promote healthy development and prevent violence and alcohol and drug abuse.

An important aspect of this interdepartmental grant program is to require local communities to coordinate various youth services in order to access funds from three federal agencies concerned with promoting healthy child development and preventing violence in schools. Local education agencies consult with community leaders in law enforcement, mental health and social services and apply for grants from the Departments of Health and Human Services, Education, and Justice using a single application. TheSubstance Abuse and Mental Health Services Administration(SAMHSA) component of this initiative will provide support to 54 local education agencies to implement the mental health intervention services and early childhood psychological and emotional development portions of their comprehensive Safe Schools/Healthy Students Strategic Plan.

Children, Public Health, and the Environment

Children are at disproportionate risk from environmental health threats, because pound for pound, they breathe more air, drink more water, and eat more food than adults. Also, children's behavior, such as playing close to the ground, leads to greater exposures. In addition to these heightened exposures, children's developing systems are more vulnerable to environmental threats, which can result in illnesses such as asthma or developmental disabilities.

Recognizing children's vulnerability to environmental health threats and the need for improved research, President Clinton issued the Executive Order on the Protection of Children from Environmental Health Risks and Safety Risks on April 21, 1997. This Executive order made children's environmental health a priority for the Federal government and included actions to improve research and created a Cabinet level Task Force on children's health and safety. The Task Force identified four areas for immediate attention: Asthma, unintentional injures, childhood cancer and developmental disorders:

Asthma, not only because it is reaching epidemic proportions among American children today, impActing over 5 million children and disproportionately affecting poor and minority children in urban communities, but children with asthma miss twice as many school days as other children and asthma has become the leading cause of school absenteeism accounting for more than 10 million lost days of school; Unintentional injuries are the leading cause of childhood mortality; Childhood cancer continues to be the leading cause of disease-related mortality for children 1-14 years of age. The President's FY2000 budget includes a request for $50 million for demonstration grants to States -- through the Medicaid program -- to test and evaluate asthma disease management.

Developmental disorders, which include birth defects and learning disabilities, are also a leading cause of childhood morbidity and mortality.

The work of this multi-agency task force holds great promise both for the content of the proposals they are considering which include such avenues as targeting research, implementation of asthma care and education programs, and establishing a coordinated, integrated, and systematic nationwide surveillance system; creating a national program to reduce mortality, morbidity, and disability caused by traumatic brain injuries; the creation of a national network for research on childhood cancer which, as a first step, will include a national cancer registry; and, target research to identify the environmental causes of birth defects, focusing on pre-natal exposures in its first year and post-natal exposures in subsequent years, as well as reduction in blood lead levels, and the context of the programmatic approach which relies on partnerships to be both effective because one agency cannot do it alone, and efficiency for our investments, as we eliminate duplication and redundancy.

For example, EPA and the HHS allocated $10.6 million for the establishment of the Centers of Excellence in Children's Environmental Health at eight leading research institutions. These unique centers will perform targeted research into children's environmental health, and translate their scientific findings into intervention and prevention strategies by working directly with communities and community groups. These centers will address several of the most important areas of children's environmental health -- the causes of asthma, effects of pesticide exposure, and developmental effects of toxins.

Mr. Chairman, we also need to be more creative in working outside government to develop innovative partnerships that can promote our multiple goals for child health. One example of this is the Department's partnership with the women of the US National Soccer Team which recently won the World Cup championship. For three years the Department has worked with these remarkable athletes to promote participation in youth soccer as a way for adolescent girls to stay physically active, promote self-esteem and reduce their risk of smoking. We know that girls who participate in strenuous sports like soccer are at significantly less risk of a variety of risk behaviors including tobacco and drug use. We also recognize that this type of community involvement creates opportunities for adults to provide important mentoring opportunities to youngsters. The objective of this activity is to harness existing community resources -- is not to create World Cup Champions -- but to promote a healthy, physically active lifestyle for children.

Mr. Chairman, for Traumatic Brain Injury (TBI) and asthma we know that while we still have a lot to learn about cause and cure, prevention is key. Unfortunately, cause and cure is less clear with autism, where we are reminded of the need for research that could lead to identifying prevention and treatment strategies. Mr. Chairman, in Fiscal Year 1999 the National Institutes of Health will spend $30 million, almost triple the NIH autism budget in 1995.

Mr. Chairman, as and your colleagues know, there are a variety of agencies in the Department which play a critical role in promoting and maintaining child health. These agencies include the Health Resources and Services Administration, Centers for Disease Control and Prevention, National Institutes of Health, Substance Abuse and Mental Health Services Administration, the Agency for Health Care Policy, Research, Indian Health Service and the Food and Drug Administration and the Health Care Financing Administration. We would be pleased to provide the Subcommittee with additional information about their specific programs and would be pleased to provide you or your staff with agency specific briefings if that would be helpful.

Closing:

Earlier this week, Secretary Shalala testified before the Senate Appropriations Committee on the problem of youth violence. She observed that the problem was so complex, that its remedy must draw upon the best that all fields of research have to offer, including education, psychiatry, social work, criminology, public health, medicine, sociology and others . Only by mobilizing these diverse disciplines can we find the type of effective, creative solutions to the problems of youth violence.

I would maintain that this approach -- seeking answers outside the existing categorical programs -- would also be a productive way to better promote children's health. As with youth development, we need to focus on building assets -- the physical, emotional, and cognitive strengths that young people need for survival and success.

Surgeon General Satcher has made it a priority to remind the public that the promotion of healthy lifestyles is not just a matter for individual resolve. To be successful, families and communities must also provide an environment that is conducive to the emotional and physical well-being of children. There is no one program, policy or legislative solution that can make this happen. It requires the efforts of the health community, the law enforcement community, the educational community, the faith community and families and children themselves to chart a safe course through all of childhood and adolescence into young adulthood.