Introduction
Good morning. I am Dr. David Satcher, Director of the Centers for Disease
Control and Prevention (CDC). With me here today is William H. Gimson,
Director, Financial Management Office, Dr. Helene Gayle, Director, National
Center for HIV/STD/TB Prevention; Dr. James Hughes, Director, National Center
for Infectious Diseases; and Dr. Mark Rosenberg, Director, National Center for
Injury Prevention and Control. I am pleased to be here today in support of the
President's FY 1997 Budget request for CDC, and I would also like to thank you
for the critical support the Committee has provided CDC during the past year. I
believe CDC's work exemplifies the vital role that good and effective government
can play in the lives of all Americans.
1996 is a very important and exciting year for our agency. Not only is the
city where our headquarters is located--Atlanta--hosting the Centennial Olympic
Games, but CDC is also celebrating its 50th anniversary. (Chart 1) Over the past
50 years there have been tremendous public health breakthroughs, and CDC is
proud to have played an essential role in many of these successes. Recently, we
kicked off our 50th Anniversary celebration during National Public Health Week
(the first week of April), and we are taking time during the year to reflect on
and appreciate our heritage. But, even more important, we are taking the time
to envision our future and determine how best to apply the lessons we have
learned over the past fifty years.
Model Approach to Public Health Problems
CDC was born out of an effort to protect U.S. soldiers and civilians from
the debilitating effects of a single disease during World War II. The Office of
Malaria Control in War Areas (MCWA) was started in Atlanta in 1942 to fight
malaria, a disease that had for centuries devastated servicemen during wartime.
Our parent organization put in place a plan to deal with the problem of malaria
that has evolved over the years to serve as the model of how CDC does business
today. We call this model the public health approach, a four-step system to
combat contemporary public health problems. (Chart 2) DELETED
CDC's public health approach involves detecting a problem through disease
surveillance, determining its causes, developing and testing potential
strategies for handling the problem, and implementing appropriate prevention
programs. By the time the Communicable Disease Center opened its doors on July
1, 1946, the foundations of this important public health model had been
established. CDC has since applied the principles of the public health approach
to combat today's leading preventable health problems. Whether it's tracking
the Ebola virus in Africa or America, reducing the incidence of smoking among
teenagers, eliminating hazards from the workplace, or preventing injuries caused
in bicycle crashes; CDC stands at the forefront of the increasingly successful
fight against disease, injury, and disability.
In its fifty years of noteworthy accomplishment, CDC has made prevention not
only a science, but a practical reality. Today, CDC has evolved into the
nation's first line of defense in the prevention and control of diseases,
injuries, and disabilities. I would like to spend a few minutes highlighting
some of the many successes CDC and public health have witnessed over the past
five decades and, also, show how these successes have laid the groundwork for
making this Nation--and the world--a safer and healthier place.
1950s and 1960s: Growth and Development
The 1950s and 1960s were a time of growth and development for CDC. Several
events had particular significance in defining and shaping the direction of CDC.
One of CDC's unique contributions to public health practice is the science
of epidemiology. In 1951, CDC created the Epidemiologic Intelligence Service
(EIS) as a combined training and service program. Since the first class of EIS
officers--internationally known as CDC's disease detectives--reported for duty
in Atlanta in July of 1951, more than 2,200 professionals have served in the EIS
program. (Chart 3) DELETED
The first EIS officers concentrated primarily on investigations of acute
infectious disease outbreaks. Today, the scope of CDC's investigation and
control efforts includes acute and chronic infectious and non-infectious
diseases, nutrition, reproductive health, injury, and illness due to
environmental and occupational hazards. As the EIS program celebrates its 45th
year, it will continue to turn out a cadre of field-trained epidemiologists able
to respond to the Nation's, indeed the world's, prevention needs.
During these early years, CDC led the fight against smallpox and polio. An
early major contribution of the EIS program came in the 1950s, shortly after
the Salk vaccine was introduced. Children who were recently vaccinated began to
come down with this terrible paralytic disease and the entire polio immunization
program was endangered. Investigations by EIS Officers showed that batches of
vaccine from one manufacturer contained live polio virus. Safety mechanisms
were put into place and the immunization program was continued and as a result
the last case of wild polio in the United States was reported in 1979.
Starting in 1960 CDC, in a joint effort with the World Health Organization
(WHO), and other national and international partners launched a world wide
campaign to eradicate smallpox, one of the worst killers and mutilators of
humankind. Smallpox is the only disease ever wiped off the face of the earth by
human efforts. The cost to the United States for the successful campaign to
eradicate smallpox was about $30 million. Since smallpox was eradicated in
1977, that investment has been returned to the United States every 26 days in
vaccine costs that are no longer necessary.
CDC has learned important lessons from our successes with polio and
smallpox. With concerted effort, collaboration with many private- and
public-sector groups, and a scientific public health approach, we can conquer
vaccine-preventable diseases. This belief is at the heart of the President's
Childhood Immunization Initiative. By educating parents and providers,
supporting on-going community outreach efforts, and making vaccine available in
health clinics and doctors' offices, the number of preschool children immunized
in the United States is at an all-time high and the number of reported
vaccine-preventable diseases are at all-time low levels. In fact, polio has
been eliminated from the Western Hemisphere.
We are now working hard to eradicate polio from this planet by the year
2000. The President's FY 1997 Budget request includes a total of $47 million
for polio eradication. Included in this request is a $20 million increase to
enhance CDC's polio surveillance, case investigation, outbreak control programs,
and immunization efforts, as well as provide much needed epidemiologic,
laboratory, and programmatic assistance to WHO. One of our partners in this
effort is Rotary International, which has donated over $250 million for
vaccine--a sum that has now grown to over $340 million through investments.
Through partnerships such as these, we can ensure that polio will never again
kill or cripple the children of the world, and we estimate that once polio is
eradicated we will save more than $230 million annually. (Chart 4) DELETED
In 1957, the Venereal Disease Unit of the Public Health Service was
transferred to CDC, and with it came a new method to stop the rampant spread of
sexually transmitted disease. The Unit had pioneered a new type of public
health worker, the Public Health Advisors (PHAs). These PHAs were trained to
work in state and local health departments, tracing persons with sexually
transmitted diseases and their contacts, to help them get treatment and stop the
spread of disease. For over 40 years, the effort to prevent the spread of
sexually transmitted diseases (STDS) has been a partnership of federal, state
and local health agencies. Working together, each with responsibility for a
specific portion of the effort, this collaborative effort has had notable
successes. For example, STDs such as chlamydia and gonorrhea if not treated can
lead to pelvic inflammatory disease (PID), infertility, and other related
complications. During 1996, an estimated 2.6 million women will be infected
with chlamydia; between 500,000 and 1 million of these women will develop PID;
100,000 to 200,000 will become infertile; and at least 50,000 will suffer a
life-threatening ectopic pregnancy. Moreover, women who are infected with
chlamydia have a three-to fivefold increased risk of acquiring HIV infection.
Infants born to chlamydia-infected mothers are at a higher risk for eye
infections and pneumonia during their first year of life.
CDC, in partnership with the Department's Office of Population Affairs,
initiated an Infertility Prevention Program in 1994 to reduce the prevalence of
chlamydia as well as gonorrhea, the leading causes of PID. The model of the
Infertility Prevention Program is a partnership among family planning, STD, and
laboratory programs. This program, focused on providing chlamydia screening
services primarily in family planning and STD clinics, expands a pilot project
initiated in Region X in 1988. This pilot project demonstrated a decrease in
chlamydia infections by 60 percent in family planning clinics over the 6 years
the project has been in place. Decreases have been observed among all racial,
ethnic, and age categories. Costs for diagnostic tests declined by 20 percent.
In 1961, CDC assumed responsibility for the collection and publication of
data on nationally notifiable diseases. For 35 years, the Morbidity and
Mortality Weekly Report (MMWR) has served as CDC's mode of communication for
disease outbreaks and trends in health and health behavior. Yet during this
period, both the audience and the demand for the information has increased. To
keep up with these demands, CDC has capitalized on technological advances to
provide the information in a timely manner. Today, the MMWR is disseminated
throughout the world, via the Internet, to people who work in, and are
interested in, public health.
Likewise, since its early years, CDC has been seen by its partners in
prevention as the central source for public health training. In recent years,
however, formidable barriers have risen that have impeded CDC's ability to
fulfill its traditional training role. To meet these new challenges, CDC has
redesigned its approach to training the public health workers through its Public
Health Training Network (PHTN). PHTN program are designed to meet specific
learner needs and use interactive and engaging media, conveniently delivered to
the learner's community. Through distance learning, CDC programs have been able
to reach previously Unattainable, larger audiences at a lower cost. For
instance, in 1995, CDC conducted a satellite conference, Epidemiology and
Prevention of Vaccine- Preventable Diseases. This interactive video conference,
offered twice a year, provided training to over 16,000 participants at over 500
viewing sites--exceeding the total number of persons trained since CDC
immunization training courses began. To date, PHTN courses have reached over
200,000 individuals in all 50 states, and this is just a beginning. our goal for
PHTN is to create a national "public health school without walls," giving every
public health worker electronic access to the highest quality training possible.
I believe CDC's innovation in these areas provides an excellent example of how
CDC has made the most of its resources in an environment where we are
increasingly being faced with shortages in both human and financial support.
Another significant event in CDC's history was the publication of the first
Surgeon General's Report on Smoking and Health, in 1964. While this report was
not published by CDC, it was a sentinel event that showed the public health
world that certain unhealthy behavior choices could lead to chronic diseases
and, with appropriate public health programs, could be changed to prevent those
diseases. CDC is continuing the precedent set by this report by developing, in
conjunction with the Surgeon General's office and the President's Council on
Physical Fitness, the first Surgeon General's report that focuses on the need
for physical activity.
Recent scientific studies have demonstrated the health benefits to all ages
of moderate levels of physical activity. Regular physical activity cuts in half
the risk of dying of coronary heart disease, the leading cause of death in the
United States, and appears to provide some protection against adult-onset
diabetes, hypertension, colon cancer, osteoporosis, and depression. And yet,
approximately 60 percent of American adults do not meet recommendations for
physical activity, and 29 percent are completely sedentary. Among adolescents,
vigorous physical activity declines sharply while in high school; the proportion
of boys who are vigorously active falls from 81 percent in 9th grade to 67
percent by the 12th grade; the proportion of vigorously active girls drops from
61 percent in grade 9 to 41 percent in grade 12.
The Surgeon General's report highlights what we have learned about physical
activity and health, what we are learning about promoting physical activity to
adults and young persons, and what we need to learn that can help Americans
adopt and maintain a more physically active lifestyle. Substantial improvements
in health can accrue to those who make the transition from inactivity to a
lifestyle that includes even moderate amounts and intensities of regular
physical activity. We plan to release this report prior to the opening of the
1996 Summer Olympics.
1970s and 1980s: New Challenges
In its third and fourth decades, CDC was faced with an array of new
challenges. Many of these events tested our resources and pushed CDC staff to a
heightened level of effort. However, these events also provided us with an
opportunity to garner the technology, expertise, and confidence that are still
serving us today as we meet many of society's major public health threats.
In 1973, the National Institute for Occupational Safety and Health (NIOSH)
became part of CDC. Within months, NIOSH was engaged in the first major federal
effort to prevent occupational diseases and injuries. It focused on potentially
dangerous toxic substances to which workers were exposed such as asbestos,
benzene, lead, and mercury, and with the assistance of the Occupational Safety
and Health Administration (OSHA), developed standards designed to protect the
worker. In developing these standards, NIOSH and OSHA were dependent on the
resources and talents of partners in federal, state, and local government and
many private sector organizations to help achieve successes in improving health.
Today, CDC continues to expand the scope and involvement of these
stakeholders in planning and implementing national strategies to improve health
and safety. For example, in 1995, CDC, working with industry, labor, and the
public, revamped outdated national standards for respirators used to protect
millions of workers from potentially hazardous environments. The new standards
have unleashed competition among respirator manufacturers to produce more
effective protection at substantially reduced prices, lowering cost and
improving worker protection across industries. The benefits to the health care
industry alone have been dramatic. Respirators available to protect health care
workers from tuberculosis (TB) cost $8 before CDC issued the new standards.
Now, respirator manufacturers are able to supply respirators for this purpose
that cost as little as 60 cents. Based on an assessment of costs at acute care
facilities, the Department of Veteran Affairs estimates it will save $16 million
annually. The health care industry as a whole is expected to save hundreds of
millions annually. The President's FY 1997 Budget also includes full funding
for a state-of-the-art occupational safety and health laboratory.
In 1975, CDC developed an improved method to measure lead in blood to assess
the exposure of children and adults to lead. Using this method, CDC was able to
take blood lead measurements in the second National Health and Examination
Survey (NHANES II) and found a close relationship between lead levels in the
population and lead levels in gasoline. (Chart 5) DELETED This finding was a
major reason the U.S. Environmental Protection Agency (EPA) reversed its
decision in the early 1980s to permit the addition of more lead to gasoline, and
instead moved rapidly to require removal of all lead from gasoline. As a result
of these actions, using data from the NHANES III, CDC was able to demonstrate
that from 1976 through 1991, the average blood lead level for persons in the
United States dropped 78 percent In the same period, the number of children ages
1 to 5 years with blood lead levels higher than 10 micrograms per decaliter has
decreased from 88 percent to 8.9 percent. This reduction is particularly
important to the health of our children because lead poisoning causes damaging
effects to a child's intellectual development, hearing, and growth.
Furthermore, by showing where the remaining blood lead poisoning problem is
highest (among urban, minority, and low-income children), NHANES III data are
helping CDC and other public health officials target future prevention efforts.
To undertake the important work of this survey, the President is requesting
a total of $14.5 million in FY 1997 to implement NHANES IV. NHANES is the only
national source of objectively measured health status data and is an important
part of our national surveillance capability for infectious diseases, behavioral
and environmental risk factors to health, undiagnosed preventable illnesses,
nutritional status, and other critical health measures. No other effort in the
public or private sector can replace the type of information available through
NHANES.
In 1976, it was CDC that discovered the bacterium that killed 34 people at
the American Legion convention in Philadelphia. Quick work by CDC scientists
unlocked the mystery of Legionaires' Disease and saved countless lives. From
this experience, we were made acutely aware of the need to be constantly
prepared to handle any newly emerging or reemerging health threats. Today, the
lab in which Legionella pneumophila was discovered 20 years ago is still in use
-- essentially unchanged. In fact, several of CDC's laboratories are more than
35 years old and are in dire need of renovation. CDC's ability to respond
quickly to today's urgent threats is being compromised by outdated laboratory
facilities. The President's FY 1997 Budget includes an increase of $4 million
for high priority laboratory renovations. These renovations are needed urgently
to assure the continued safety of scientists working with highly infectious and
dangerous organisms until a new laboratory building, currently in the design
phase, is available.
In 1981, when physicians started noticing that a number young male patients
were developing a rare and deadly pneumonia, they turned to the CDC for help and
they got it. It was CDC who helped the nation -- and the world -- understand
that the virus that causes AIDS was communicable and preventable. Since this
discovery, CDC has led the nation's highly successful effort to educate
individuals about AIDS and the human immunodeficiency virus (HIV) and implement
programs that help individuals reduce their risk for HIV infection. As the
science progresses and evolves, so must our prevention messages and programs.
However, the fight against AIDS is far from over. AIDS is one of the few
infectious diseases that can be vanquished 100 percent through changes in
personal behavior. Tragically, data on adolescents 13-19 years of age
highlight that HIV infections are continuing to occur among our vulnerable youth
in the United States. A large number of adolescents are currently living with
HIV infection, and many others are engaging in sexual behaviors that place them
at risk for HIV infection. Factors associated with early onset of sexual
activity include level of parental supervision, sexual behavior of peers, and
communication with parents about sex. CDC has been implementing prevention
programs that encourage adolescents to delay sexual activity and, among teens
who are sexually active, to reduce their risk by adopting abstinence or
correctly and consistently using condoms. The President's FY 1997 Budget
request includes $617 minion for HIV/AIDS prevention activities and includes
increased funding for prevention programs and h to help develop interventions
that are targeted, appropriate, and focused on individual, social, and
community-level change.
In 1986, Congress and the Administration, recognizing that injuries were a
major cause of death and disability in this country, made additional funding
available to CDC for developing a separate, comprehensive injury control
program. CDC made the injury control program a separate Center within the
agency in June, 1992, to concentrate resources on combating the serious public
health problem of non-occupational injury.
By nearly every measure, injury ranks as one of the nation's most pressing
health problems. Injuries kill more than 145,000 and disable more than 72,000
persons each year and, most tragically, kill and disable more of our country's
children and young adults than any other disease or illness. Using traditional
scientific methods of the public health model that have been successful against
infectious diseases and environmental emergencies, CDC, often collaborating with
the private health and injury control community, has developed prevention
strategies that have been highly successful or are demonstrating promising
results. For example, CDC collaborated on a project in Oklahoma City to
establish a smoke detector distribution program within a high-risk community.
As a result of this program, bum-related injuries in the target area were
reduced by 83 percent, while the rate in the rest of the city increased 33
percent. At least 32 injuries and deaths were prevented.
In another example, falls are the leading cause of death for people over 75
and the second leading cause for people over 65. Many who survive a fall end up
with disabilities that cost them their independence and reduce their quality of
life. According to a CDC study, exercise is an effective prevention measure
against injuries caused by falls among the elderly. Older people who exercise
decrease by 50 percent their risk of fracturing a hip in a fall. Other work by
CDC scientists includes developing and evaluating a checklist that older people
and health departments can use to identify hazards in the home and showing the
relationship between certain medications and falls among older women. The
tremendous potential of these, and CDC's other injury control programs, is
especially important not only for helping people live longer, but also better,
more productive lives.
1990s: Honing Our Skills
In the current decade, CDC has once again been reminded that it must never
become complacent. In just a few short years, CDC has witnessed the reemergence
of old enemies and the emergence of new threats to health. In addition, we have
recognized that our prevention programs can no longer be seen as a "one size
fits all" but, instead, must be specifically designed to meet the needs of
particular individuals, groups, or communities. I believe CDC's work in
addressing infectious diseases and programs targeted for women provide two
excellent examples of how CDC has risen to meet the challenges this decade has
presented.
Infectious diseases remain the leading cause of death worldwide. Recently,
CDC has been working to stop the emergence of new infectious diseases such as
the Ebola and hanta viruses and, at the same time, prevent outbreaks of food and
waterborne illnesses, such as those caused by E. coli 0157.H7 and
cryptosporidium. (Chart 6) DELETED To meet the challenges posed by these
infectious disease threats, a strong public health capacity at both the national
and state levels must be in place. Unfortunately, the public health
infrastructure currently in this country, as well as worldwide, is poorly
prepared to address the challenges of emerging infections. The President's FY
1997 Budget request includes a total of $45 million for investment in the'
incremental implementation of CDC's national strategy, 'Addressing Emerging
Infectious Disease Threats: A Prevention Strategy for the United States.'
This plan specifies necessary actions for revitalizing our nation's ability
to identify, contain, and prevent illness from emerging infectious diseases.
Particularly critical to meeting the challenge are CDC's partnerships with state
health departments and other domestic and international organizations. Each of
these partners will play an integral role in the cooperative efforts required to
safeguard the public's health from emerging infectious disease threats. We are
very pleased with the progress we have made with funds provided by the Committee
to begin implementation of the highest priority items of the plan, and we look
forward to continued implementation of the plan.
In recent years, women's health has emerged as a prominent public health
issue and is currently one of CDC's highest priorities. CDC's strategy is to
focus on the most significant health issues faced by women at every stage of
their lives. This approach has heightened sensitivity to the health needs of
women, while ensuring that women's health activities are interwoven with
prevention programs that protect and promote the health of all Americans.
In 1995, an estimated 198,000 women were diagnosed with either breast or
cervical cancer; more than 50,000 died. Recent data show that the death rate
from breast cancer from 1989 to 1992 in the U.S. declined by approximately 4.7
percent. Most public health experts believe that one contributing factor is the
increase in the utilization of screening mammography. CDC's Breast and Cervical
Cancer Early Detection and Control Program funds 50 state health agencies, 3
territories, the District of Columbia, and 9 tribal organizations. This
national program provides critical breast and cervical cancer screening services
to women of low income, the elderly, and minorities, including Native Americans.
As a result of the program, over 400,000 Pap tests and 274,000 mammogmms have
been provided to eligible women.
CDC's Unique Role
To fulfill our vision of Healthy People in a Healthy World through
Prevention, CDC today addresses the leading, preventable health problems
affecting Americans. (Chart 7) DELETED CDC has a unique capability for rapid
detection and investigation of outbreak and epidemics, accompanied by the
laboratory expertise required to investigate known diseases and identify causes
of new diseases. CDC's leadership in rapid response to urgent threats to
health is based both on its own skill and resources as well as on its
partnership with state and local health departments, other private and public
sector organizations throughout the nation, and international entities. Despite
a tight fiscal environment, CDC must keep this essential ability to respond to
infectious and chronic diseases as well as environmental and occupational
hazards. No other Federal agency, no state or local agency, nor any private
organization has the expertise or resources to assume responsibility for this
alone. We must all work together because in many ways, this capability to
protect ourselves against these threats to health is as important to the
national security as our ability to defend ourselves against military
aggression.
Conclusion
As the twenty-first century approaches, CDC and the nation's public health
system faces challenges far more complex than those foreseen in the 1940's. Mr.
Chairman, I urge you and the other members of the Subcommittee to continue your
support for programs that improve the quality of life of all our citizens by
preventing illness, injury, and disability. An investment in public health is
an investment in the health of our communities. Public health promotion as
promised by CDC and its partners is a sound investment. Public health saves
lives, and public health saves money. With your support for the President's FY
1997 Budget request of $2,229,900,000 for CDC, we will be able to make
prevention pay dividends for more Americans.
I will be happy to answer any questions now.
