Copyright 2000 Federal News Service, Inc.
Federal News Service
May 11, 2000, Thursday
SECTION: CAPITOL HILL HEARING
LENGTH: 23324 words
HEADLINE:
HEARING OF THE HEALTH AND ENVIRONMENT SUBCOMMITTEE OF THE HOUSE
COMMERCE COMMITTEE
SUBJECT: THE HEALTH CARE FAIRNESS ACT
CHAIRED BY: REPRESENTATIVE MICHAEL BILIRAKIS (R-FL)
WITNESSES:
REP. JESSE JACKSON JR. (D-IL);
REP.
JOHN LEWIS (D-GA);
LOUIS SULLIVAN, PRESIDENT, MOREHOUSE SCHOOL OF
MEDICINE;
DAVID SATCHER, SURGEON GENERAL;
KERMIT
SMITH, CHIEF MEDICAL OFFICER, INDIAN HEALTH SERVICE;
JOHN RUFFIN,
ASSOCIATE DIRECTOR FOR RESEARCH ON MINORITY HEALTH, NATIONAL INSTITUTES OF
HEALTH;
JORDAN COHEN, PRESIDENT AND CEO, ASSOCIATION OF AMERICAN
MEDICAL COLLEGES;
LOCATION: 2322 RAYBURN HOUSE
OFFICE BUILDING, WASHINGTON, D.C.
TIME: 11:30 AM. EDT DATE:
THURSDAY, MAY 11, 2000
BODY:
REP. TOM COBURN
(R-OK): The committee will come to order. First of all I apologize to all those
in the room and my fellow members for the tardiness for the beginning of this.
The votes this morning did change our schedules and then the briefings on China,
which a lot of members are involved in, could not be missed.
What we'd
like to do, and actually we're going to have opening statements and I'm going to
dispense and enter mine into the record, and will not recognize the ranking
member Mr. Brown for his opening statement.
REP. SHERROD BROWN (D-OH):
Thank you Mr. Chairman. I want to thank my colleagues Mr. Thompson, Mr. Lewis,
Mr. Jackson and others for joining us today as distinguished panel. I'd also
like to extend a special welcome to Dr. Satcher, who among his many
accomplishments throughout his career, was first in his class at Decase (ph)
Western Reserve University Medical School, some not too many years ago, in
Cleveland, Ohio. And Dr. Sullivan it's nice to have you with us today too, thank
you.
I'm a co-sponsor of the Health Care Fairness Act, as all the
witnesses are today. This legislation makes sense. We need the research that
HR-3250 fosters to make decisions about the health care system. We need the
education 3250 facilitates to reduce disparities in health. We need the training
3250 supports to reduce disparities in health care.
It's as simple as
that and complicated as that. If I polled everyone in the room on what the
criteria should be used to evaluate the US health care system, my guess is the
answers wouldn't vary all that much. Most of us would mention access, quality,
costs. The system should provide more Americans - all Americans access to high
quality care at a reasonable cost. And I hope equity would work its way into the
formula.
A health care system that perpetuates significant and
reversible racial, ethnic or socio-economic disparities in health and life
expectancy is not my idea of a good health care system. In a nation like ours,
one that is increasingly defined by the diversity of its population, it's my
idea of a system on its way out. But the way we judge our health care system
isn't logical or isn't explicit.
If we actually used standards like
access, quality, efficiency and equity to guide health care policy and health
care spending, we wouldn't even need this legislation. Universal coverage would
be the priority. Research in disparities in health and health care, strategies
to minimize those disparities would be a priority.
Now let's look at the
way the US health care system actually works. Forty four million people are
uninsured. Certain minority populations, especially Hispanics, are far more
likely to be uninsured than white Americans. The nation subsidizes health
insurance for individuals fortunate enough to be employed by a firm that offers
health coverage. Their premiums are pre-tax.
We also cover low income
children and a few other discrete categories of very poor people, and we provide
incomplete but valuable coverage to the elderly. If you don't fall into one of
those categories, tough luck. The nation funds enormous amounts of research,
very little of it devoted to understanding why there are significant disparities
in health and health care between populations in the United States. Even less of
it devoted to doing something about those disparities.
Dr. Satcher did
his best at CDC. Ed Towns and others on this subcommittee have done their best,
but it's changing much, much too slowly. Over time enough evidence has
accumulated so that there's no doubt about it; there is significant disparities
in health and in health care. Minority populations, as we all know, have higher
rates of cancer, higher rates of heart disease, higher rates of diabetes, higher
rates of HIV AIDS. And that's just a partial list.
Minorities have
shorter life expectancies, higher infant mortality rates and higher incidence of
premature death. Minorities are less likely to receive cancer screening and less
likely to receive monitoring. Minorities are less likely to receive childhood
and adult vaccinations. Doctors are four times more likely to correctly identify
a heart attack and hospitalize that patient if that patient is white.
According to recent research doctors are getting better at treating
cancer pain, unless you're an Hispanic or African-American. We have a top notch
health care system. What this nation is spending money on is subsidizing health
insurance for millions of working Americans and other select groups, financing
ground breaking research that fuels medical advancement throughout the world.
What this nation is spending money on isn't wrong, but it isn't 100 percent
right either.
We need to work on the system until it doesn't matter what
your race is, what your ethnicity is, what your employment status is. You should
still be a beneficiary of medical advancement and a recipient of the highest
quality care that this nation has to offer. The Health Care Fairness Act sets
the stage for that system. I'm thrilled the sub-committee's finally paying
attention to this very important legislation. Thank you Mr. Chairman.
REP. COBURN: Thank you. The gentleman from New York.
REP.
EDOLPHUS TOWNS (D-NY): Thank you very much Mr. Chairman, and also let me thank
the ranking member Mr. Brown for his outstanding work in this area. Also I'm
delighted to see the former Secretary of Health, Dr. Sullivan, and of course the
Surgeon General Satcher, and my colleagues, Mr. Thompson, Lewis, and of course
Jackson and Rodriguez.
Let me just say that we have gotten tremendous
advances in the area of health here in the last few years, in the areas of
treatment and new technologies, new antibiotics, surgeries on unborn children to
reverse birth defects, but even with all these wonderful developments, there are
still inequities in our health care system.
There is a growing mountain
of evidence that not all patients get the same attention of being treated
equally under our system of care.
There is compelling evidence that
there are racial and ethnic health disparities and now is the time to address
this issue. A number of studies published in the New England Journal of
Medicine, the Journal of the American Medical Association, and by the Kaiser
Family Foundation, demonstrates the extent of racial and ethnic health
disparities in our medical system. These studies range from decreased aggressive
cancer care in blacks to a perception of minority groups that they receive a
lower quality of health care. We cannot continue to allow our health care
professionals to treat patients differently because of the patients ethnic
background. That is unacceptable in the United States of America.
This
complex problem suggests the need for a comprehensive answer, and that is
HR-3250, the Health Care Fairness Act. This bill addresses the issue of health
disparities from a number of different and crucial vantage points. It first and
foremost establishes a center at the NIH to increase the breadth and depth of
research in this area. I think it is of the utmost importance that a premier
research center, such as NIH, takes a leadership role in addressing health
disparities and aiding the transfer of research information with
patient-friendly and useful data.
The bill also deals with the education
of physicians skill ranges, to begin to highlight their biases and change them.
These are only two of the points I wanted to highlight in this bill. Along with
the comprehensive approach to this bill, I want to mention our community health
centers and the important role that they play in treating many of the patients
this bill will positively impact.
Our nations community health centers
provide care to over 7 million minorities each year. The culturally sensitive
care provided at these health centers is delivered in an efficient and effective
manner, leading to documented decreases in preventable illnesses, an increased
rate of childhood immunization, and reductions in appropriate usage of hospital
emergency rooms and a dramatic drop in infant mortality rates, to name just a
few. I think we should look at how service delivery models, such as community
health centers, are currently working to decrease these disparities., I also
want to again acknowledge both our Surgeon General and, of course, the former
Secretary of Health Dr. Sullivan, now president of Morehouse Medical School, on
their leadership in the area of reducing health disparities. I'm looking forward
to the enlightened testimony coming first from our colleagues and others who
will be giving us information as to why we might need to move very rapidly with
HR- 3250. On that note, Mr. Chairman, I yield back.
REP. COBURN: I thank
you and recognize the gentleman from California.
REP. HENRY WAXMAN
(D-CA): Thank you very much Mr. Chairman. For years this subcommittee has led
Congressional efforts to eliminate the persistent health disparities in
communities of color. I hope that today's hearing marks a renewal of these
efforts to improve access to care and expand research of importance for all
Americans.
The last time we addressed this issue was in the 103rd
Congress when Senator Kennedy and I sponsored the NIH Revitalization Act, which
established the NIH Office of Research on Minority Health, and the Minority
Health Improvement Act, which would have established national priorities in
improving the health status of minorities. I'm pleased that we're going to hear
from Surgeon General Satcher and Dr. Louis Sullivan testify to our government's
current and past efforts. They can attest to the progress which has been made.
But as one measure of the long road ahead of us all, I want to read two
conclusions from Institute of Medicine's recent report on the quote, "Unequal
burden of cancer," unquote, on communities of color. One, the research priority
setting process at NCI and NIH fails to serve the needs of ethnic minorities and
medically under-served groups. And, quote, "The committee found little evidence
that NCI or NIH has undertaken a thorough assessment of training programs to
determine whether these programs are producing adequate numbers of ethnic
minority researchers in all appropriate cancer research fields."
I think
these conclusions speak volumes about the need for Congressional action. The
administration is certainly not idle. I know the NIH has convened an internal
working group on health disparities, but I am certain that every member and
witness here today will agree that there is little danger of doing too much for
Americans who have historically had to settle for too little attention and too
few resources. As a co-sponsor of HR-3250, I believe this bipartisan legislation
would be of enormous help.
Mr. Chairman I strongly encourage you to
schedule a mark up for next week or at the earliest possible date. The remaining
time in this session is very short, for the need for health care equity is very
great.
REP. COBURN: I thank the gentleman from California. The
gentlelady from California.
REP. ANNA ESHOO (D-CA): Thank you Mr.
Chairman and good afternoon everyone. Thank you for holding this very important
hearing on HR-3250. I think that the legislation really marks a historic effort
to improve the health of minorities across our country. I want to commend our
colleague, Congressman Bennie Thompson, for introducing the bill.
It is
a solid piece of work. It's thoughtful. I've gone over it section by section and
I salute you for the work that you've done on this. And also our distinguished
Chairman for taking the first important step toward the enactment of this
legislation by holding today's hearing.
In February 1998 President
Clinton challenged our nation to an ambitious goal. By the year 2010 that we
must eliminate long-standing disparities in health status experienced by all
racial and ethnic minority populations in our nation. This challenge followed a
series of disturbing findings that despite significant improvements in the
health of Americans, that minority Americans continue to suffer from certain
diseases at up to five times the rate of white Americans.
Here are some
examples. African-American men under 65 suffer from prostate cancer and heart
disease at nearly twice the rate of whites. Vietnamese women suffer from
cervical cancer at nearly five times the rate of whites. Latinos have two to
three times the rate of stomach cancer. Native Americans suffer from diabetes at
nearly three times the average rate, while African-Americans suffer 70 percent
higher rates than white Americans. That's astronomical, when you stop and think
of that. I'm going to repeat that. African-Americans suffer 70 percent higher
rates than white Americans in that area.
We have to close these gaps.
Much more needs to be known about why minority populations are experiencing such
desperately high rates, and other diseases that we really can target much needed
resources toward eliminating the disparities. This legislation tackles the
problem by establishing the new National Center for Research on Minority Health
and Health Disparities at NIH, which I am very fond of calling our National
Institute of Hope.
And I think that if we can build this legislation
into our National Institutes of Health, that it really is going to give hope to
so many Americans across our country. The bill also authorizes the Agency for
Healthcare Research and Quality to conduct and support research, which is a
very, very important part of this effort. We have to learn more so that we can
do better.
I'm especially excited about the provisions in the
legislation aimed at education and outreach surrounding minority health. Too few
health care professionals today are really aware of the special health care
needs of minority populations, or even how to provide them. So under this bill
grants will be available to medical schools and nursing schools to incorporate
the cultural awareness programs in that very special education.
Community and rural health centers will receive incentive payments -
incentive payments, which is very important to develop innovative strategies to
reduce ethnic health disparities for health professionals. And finally the bill
directs the Secretary to develop a system to evaluate the performance of
Medicare and Medicaid, and how they are doing. So I want to welcome the very,
very distinguished people that are here to testify today.
We're
fortunate to have the Surgeon General, Dr. Satcher, and to hear his enlightened
views. And a very warm and special welcome to the former Secretary of Health and
Human Services, Dr. Louis Sullivan.
He's participated in more than one
conference that I've attended on health care. To each and every one of you, it
isn't very often that we come into this hearing room and that I see a very long
line out in the corridor. So this is an issue that I think all Americans care
about. This Congress can do something about it, and I hope after this hearing
that we will move to mark up and move to the floor. Thank you.
REP.
COBURN: Thank you. I just wanted to make a couple of comments. Much of what I've
heard in our opening statements, as a practicing physician I agree with. There's
a tremendous disparity, but not all is despair.
There are lots of
minorities that get great care, and I think it's very important that we focus to
those who don't, because there's lots of non-minorities that don't get great
care too. And what we want to do is keep in balance. And one of your statements,
even though it's meant - you know in a lot of communities, Muskogee, Oklahoma
you don't just have tough luck if you don't have insurance, because you know
what, the physician community, the hospital community, the nursing community,
the pharmacist community, they work to take care of the people.
Now that
doesn't mean they're all taken care of as great as we can. So I want to make
sure as we hear our testimony and we put our words in the record that where
credit needs to be given -- there are a lot of communities, communities of color
and non-color, that are doing a great job taking care of those folks that don't
have what we want everybody to have. And for us to say that the problem is
without that light, there is light, we just have to do a whole lot better. And
there are a lot of people who we need to care for that are not being cared for
today.
And with that I would like to recognize our co-members in the
House and the honorable Bennie Thompson.
REP. BENNIE THOMPSON (D-MA):
Thank you Mr. Chairman. And I would like to compliment you and this committee
for conducting this hearing. It's obviously the first step in the right
direction to address the health care inequities in this country.
I also
want to compliment Mr. Louis, Mr. Jackson and Mr. Watts and other members who
have also co-sponsored this legislation. It's long overdue, and as you will hear
from my colleagues, and as you've heard from my esteemed members on the
committee also, we have a problem.
This is America. This is the greatest
country in the world. The statistics quoted to you earlier today should cause
all of us great concern. We can put people on the moon. We can do a number of
things, but yet and still we have absolutely too many people of color suffering
and dying needlessly in this country.
So for that reason, we offered
this legislation and feel that reasonable people will, in fact, support it. I
can give you all the demographics, but we know the story. We have to come up and
craft a solution. We see this legislation as one effort in crafting that
solution. The district I represent Mr. Chairman, we have 24 counties. All 24
counties that I represent are medically under-served. We need help.
This
legislation addresses that and I look forward to the debate and the discussion
as we move this legislation forward. Thank you.
REP. COBURN: I thank the
gentleman. The Gentleman from Georgia, Mr. Lewis.
REP. JOHN LEWIS
(D-GA): Thank you Mr. Chairman, ranking member Brown, members of the committee,
Mr. Towns and (Asher ?). Mr. Chairman, I want to commend you and members of the
committee for holding this hearing on such an important piece of legislation,
HR- 3250, the Health Care Fairness Act. I also want to commend Representative
Watts, (Moran ?), Thompson, Jackson, Rodriguez and Underwood for their
commitment to making this bill a top priority.
They are my friends and
they are my colleagues and they care. I'm glad to be here with them today. I
especially want to thank Dr. Sullivan and his staff and the many others
concerned about minority health, for all of the help they have given me and my
staff in developing and promoting this legislation. As a member of the Ways and
Means Subcommittee on Health, I've long been committed to eliminating health
disparities. It is my hope that with today's focus on HR-3250, we can move
quickly to eliminate those disparities.
We all know how important this
issue is. Over the past two decades we have made great advances as a nation in
science and medicine. However all of our citizens have not shared in the
benefits of these advances. Minority populations have higher rates of death from
cancer and heart disease, as well as a higher rate of diabetes and other severe
health problems. That is why we introduced this bipartisan Health Care Fairness
Act, a bill supported by members of the Hispanic Caucus, the Asian-Pacific
Islands Caucus, and all members of the Congressional Black Caucus.
HR-3250 is also supported by the American Hospital Association, the
National Medical Association, the National Asian Women's Health Organization,
the Organization of Minority Health Professional Schools, the Association of
Black (Philologists ?), and many other organizations. The Health Care Fairness
Act includes an increased commitment to research on minority health, improved
data systems, culturally sensitive health care delivery and public awareness for
the existence of minority health disparities.
We must make the
commitment, the necessary commitment, to eliminate minority disparities. We must
do it for the sake, not just of the minority community, but the respect of our
nation. By focusing attention and federal resources on this problem, the Health
Care Fairness Act gives us a chance - a chance to bridge the health care gap.
Mr. Chairman and members of the committee I ask for your commitment and
your help to not only mark up HR-3250, but pass this bill before the end of the
106th Congress. I look forward to working with you in a bipartisan manner to
make sure we pass HR-3250. Thank you very much.
REP. COBURN: I thank the
gentleman. Mr. Jackson.
REP. JESSE JACKSON JR. (D-IL): Mr. Chairman,
ranking member Brown and members of the subcommittee. I want to thank you for
the opportunity to discuss with you the issue of minority health research at
NIH. I am very pleased to be joined by my colleagues Mr. Rodriguez, Mr.
Underwood, Mr. Lewis and Mr. Thompson on this panel to share ideas and concrete
steps this Congress may take to address health disparities in this country
between blacks and other ethnic minorities in the general population.
In
this time of national economic prosperity and, in particular double digit growth
for the National Institute of Health, Chairman Porter has set a single goal of
increasing appropriations for NIH by 15 percent every year. I am disappointed to
report that the health status gap among blacks and other under-served
populations is getting worse and not better. In my view the National Institute
of Health could and should be doing more to address health care needs of all
Americans.
At the beginning of the 106th Congress I was very pleased to
be appointed to the Appropriations Committee and to its Labor, Health and Human
Services and Education Subcommittee. Congressman Louis Stokes of Ohio made
gigantic steps and strides in improving minority health during his long and
distinguished service on that panel, and I hope to make a similar contribution.
One of the many benefits of serving on the subcommittee is the opportunity to
carefully review the program activity and priorities of the Institute, and to
question the health care professionals and researchers that carry out this vital
work.
In fact, the subcommittee held more than 40 hearings just this
year alone, and about half day session in which those hearings were dedicated to
the oversight of NIH. I was privileged to attend almost all of those sessions
this year as well as last year. In January of 1999 I had the privilege of
meeting with Dr. Louis Sullivan, the former HHS Secretary and current president
of Morehouse School of Medicine. Dr. Sullivan shared with me testimony he gave
before the Senate Labor, Health and Human Services Appropriations Subcommittee
concerning the Institute of Medicine's report that demonstrated a disturbingly
low level of support for cancer research among minorities through the National
Cancer Institute.
The cornerstone recommendation made by Dr. Sullivan in
his testimony was to elevate the existing NIH Office of Research on Minority
Health to center status.
What became increasingly clear across my
inquiry at NIH, was that the problem was not specifically centered in the
National Cancer Institute, that amongst its 23 institutes, 3 centers and 3
offices, a general lack of coordination on these fundamental problems was clear
and it existed. He contended that the existing structure at NIH did not
adequately address or prioritize the issue of health disparities.
After
asking scores of questions to the NIH director and the directors of the
institute and centers during last year's hearings about these disparities, I
became more convinced than ever that Dr. Sullivan was right. The Office of
Research on Minority Health needed to be elevated to center status.
Consequently, I worked with Dr. Sullivan and other health care professionals to
fashion a bill, which I also support with Congressman Thompson and Congressman
Lewis, the product of that bill, HR-2391, or Title I of 3250 which I introduced
on June 30, 1999.
The bill in plain terms does this. It provides the
director of the center a seat at the table when NIH institutes and center
directors meet to discuss NIH policy and priorities. Presently, the Office of
Research on Minority Health, when all of the directors and institutes meet, is
not even in the room. They don't have a seat at the table to coordinate across
the 23 institutes and 3 centers and the 3 offices - general coordination on
these critical issues. The current director does not attend these meetings.
Secondly, it calls for health status disparities to be prioritized at
NIH through the establishment of an NIH-wide strategic plan for health
disparities, with the center playing the key role in that strategic plan.
Thirdly, it establishes a grant making authority for the national center, which
the office presently does not have. That is, researchers who might pursue issues
such as health disparities in diabetes, cancer research or any other necessary
and needed form of study, there presently is no grant making authority in that
office to encourage researchers to study these various disparities. Right now
the office director can't spend his own budget unless an Institute director
allows him to fund a grant through his or her institute. This is unacceptable.
REP. COBURN: Would you summarize Mr. Jackson.
REP. JACKSON: I'm
just about one paragraph away sir. Fourthly, HR-3250 provides institutional
support for those minority health profession school which have a history and
mission to serve and train minority health professionals and conduct research on
health disparities. If we're ever going to solve the problem of health
disparities, institutions which have a mission to solve these problems must be
strong and they must be viable.
Mr. Chairman I urge this subcommittee to
move forward on legislation that would elevate the Office of Research on
Minority Health to a center. Elevating this office would better coordinate these
efforts at NIH, and therefore save lives and families from being strapped by
illness and anguish. Together we can ensure the health care needs of all
Americans are adequately addressed. I thank you Mr. Chairman, I thank ranking
member Brown and members of the subcommittee for this opportunity to present my
views.
REP. COBURN: Thank you. Mr. Underwood.
REP. ROBERT
UNDERWOOD: (D-GUAM): Good afternoon Mr. Chairman, ranking member Brown,
distinguished members of the committee. Thank you for the opportunity to speak
before you today on a matter of great importance to us in this room, our health.
And I'm here in my capacity as Chairman of the Congressional Asian-Pacific
Caucus and I join in strong support with other members of this panel to urge the
committee's support of HR-3250.
The Asian-American Pacific Islander
community is the most ethnically and racially diverse community in our country.
AAPIs are comprised of both immigrant populations as well as indigenous
populations from the Pacific Islands. Census data reports that the
Asian-American Pacific Islander community is the fastest growing community in
our country today. We can expect to grow from a population of about 10 million,
or about 5 percent of the total US population, to 10 percent by the year 2050.
Asian-Americans and Pacific Islanders are often labeled as the model
minority, with few health or social problems. This is a myth and a gross
misrepresentation of the situation. Within this population alone there exists
divergent economic and academic achievement rates and ethnically and racially
diverse cultures. Large sub-populations of East Asians and South Asians often
skew the reality for smaller sub-populations of Southeast Asians and Pacific
Islanders.
Recent Department of Health and Human Services data shows
that AAPIs experience the highest rates of tuberculosis and hepatitis-b in the
country. In fact, cervical cancer incidences are five times higher for
Vietnamese women. Liver cancer among Vietnamese is found to be 11 times higher
than the general population. Native Hawaiians have the second highest mortality
through lung cancer. Diabetes effects Tsumoro's (ph) natives of Guam at five
times the national average. And infant mortality rates in the US insular Pacific
areas are more than double the national average.
It is clear that the
face of America is becoming increasing diverse as its minority populations
continue to grow. And as our minority populations increase so will the
complexity of our health situation, which means that we need innovative
approaches to deal with this issue. The Health Care Fairness Act lays out a plan
to reduce racial and ethnic disparities in health care and health care outcomes.
By elevating the Office of Research on Minority Health to create a Center for
Health Disparities Research at the National Institutes of Health we will
significantly increase the support for research on health disparities, improving
data collections relating to race and ethnicity, and funding major increases in
minority medical training and curriculum development.
The NIH needs a
strong and effective coordinating body to focus research and awareness on the
health care needs of all minorities. There's also much room for improvement in
the methods of data collection. Within the Asian-American Pacific Islander
community there exists scant local and federal data to document the needs of our
communities. It is only with the emergence of more recent and improved data
collections that we are beginning to realize the unique needs of the AAPI
communities.
The Health Care Fairness Act represents a comprehensive,
bipartisan effort to effectively address the health care needs of all our
communities. As chairman of the Congressional Asian Pacific Caucus I strongly
urge your support and commitment to bridge the gap which denies minority
Americans from receiving fair access to health care, health care that has
meaning in their cultures and in their lives, and other quality of life
services. And I join with my colleagues on this panel to urge you to move this
bill forward. Thank you very much.
REP. COBURN: Thank you. Mr.
Rodriguez.
REP. CIRO RODRIGUEZ (D-TX): Thank you Mr. Chairman and thank
you Congressman Brown, leading Democrat. I want to also thank the member, Mr.
Bennie Thompson, Congressman Lewis, Congressman Jackson, and Congressman
Underwood for their efforts in the area of health care.
Let me just say
quickly say that the Hispanic Caucus as of last year had some hearings, and one
of the things that we found from that hearing is that there were five areas of
concern that we had. One of those was access to health care. And as you've
indicated Mr. Chairman, it's not only just minorities in that area. One of the
things that we've found, that there is a disparity in terms of Hispanics, that
we're one of the largest number of uninsured, but beyond that anyone who is
working for a small company, who is not working for government, not working for
a major corporation, but is making money, doesn't qualify for Medicaid, finds
themselves without the access to health care. And the need for us to be able to
do something in that area is key.
Secondly, we found out that in the
area of funding, when it comes to Hispanics, we found that there is definitely a
disparity in that specific area. We find that a lot of community organizations
out there don't have access to those services and that there's a need for us to
be a little more responsive in terms of governmental entities in reaching out to
those.
Thirdly, we found that cultural competency information is key,
and I'll just give you a quick example. When a doctor testified to the fact that
we had a woman who was told that she was positive when it came to HIV, and in
Hispanol, when you say "positivo," it's like in English, you think everything is
okay. And that's what she thought. Later she had a child and found herself and
both HIV positive. And that was unfortunate.
Thirdly (sic) we also found
in the testimony that the lack of representation in terms of health profession,
in terms of Hispanic, in all the fields of the health profession - the need for
us to make sure that we hold not only agencies accountable, but the schools to
allow individuals to be able to have that opportunity, to be able to meet some
of the needs of our constituencies that are out there.
Finally, the
fifth area that we found is there's a lack of data collection, and the need for
us to be able to get some data. One of the things, for example, finding out why
is it that Hispanics are disproportionately hit with diabetes, and a variety of
other issues. And so, those are the five areas that we found that were critical.
This bill allows us an opportunity to move forward in some of those
areas, and we're optimistic and we're pleased that you have this hearing to
allow us that opportunity to be able to do that. There's no doubt that there's a
need for us to zero in on these areas, and there's a need for us to make sure
that we prioritize those items. And I think that the individuals that you see
before you are eager to move forward, and I want to thank you for allowing us
this opportunity.
REP. COBURN: Thank you very much for your testimony.
The gentleman from Arizona, Mr. Hayworth.
REP. J. D. HAYWORTH (R-AZ):
Thank you Mr. Chairman and it's an honor to be here with you, and talk about a
dramatic entrance. We always try to look for drama where ever we can find it.
I'm here today in my capacity as co-chairman of the Congressional Native
American Caucus. I want to thank you Mr. Chairman for offering all of us this
opportunity to testify on Hr-3250, the Health Care Fairness Act. I would like to
commend all of you for holding this hearing today on ways to address minority
health disparities and health research education and access to health care in
minority populations.
In 1976 Congress enacted the Indian Health Care
Improvement Act. The act is one of the most comprehensive efforts by Congress to
address the health needs and health status of American Indians and Alaska
natives. Although improvements in the health status of American Indians and
Alaska natives have been accomplished, the unmet health needs of this population
continues to be staggering.
As indicated in recent studies by the
Centers for Disease Control and Prevention, CDC, the disparity between the
health of Native Americans and the rest of the population is ever widening.
Native Americans suffer the worst health status of any racial or ethnic group in
America, with a diabetes rate that is three times greater than the general
population, and a death rate 4.3 times greater than the general population from
complications of diabetes.
In addition, Native Americans suffer rates of
heart disease two times as high as the general population. Cancer and alcoholism
six times the national rate. Hepatitis two times as high as the general
population. And tuberculosis at five times as high as the general population. A
stunning example of the disparity is the Gila River Indian Community in the
Sixth Congressional District in Arizona, whom I represent.
The community
is well known to medical officials for its shockingly high rate of type-2, adult
onset diabetes. According to the World Health Organization, the Pima Indians,
who make up the majority of this particular community's population, have the
highest known rate of diabetes in the world. Community members are twelve times
more likely to die of diabetes and its severe complication, than the average
American.
For over three decades members of the community have been
studied by the National Institutes of Health and outside parties. The National
Institute for Diabetes and Digestive and Kidney Diseases has supported a field
research station in Arizona since 1965. Community members have been weighed,
poked, prodded, x-rayed and screened at a cost to taxpayers of more than
$100 million. Based on the data obtained, NIH was able to
develop new approaches to the treatment of Type1 diabetes, juvenile diabetes.
The NIH research program findings failed to study the treatment and prevention
of Type2 diabetes, the type of diabetes that effects the very people who were
used to obtain the data.
Despite three decades of research, the Type 2
diabetes epidemic within the community continues to accelerate. In a disturbing
development, the age of onset of Type 2 diabetes has been decreasing steadily.
In fact, within the community the term adult onset diabetes is rapidly becoming
a misnomer. The community also has the largest known cluster of children with
Type 2 diabetes in the world.
Congress has a special trust
responsibility to assure the highest possible health status is achieved for
Native Americans. Despite the trust responsibility, American Natives and Alaskan
natives continue to bear a disproportionate burden of illness and premature
mortality in comparison with other American populations. The lesson to learn
from the Gila experience is that tribal self-interest must be taken into
consideration.
Congress must look for ways to give tribes more direct
control over the prevention, intervention and treatment of serious diseases
effecting their populations. We look forward to working with the committee to
develop solutions for innovative and culturally sensitive methods to address
health disparities for Native Americans and Alaska natives. And again I thank
the chair and committee.
REP. COBURN: Thank you Mr. Hayworth. Mr. Watts
welcome.
REP. J. C. WATTS JR. (D-OK): Thank you sir.
REP.
COBURN: You're recognized for three minutes.
REP. WATTS: Mr. Coburn
thank you very much. And Chairman Bilirakis thank you very much for holding this
hearing, and other members of this committee. And I am going to have to leave,
so I do appreciate your bearing with me.
Again, I'd like to thank you
all for holding this hearing today concerning HR-3250, the Health Care Fairness
Act. I'd also like to thank my colleagues, all who are present today, especially
Mr. Lewis, Mr. Norwood and Mr. Jackson and all the other members who have
championed this critical legislation. I'm also proud to have testifying here
today Dr. John Harley, who is a member of the Oklahoma Medical Research
Foundation.
OMRF is truly a beacon of excellence and scientific research
for the state of Oklahoma and the nation. The scientists at OMRF play a
significant role in uncovering clues to the origin of human disease, and thereby
building a bio-medical industry. OMRF discoveries are helping lead the way in
the fight against cancer, heart disease, stroke, diabetes, lupus and other
diseases that plague mankind, and especially minorities.
Just as OMRF
medical research is helping to address the disparities in health, so will the
Health Care Fairness Act. The Health Care Fairness Act comprehensively addresses
health disparities by elevating the existing Office of Research on Minority
Health and the National Institutes of Health, to a national Center for Research
on Minority Health. It also addresses bias in health care through education,
improved data systems, and strengthened public awareness.
Despite
continuing advances in research and medicine, disparities in health care are an
ever increasing problem and concern. This is evidenced by the fact that minority
Americans lag behind on nearly every health indicator, including health care
coverage, access to care, life expectancy, and disease rates. Ethnic minorities
and individuals in medically under-served rural communities continue to suffer
disproportionately from many diseases, such as cancer, diabetes and
cardiovascular diseases.
There have been numerous studies in scientific
journals showing the severity of racial and ethnic health disparities and the
need for action in order to remedy this grave problem. As previously noted,
disease rates and access to health care are two of the many different many
facets of health disparity. In October of 1999 the Henry J. Kaiser Family
Foundation found that many studies have repeatedly documented that
African-Americans were significantly less likely than whites to receive
diagnostic and surgical interventions for heart disease and stroke.
Numerous studies have also found that racial and ethnic minorities were
more likely than whites to be diagnosed with cancer at advanced stages, and less
likely to receive major therapeutic interventions.
With regards to
diabetes, in which I lost a mother several years ago, racial differences have
been documented in the degree and method of diabetes control. Mr. Chairman in
closing, I would like to point out the obvious. Access to quality health care is
crucial.
We must all work together to see that the health care needs of
everyone, including minority and rural populations, are met. There is no single
cause of racial disparities in health and there's no single solution. But there
is no doubt that greater public awareness is mandatory if we are to have an
impact on this problem.
The elimination of health disparities must be a
higher priority. The Health Care Fairness Act will increase our knowledge of the
nature and causes of health disparities, improve the quality and outcomes of
health care services for minority populations, and aid in bringing us closer to
our mutual goal of closing the long-standing gap in health care.
I am
deeply committed to this piece of legislation and I urge all of the members of
Congress to support us in our efforts to rectify this inequality in health care.
Mr. Chairman, Mr. Coburn and members of the committee, I thank you for your time
and your sincere interest in addressing this very critical issue.
REP.
COBURN: Thank you Mr. Watts. I believe that the committee is not going to be
asking questions of this panel. I do want to tell you that I do think all
members of this subcommittee see that the problem is real and will be making
every effort to support you in your efforts.
REP. MICHAEL BILIRAKIS
(R-FL): Mr. Chairman if I may, I don't want to really ask a question, but
certainly the details of the bill, of the larger bill, Mr. Lewis and Mr.
Thompson's bill, is significant. But obviously regarding the Center, of course,
might be the stumbling block, and we would hope that it would not be.
So
I guess that I just wanted to suggest to you gentlemen, knowing that and maybe
wanting to talk to us, because Mr. Jackson and I have had long discussions about
this, you may want to sort of gather together, if you will, your ammunition and
that sort of things that Mr. Jackson and I spoke about towards that end. Because
some of us feel very strongly about creating the Center, and then there are
others who raise, of course, technicalities. The fact that the director
apparently, I use the word apparently - maybe we'll find out a little bit more
in a little while - apparently is not supported or at least is not expressing
any support.
But thank you Mr. Chairman.
REP. COBURN: Thank you.
(Panel change)
REP. BILIRAKIS: Let's have order please. Not
knowing whether Mr. Coburn, in sitting in the chair has placed into record the
opening statements of all members of the subcommittee, I will now say without
objection my opening statement and all the other opening statements will be made
a part of the record. I don't know, did he offer an opportunity for opening
statements?
REP. COBURN: Everyone but Mr. Barrett, and we got mine.
REP. BILIRAKIS: Okay. Ed, did you make your opening statement? You were
able to do so. Okay, so in any case that's the case. Panel two will consist of -
and at first I do want to apologize. We scheduled this around - I had a veterans
committee mark up on an education bill for veterans, and that was scheduled for
10 o'clock. So we scheduled this hearing for 11:30 figuring I'd be able to get
out of that. Then of course they called the votes shortly after 10 o'clock and
we had six votes which meant that that mark up was delayed and consequently
everything was set back.
I appreciate very much Dr. Coburn taking the
time to come over here to at least get it started so we didn't get started too
late. The second panel consists of the very honorable David Satcher, US Surgeon
General. And he is accompanied by Dr. Kermit Smith, who is a chief medical
officer of the Indian Health Service; and Dr. John Ruffin, associate director -
I probably mispronounced that, did I?
MR. JOHN RUFFIN: Absolutely
correct.
REP. BILIRAKIS: Absolutely correct, Dr. John Ruffin, associate
director of the Research for Minority Health with the National Institutes of
Health. I thank you gentlemen. Welcome to our hearing and Dr. Satcher you're
testifying on behalf of the administration? The clock ordinarily is five
minutes, you have ten minutes and hopefully you can get your point across within
that period of time, but we'll certainly extend it if we have to. Please proceed
sir.
DR. DAVID SATCHER: Thank you very much, Congressman Brown and
members of the subcommittee. I want to express my appreciation for the
invitation to testify at this very important hearing on ways to improve the
quality of health and health care for minorities and HR- 3250, the Health Care
Fairness Act of 1999. As you've pointed out, with me today are experts from the
Indian Health Service, Dr. Kermit Smith; and from NIH Dr. John Ruffin, the
associate director of the Office of Research on Minority Health at NIH.
Let me say also how much we appreciate the testimony of panel one, and
how much we appreciate the presence of Secretary Sullivan and his outstanding
contributions in this area before, during and since he's served as Secretary of
the Department of Health and Human Services. It's great to be here with them.
And also Dr. Cohen, Dr. Jody Cohen from the American Association of Medical
Colleges, who in the face of incredible odds has worked so hard to improve the
representation of minorities in the health profession.
Your topic could
not be more appropriate, for as we examine the state of minority health in
America we're really addressing the status of our nation's health overall and
the strength of our public health system. Despite notable progress in the
overall health of the nation, there are continuing disparities in the burden of
illness and death experienced by African-Americans, Hispanics, American Indians
and Alaskan natives, and Pacific Islanders compared to the US population as a
whole.
These disparities are not explained by biologic or genetic
characteristics of racial and ethnic groups. Instead they're believed to be the
results of a complex interaction among genetic variation, environmental factors,
economics, specific health behaviors and discrimination, including
discrimination in access and quality of health care. The Department of Health
and Human Services adopted the commitment to eliminate disparities in health on
the basis of race and ethnicity by the year 2010. I think we did this first in
response to President Clinton's request that a health component be added to the
race initiative which he announced in 1997.
Secondly, the goal of
eliminating disparities in health is one of the two goals of Healthy People
2010. We will focus initially on six key areas that reflect areas of disparity
across multiple racial and ethnic minority groups. And they are: infant
mortality, breast and cervical cancer screening and management, cardiovascular
disease risk factor reduction, diabetes complications, adult and childhood
immunization, and HIV infections and AIDS.
We want to make it clear,
however, that we are not limiting our efforts to these six areas with which we
will begin. There are many other areas of disparity. Sunday we will celebrate
mothers day. This morning earlier I was with Senator Chris Bond and
Congresswoman Nita Lowey and Cynthia McKinney to talk about safe motherhood.
African- American women are four times more likely to die during and around
pregnancy than other majority women in this country.
We could talk about
asthma. There are several areas of disparity and the idea here is to begin with
these six where we have the kind of data base where we can measure our progress,
and we believe that we can have a great impact. But all of these areas are of
concern to us.
I want to speak briefly about what we're doing, since
you've heard the statistics relative to these disparities. We have begun a
program to address disparities starting with President Clinton's announcement in
February of 1998 shortly after I became Surgeon General. One component of the
department's initiative is the racial and ethnic approaches to community health,
2010 program or Reach 2010. It is designed to help communities mobilize and
organize their resources in support of effective and sustainable programs that
will eliminate health disparities.
So far, 32 communities have been
funded to develop plans for eliminating disparities in one of these six areas,
some of them more than one. Others will be funded later this year. And those
among the 32 communities with acceptable plans will receive programmatic
funding. The Office of Civil Rights has played a very critical role in the
department's initiative to eliminate disparities in health. They have focused on
enforcement, education and outreach and, I think, are doing a great job.
I want to just give you a few examples of the work of the Office of
Civil Rights. These cases illustrate the discrimination that regrettably still
is alive and well in the health care setting. The Office of Civil Rights
recently reached a settlement with the National Home Health Agency that had
engaged in medical redlining, that is it refused to serve a predominantly
minority area of New Haven, Connecticut.
The Office of Civil Rights
reached an agreement with a national pharmacy chain that had repeatedly failed
to fill the prescriptions of African-American Medicaid recipients in Texas. The
Office of Civil Rights reached a settlement with a hospital in South Carolina
that had a policy in effect of not giving epidurals to women who did not speak
English. And they're having several of those kinds of experiences, but I think
what we're finding is that through a process of enforcement, education and
communication, that we can, in fact, make significant progress.
The NIH
has established a working group on health disparities that is currently
developing a strategic plan to expand training programs for minority researchers
to set priorities and to synchronize multi-disciplinary research. That strategic
plan will be reviewed by the Office of Research on Minority Health and its
public advisement committee. I do want to point out, Mr. Chairman, that after
much discussion the former director of NIH, Dr. Ramos (ph), has written a letter
in support of the development of the Center. And certainly the present, acting
director of the NIH, Dr. Kirstine (ph) supports the development of the Center. I
wanted to make that point because I think it is important, as you pointed out,
in terms of their positions.
Addressing the challenge of health
improvement is a shared responsibility that requires the active participation
and leadership of the federal government, state and local governments, other
policy makers, health care providers, professionals, business leaders, etcetera.
The Agency for Health Care Research and Quality plans to establish this summer
four centers of excellence that will identify practical tools and strategies to
eliminate racial and ethnic disparities in the health care system.
PHSER
is leading a campaign for 100 percent access and zero percent disparities by the
year 2010. The other area of development that I think is really important is the
development of partnerships between our department and many private sector
groups. We are partnered with grant makers in health, which represents over 200
health related foundations in this country. And they're working with foundations
and corporate giving programs to improve the nations health and they have made
elimination of disparities a priority.
The California endowment has
initiated a program in multi- cultural health aimed at eliminating health
disparities, and through collaboration with the CDC Foundation, has already
funded three additional Reach 2010 projects in California. Likewise, the Robert
Wood Johnson Foundation, the Commonwealth Foundation, the Kaiser Family
Foundation and others have funded programs for the elimination of disparities in
health. On April 24, 2000 our department and the American Public Health
Association announced a partnership to eliminate racial and ethnic disparities.
The partnership includes a three phase plan to develop a blueprint of guidelines
for our collaboration, to develop a detailed, comprehensive national plan, and
thirdly to implement that plan by 2002.
I think this is really important
since the American Public Health Association represents 55,000 members, many of
them leaders in public health throughout this country. When asked to rank issues
for the year 2010, they listed the elimination of disparities as their number
one priority. So we're partnering and very happy to be partnering with the
American Public Health Association.
The role of the Health Care Fairness
Act of 1999 in improving minority health we think is significant and I will
close with these comments. We thank you for your support of our initiative to
eliminate racial and ethnic disparities in health and its parallel emphasis will
then help 2010. The proposed Health Care Fairness Act of 1999 addresses several
of the key elements the department has identified as essential to a
comprehensive approach toward eliminating disparities. They include: the
development of a balanced and comprehensive research agenda that addresses the
unequal burden of morbidity and mortality in racial and ethnic minorities;
supporting efforts to improve the quality and outcome of health care services,
as well as addressing the social determinants of health, including but not
limited to access to care; the ten leading health indicators of Help to People
2010, five of which deal with lifestyles and five with health care system
issues; strengthening the data collection infrastructure of HHS; recognition of
the important role of the Office of Civil Rights; support for graduate health
education curriculum development; and continuing medical education efforts to
reduce disparity in health and health outcomes, as well as increasing the
knowledge base with respect to cultural competency.
Mr. Chairman,
members of the committee, as Surgeon General of the United States and as one who
has a major responsibility in this area, I'm encouraged by the evidence of the
bipartisan public, private and federal, state and local commitment that is
developing in this country. As we continue our work to improve the lives of our
fellow Americans, let me leave you with the premise upon which the US Public
Health Service was founded in 1798 as the Marine Hospital Service. And that
premise is to the extent that we respond to the needs of the most vulnerable
among us, we do most to promote and protect the health of the nation.
Thank you for the opportunity to share with you some of our department's
activities and our perspectives. We appreciate your support and we look forward
to our continuing partnership to improve the health and the health care system
in this country. We'll be happy to respond to any questions.
REP.
BILIRAKIS: Thank you, thank you very much Doctor. The chair will recognize
himself for five minutes. You and Dr. Ruffin made a comment that -- well you
mentioned Dr. Varmus' letter. Of course, that is not done as Dr. Varmus,
director of NIH has done, after he's given up that position. Believe me it would
have made our lives a lot easier if he had done it prior to that point.
Now, you both mentioned though that the administration is supportive of
elevating the office to a center, or is it the current NIH director, or is it
both?
DR. SATCHER: The administration, as you know, within the budget
submitted by the President, does not have a position on the Center proposal. So
I'm not speaking for the administration in terms of a specific proposal. But as
you know, the administration is strongly supportive of the strategy to eliminate
disparities in health and believes that research targeted to that is critical.
REP. BILIRAKIS: Well doctor I should like to think that we are all
supportive of that, but we are not talking about doing something which
apparently is a little - well I hate to use the word controversial, but
questionable in terms of elevating the office. And by gosh you'd like to think
that the people directly effected, I mean obviously the public is directly
effected, but you know what I mean, I'm talking about the director and his staff
and NIH and whatnot. You'd like to know what their position on it is and I don't
think that your comments go directly to that. Dr. Ruffin do you have any other
comment?
DR. RUFFIN: Yes Mr. Chairman, in all of my conversations with
the current director of the National Institutes of Health, she's not opposed to
the elevation of the office. Now Mr. Mark Velanski (ph) who is our legislative
individual there, is also accompanying me today at this meeting, and if I'm
wrong about that in any way then Mark can correct me on that. But in all of my
conversations with the current director of NIH, there's been no opposition to
the elevation of the office.
REP. BILIRAKIS: Well, maybe I'm sort of
splitting hairs here, but Mr. Jackson has also basically responded in the same
way in the sense that the current director is not in opposition.
But
that could be a sort of ambivalence, if you will. And I guess it's significant
to know because as I understand it the way the organizational lines would lie
and the responsibilities and the control, if you will. I understand that the
director maybe may not have anything to do with the funding of the center, which
may be all right. But you'd like to hear these things from the director.
DR. RUFFIN: Well I certainly wouldn't be able to speak directly for the
director of NIH, but again only to translate my conversations with her on that
issue.
REP. BILIRAKIS: Does the administration have a position on the
entire bill, HR-3250? And if it does not have a position will it be providing a
formal position on this legislation? Can you all tell me that?
DR.
SATCHER: I can't tell you if the administration will submit a formal position
because as I said before, I think when the President submitted his budget OMB
was not in a position to speak to this particular legislation at the time. I do
want to make it clear, and I speak as obviously representing the administration,
it certainly is in my professional opinion and speaking as Surgeon General and
having responsibility for dealing with the best science, this legislation is
consistent with what we're trying to do to eliminate disparities in health in
this country. And it's needed in order to do it.
REP. BILIRAKIS: Well
you know Doctor I agree with you. I think it's needed. By gosh I think we should
have a President of the United States who should tell us the same thing, or at
least his director of NIH. And I can't quite understand in my mind - I don't
know Mr. Jackson how can any of us really understand, you know - I don't mean to
slight your remarks and your response, but it doesn't tell us what we need to
hear, I think. How would -
DR. SATCHER: So you want a statement from the
administration that it supports this specific legislation?
REP.
BILIRAKIS: Supports this legislation and all areas of this legislation, if you
will, and if there are any areas that they don't support they should let us
know. And of course more specifically, not again to belittle the other areas,
but more specifically regarding the Center. The chair now yields to Mr. Brown.
Thank you.
REP. BROWN: Thank you. Dr. Satcher it's a pleasure to have
you in front of us. Your successor in CDC gives a speech about public health
saying that - talking about 100 years ago the life expectancy in this country
was 46. Now it's some 30 years longer than that. Some of the success he points
out is in high-tech medicine. Most of the success, 70-80 percent of that 30 year
lengthening of life-span is due to strides in public health, everything from
vaccines to safe drinking water to better sewage disposal, controlling of lead
poisoning, seat belts, all kinds of things like that.
You worked first
at CDC, now at Public Health Services, has been exemplary in sort of exploring
that. I'd like you to discuss with us the disparities in public health delivery
of services, everything from whether it's inner city hospitals or vaccines or
where ever you might want to go with the question. But do we know enough about
these disparities in the public health part of our health care system.
DR. SATCHER: I think we're learning more every day. These are the 10
leading health indicators for Healthy People 2010, and as I said five of them
are in lifestyles: tobacco use, physical activity, overweight and obesity,
substance abuse, responsible sexual behavior. Five are in the health system:
mental health, injury and violence, environmental quality, immunization, access
to health care. In virtually all of these areas we can identify disparities.
Starting with access to health care, as you know and as you've heard,
Hispanics are most likely to be uninsured of any group in this country. One out
of three Hispanics are uninsured. African-Americans are next most likely to be
uninsured. But even among those who are insured, the probability of having a
personal physician is lowest among Hispanics and African-Americans.
Hispanics and African-Americans together make up 25 percent of the
population, and yet 70 percent of the people who live in under- served
communities in this country are: in the area of immunization - and let me take
adult immunization now - influenza and numacoccya (ph) vaccine, where we're not
doing as well as we should be doing with the elderly. Sixty-seven percent of
whites in the last year for which we have data, 1997, received the influenza
vaccine; sixty-seven percent of whites over 65. Fifty percent of
African-Americans and 58 percent of Hispanics.
In the numacoccya
vaccine, it's even worse. Forty-seven percent of whites over 65, 34 percent of
Hispanics, 30 percent of African- Americans. Even in the area of environmental
quality, today in this country African-American and Hispanic children are much
more likely to live within two miles of hazardous waste sites than other groups
in this country. In fact 40 percent of the people who live within two miles of
hazardous waste sites in this country are African-Americans or Hispanics. And if
you add American Indians, it's about 50 percent.
So in all of these
areas we can point to disparities. And we take the position that we believe that
if we can attack these areas of disparities, with the health system - and let me
add, we're not just talking about the health system, we're also talking about
lifestyles. And we have to be very clear about that.
Lifestyles like
tobacco use and physical activity, substance abuse, are areas of opportunity
here. They are not just individual responsibility. In many cases they are
community responsibilities. I mean if people attend schools where they don't
offer courses in physical education, they're less likely to be physically
active. If they live in communities where it's not safe or doesn't appear to be
safe to get out and walk or jog on the street, or bike, where you don't have
biking trails, they're less likely to be physically active.
So in all of
these areas I think we can identify opportunities for intervention, and many of
them are public health. The only other thing I will say, because I've had some
minor disagreements with some of my colleagues - they're not major - when we say
that 50 percent of disparities or variations in morbidity and mortality are due
to lifestyle, 20 percent to environment, 20 percent to genetics and 10 percent
to access to care; the only problem with that is that we know that a really
concerned physician provider influences lifestyle significantly.
If
every physician would ask his or her patient if he or she smoked, and then asked
them to quit, without even implementing a smoking cessation program, two million
more people would stop smoking in this country every year. If physicians wrote
prescriptions like the Surgeon General's prescription, prescribing physical
activity and good nutrition for their patients, many more people would have
appropriate lifestyles. So we believe that a pediatrician who's concerned about
whether his child - his patient is exposed to lead, does the appropriate
screening, intervenes with the appropriate agencies, makes a big difference in
these areas.
So I've put a little more weight on access to care than
some of my colleagues do because I believe that we as physicians have some
tremendous opportunities to intervene. Dr. Kermit Smith here from the Indian
Health Service can probably talk more to that than I can because they've done
some outstanding things in Indian Health Service.
REP. BILIRAKIS: Well
the time has expired, but without objection Mr. Brown has an additional minute.
Go ahead Mr. Smith.
DR. KERMIT SMITH: Good morning, thank you for the
opportunity. The activities we've been engaged in, our numbers might be a little
bit different. Access might be a bit better, but again, we were talking about we
have a large population of native Americans who live in the cities we don't deal
with in Indian Health Services. Those that are on a reservation or in areas
where we provide care, we may see only 70 to 75 percent of those people who live
in those areas.
But we have made some real strides in the public health
activities we've been involved in, sanitation. We still, however, have areas
where we have no electricity, where we have no telephones, and so in those areas
we are still trying to catch up. The activities related to smoking cessation,
other behavior activities, we have made some strides, but when we look at our
mortality and our morbidity, about 50 percent of the morbidity in our people is
still related to behavioral activities.
REP. BROWN: Mr. Chairman, one
point of clarification, to go back to what Dr. Satcher said, you said at the
beginning of your comments even among insured Americans there is a disparity, a
racial disparity between whites and minorities over the number of people that
actually have a primary care physician with whom they have some relationship.
DR. SATCHER: Or even a personal physician. And ideally that would be a
primary care physician, but if you just use the word personal, there are
dramatic disparities.
REP. BROWN: So minorities are less likely to -
even insured minorities - are less likely to hear from a doctor about those
issues?
DR. SATCHER: Exactly.
REP. BILIRAKIS: The gentleman's
time has expired. Dr. Coburn.
REP. COBURN: Thank you, I just want to
follow up on that. Is that because there are none available or because they
don't seek them out? Where's the motivation here?
DR. SATCHER: Well I
think it's a very good question. And you're going to hear some of that from the
next panel. I know Kevin Chilman (sp) is here who has done some very interesting
research. But it gets back Congressman Coburn to the under-served community. You
can have Medicaid or Medicare, for example, and if you live in a community where
you don't have access to a physician you're less likely to get the flu shot. Or
even if you have a physician but you don't have the kind of relationship where
they really reach out to make sure that you get your shot -
REP. COBURN:
You're describing the doctor instead of physician.
DR. SATCHER: Well -
REP. COBURN: A physician always reaches out.
DR. SATCHER:
Especially if it's Tom Coburn.
REP. COBURN: No, that's the difference.
DR. SATCHER: I agree.
REP. COBURN: And I think it's one of the
things that we ought to have a discussion about because part of our problem in
access to care, is not on the receipt end, it's on the professional side.
DR. SATCHER: Exactly.
REP. COBURN: And we need to do a much
better job in our profession of knowing what it takes to reach out to get
somebody to change their lifestyle, or to think about it or to think about the
community. It's not just about money in terms of being a doctor.
DR.
SATCHER: But let me just say I think it is significant, Congressman Coburn, that
when you have such an under-representation of African-Americans, Hispanics,
American Indians, of physicians, the cultural barriers, the reaching out, there
is a difference. It's one of our major concerns.
REP. COBURN: Oh I
agree. My latest partner is an African-American female who graduated from Duke
Medical School and she has taught me tons with my own patients, culturally, that
I had no knowledge of in terms of interacting with them. And so she's been a
great benefit to teach me the cultural things. Where did I get it, I didn't get
it in medical school that's for sure. And so that's the other side of it, but I
was saying were going to have to address the professional side of this as well
after you all bring us some research to tell us what we need to do with this
bill.
You know one of my favorite issues to visit with you about is what
we saw on HIV. And we're getting ready to re-authorize Ryan White, and we've
seen this disease move to the minority communities. I mean that's where it's
shifting. And do you have recommendations for us as we do that in terms of
making sure we address - because one of the things the report, the Inspector
General and GAO report said was, and I quote, "Minority, African-American,
Hispanic and women are served by the Ryan White Care Act in
higher proportions than the representation in the AIDS population, yet they
generally receive less appropriate health care." In other words they're there,
but they're not getting the health care appropriate for them. Do you have any
recommendations for us, not just on this bill but as we look at that, on what we
should do?
DR. SATCHER: I think it's not unrelated to what we were just
discussing in terms of - you know we know that African-Americans are less likely
to be insured. We also know that they're less likely to have that kind of
personal physician and the kind of relationship where they're more likely to get
the care that they need. So I think that we're on the right track at looking at
this whole doctor-patient relationship and making it a part of our discussion of
access.
When I use the word access, I'm not just talking about
availability, but I'm talking about access to a relationship that's going to
result in your getting the kind of care that you need, whether it's for AIDS,
which it is in this case. We have some, we think, very good opportunities under
Ryan White. As you know when I testified we made a recommendation for expanding
some of those opportunities to communities that tend to get left out.
But we're struggling here, we're trying to make sure that people who
need a personal relationship with a physician, a caring relationship, that
they're able to find it. And we have to come up with some innovative strategies
that might well go beyond physicians to health care teams that are innovative in
getting people out there. And we may need to be a little more aggressive in
terms of some of our programs like loan forgiveness programs and things like
that - and loan repayment to get more physicians into some of these communities.
REP. COBURN: One of the things that we're debating with in the Ryan
White Reauthorization is how we allocate the money. And of course this is a
delayed disease. Where we have historically measured AIDS cases, rather than HIV
prevalence, and I believe we have 33 states now, or 34 states that have HIV
prevalence data, how should we in terms of addressing - as this moves to the
minority community and communities of color, and especially women, because
that's where it's going - how should we allocate the money? Should we use
prevalence data or should we use the same old average AIDS data that we've used
in the past? Do you have a recommendation in that regard?
DR. SATCHER: I
think we've got to go beyond AIDS. As you know, I agree with the position and
the recommendation of CDC that we should have HIV name reporting. While I
understand the fears of people who oppose it, by saying we still live in a
country where you can be discriminated against in hiring policy, etcetera, if
people know you have HIV, I just think somehow we as a nation have got to
guarantee the confidentiality but also the protection of people who are
diagnosed as positive for HIV.
I don't think we've done that yet. But I
agree with you, and I know how strongly you feel about this, that we need name
reporting. And we also need to be able to track this disease as we do other
sexually transmitted diseases. But in order to get there we've got to get rid of
some of the fear and stigma surrounding this problem.
REP. COBURN: And
we've got to have a bill like this to make sure that everybody has access.
DR. SATCHER: Exactly.
REP. BILIRAKIS: Thank you Doctor. A vote
is being called but I believe Mr. Barrett is here.
REP. BARRETT: Thank
you very much. I'll be brief. Dr. Satcher I want to thank you. You came to
Milwaukee in December at our health conference and I still hear people say how
wonderful you were, so I appreciate your willingness to come out to the great
Midwest to visit with us.
DR. SATCHER: I enjoyed being with you.
REP. THOMAS BARRETT (D-WI): You'll have to excuse my slow, deliberate
approach here but for me it would be helpful if you could just name me three
illnesses or conditions where you see a disparity between the majority community
and the minority community, where you think we could make a difference. And
again that's a pretty fundamental question, but if we could go over that just
again quickly.
DR. SATCHER: Let me take a couple, and I hope I'm being
responsive to your question, let me start with infant mortality. Obviously I
feel very strongly that as a nation, if there's any area where we ought to make
a commitment to universal access, it's to prenatal care. We ought to do
everything we can to make sure that every woman has access to prenatal care
beginning in the first trimester of pregnancy.
We talked about that this
morning in terms of safe motherhood. So I believe that we could make a
difference if we set up systems in this country to assure that universal access
to prenatal care, and to really target communities. Because we're down to a few
areas where I think we have major problems. As we said this morning, we've made
dramatic progress in this country in the last 50 years in terms of reducing
maternal mortality. And yet we've not made any progress since 1982.
And
today, African-American women are four times more likely to die during
pregnancy, while the health of the mother has a lot to do with the health of the
baby, starting from the beginning of conception and even before, in terms of
folic acid. So we can make a lot of difference. We believe in making sure that
every child has an opportunity for a healthy start in life in this country, by
really focusing on the health of the mother before and during pregnancy, access
to quality prenatal care, and involvement in systems of care that even go beyond
that. That's one.
I would take diabetes because again, American Indians
are three times more likely to suffer diabetes in this country. We spend a lot
of our resources in that area treating complications, like end stage Renal
disease, and blindness. I have visited hospitals on Indian reservations where -
very small hospitals, 24 beds - and yet 30 or more people are being dialyzed for
end-state renal disease. We need to aggressively fund programs to prevent the 30
percent of Type 2 diabetes that we can prevent, with aggressive prevention
programs.
But also, early diagnosis and tight control of diabetes -- we
have research showing that with early diagnosis and the tight control of
diabetes we can prevent most of these complications, 90 percent of them. We need
to move to do that because we have the ability to do it. So that's an area.
It's interesting, breast cancer is interesting. We made progress in the
'90s, really for the first time in terms of cancer mortality. Actually,
Caucasian women in this country have the highest incidence of breast cancer.
REP. BILIRAKIS: Doctor forgive me for a moment. Tom, we're going to go a
little bit out of order here because Dr. Sullivan has a plane to catch and we
have these votes, which probably means about an hour or close to it.
REP. BARNETT: I yield back my time.
REP. BILIRAKIS: I didn't
mean that, but I did want to ask you all would not mind if we asked Dr. Sullivan
to come up right now so he can give his testimony, so that we can hear what he
has to say. We're not going to have an opportunity to question him. Now Dr.
Satcher I don't know, I hate to have you cooling your heals for at least an
hour.
DR. SATCHER: I have to leave, I didn't know what time it was.
REP. BILIRAKIS: You have to leave also?
DR. SATCHER: No, we
apologize, but this is the way it is up here. This is our life, these votes are
called and -
DR. SATCHER: I'd feel terrible if I took time away from Dr.
Sullivan.
REP. BILIRAKIS: No, he's taking time away from you as a matter
of fact. Dr. Sullivan please come forward. Dr. Sullivan as we know is president
of the Morehouse School of Medicine in Atlanta. He's appeared before this
committee many times. Dr. Satcher you know I really don't like the idea of Ms.
Eshoo and Mr. Green not having an opportunity to question you, but if you've got
to leave I guess you have to leave.
REP. ESHOO: Can I just say something
Mr. Chairman? I think that it's really an honor to have you grace our hearing
room and I salute our Chairman because he's the one that really made this come
about. I'd like to ask for unanimous consent that members be able to direct
questions to our Surgeon General.
REP. BILIRAKIS: Yes, written questions
and you certainly don't mind that do you? Without objection that will be the
case. Dr. Sullivan please proceed. Tom forgive me for interrupting, I know you
understand. Doctor please proceed.
DR. SULLIVAN: Thank you very much Mr.
Chairman, Mr. Brown and members of the committee, I'm very pleased to have this
opportunity to appear before you on this bill that you have under consideration.
I will abbreviate my comments because many of the things I was going to say have
been said by previous speakers. But I'd like to commend Congressman Jesse
Jackson, Congressman Norwood, J.C. Watts, John Lewis, Bennie Thompson and Nathan
Deal for their leadership and commitment to improving the health status of
Americans.
Let me say that in 1985 Secretary Margaret Heckler issued a
report on black and minority health in the United States, which among other
things showed that there was 79,000 excess deaths in the nations minority
communities because of health disparities. And in 1990 the Council of Higher
Education also pointed out that among the grants from the National Institutes of
Health, less than one percent went to minority investigators, whether they were
at majority institutions or minority institutions. In January of last year I was
asked to testify before the Senate Appropriations Subcommittee on Labor, Health
and Human Services and Education and Related Agencies regarding the Institute of
Medicine's study "The Unequal Burden of Cancer."
This landmark study
determined that although ethnic minorities and medically under-served
populations suffered disproportionately from virtually every form of cancer, the
National Cancer Institute, with a $3 billion budget, committed
only $24 million - or less than 1 percent of its entire budget
- to the study of cancer in minority populations. Unfortunately, this study
reinforced what many of us have known for years, that the culture, the structure
and the programs of NIH as a whole serve the majority population very well, but
fall short in addressing the needs of our nation's minority populations.
Mr. Chairman our first chart is one that shows what the Chronicle of
Higher Education has demonstrated. The gray area represents the percentage of
grants from NIH going to majority investigators: that's 89.7 percent; the
percentage going to African-American investigators: 0.4 percent; to Hispanic
investigators: 1.5 percent; to Asian investigators: 8.1 percent. So it shows the
disparity in the granting mechanisms at NIH.
Despite the troubling
findings of the IM study, the Chronicle of Higher Education article, and
numerous other reports on minority health in our country, our society has failed
to take the necessary steps to adequately address the persistent health status
gaps in our nations population. If we as a nation are to solve these complex
problems, we must take an aggressive approach on all fronts. At the core of
improving the health status of all Americans, is a strong bio- medical research
effort aimed at understanding the factors which contribute to our nation's
health problems.
That's why when asked by Senator Specter at last year's
hearing in the Senate what changes I thought were needed at NIH to improve the
agency's commitment to minority health research, I recommended elevating the
Office of Research on Minority Health to center status. The same that had
occurred with the NIH Office of Alternative Medicine, which was elevated to the
center for complementary and alternative medicine. The Genome Project was
elevated to center status and then institute status. I announced the Genome
Project in 1990 during my time as secretary.
I was also please to work
with the Congress during my time as Secretary to establish the Office of
Minority Health Research. Not withstanding the success of this office in
addressing health status disparities, and supporting research focused on
improving minority health, the magnitude of the health status disparities
problem warrants an even more aggressive approach.
Currently, this
office does not have the authority, as you've heard, to play a leadership role
in advancing the priority of minority health research at NIH. Now I'll not go
into detail -
REP. BILIRAKIS: Doctor, could it have more authority
without necessarily elevation to the center?
DR. SULLIVAN: I think
that's very difficult to do Mr. Chairman, it's splitting hairs. And I guess my
response also is this. We're talking about a problem that affects more than 25
percent of our nation's population, one-quarter of our population are
minorities. By the year 2050, as you know, it will indeed be half of our
population.
So my position is this is a major issue, I don't think half
steps are enough. I think it should be given the full authority of grant making
authority here because we have done this in other instances. So let me say that
I applaud Congressman Jesse Jackson, Charlie Norwood and the 86 co-sponsors of
their bill, 2391. This bipartisan legislation would establish at NIH this center
that we have discussed.
REP. BILIRAKIS: We have less than four minutes
Doctor.
DR. SULLIVAN: Yes, I'll try and conclude in two.
REP.
BILIRAKIS: To make our vote. In other words, you don't have four minutes, we
have four minutes.
DR. SULLIVAN: I understand. I'd like to show, as you
leave, one other chart because this addresses - one of the features of the bill
that is to establish research endowments for supporting research at the nation's
four minority medical schools. What this chart shows is the endowment at the
nation's medical schools that shows $1.7 billion at Harvard,
$1.3 billion at Washington University, but an average of
$130 million at the nation's majority schools. The nation's
four minority schools have an average of less than $10 million.
So this bill also would help to give greater capacity for research at
the nation's minority medical schools. With that Mr. Chairman I thank you very
much.
REP. GENE GREEN (D-TX): Mr. Chairman I'd like to place in the
record the Congressional Hispanic Caucus report on Hispanic health in the United
States. It was done by the Caucus. And also my opening statement.
REP.
BILIRAKIS: Without objection, and I would hope that we all would have an
opportunity to read Dr. Sullivan's testimony. It was very powerful. And thank
you so much for being her Doctor, forgive me for treating you this way, but you
know what it's like here. Well we're going to have to adjourn for anywhere from
45 minutes to an hour, depending on how long it takes us to address five votes.
(Recess)
REP. JAMES GREENWOOD (R-PA): Okay, we're going to
reconvene the hearing and I'm Congressman Jim Greenwood and the Chairman has
asked me to preside briefly while he tries to - do we have all our witnesses
here? I'll tell you what, if the witnesses could take their seats we'll see how
many of them we don't have. Upon further consideration, apparently the
subcommittee chairman has indicated at ten after two, we'll reconvene in an hour
or so, so we'll reconvene at ten after - six more minutes. Stay put.
The
hour of 2:10 having arisen, we will start and assume that the other witnesses
will hear your eloquent testimony and come running in. And I'll introduce panel
three, is that correct? We have Dr. Gilbert Friedell, director for cancer
control, Markey Cancer Center, University of Kentucky testifying on behalf of
the Institute of Medicine. We have Dr. Jordan Cohen, president and CEO of the
Association of American Medical Colleges; Dr. Kevin Schulman, is associate
professor of medicine and director of the Center for Clinical and Genetic
Economics, Duke University Medical Center. E. Ann Peterson is not here yet. Dr.
John Harley is a member and program head of the Oklahoma Medical Research
Foundation. And Mr. Friedell if you would start us off.
DR. GILBERT
FRIEDELL: Thank you Mr. Chairman. I'm delighted to be here and appreciate the
opportunity to testify. I'm speaking here on behalf of the Institute of Medicine
committee which provided this report on "The Unequal Burden of Cancer: An
Assessment of NIH Research and Programs for Ethnic Minorities and the Medically
Under-Served." I stress those last few words because so far much of the comment
has been about minority health, whereas the report for NIH was something a
little broader than that.
Much of what I wanted to say has been said so
I'll be brief about my remarks. As you all know, one in four deaths in the
country are attributable to cancer. It's expected to become the leading killer
in the next century. People have referred to some of these numbers, but I'll
repeat them. African-American men are more likely to be diagnosed with prostate
cancer than white men. Asian-Americans are more likely to develop stomach and
liver cancer. Cervical cancer is higher among Hispanic and Vietnamese-American
women. African-American women, though less likely to develop breast cancer, are
less likely to survive it.
I would point out though, that the highest
incidence in mortality rates for lung cancer are in the rural poor population in
Appalachian Kentucky. And Native Americans have the lowest cancer survival rate
of all. The key question then for researchers and public health officials is why
these differences in cancer incidence mortality and survival persist? The
fifteen member committee that I served on looked at these questions, assessed
how NIH prioritizes cancer research among minority and medically under-served
populations, how it applies research findings to prevention and treatment.
We looked at the adequacy of procedures related to including minorities
in clinical trials, and the communication of these results to the general
public. I'd like to make five particular points this afternoon summarizing some
of these major findings, and you'll appreciate that these are five brief points
out of a report of several hundred pages. Number one, better surveillance
efforts are needed to provide a more complete picture of the burden of cancer
among minority and medically under-served individuals.
The report, you
understand, was about cancer, not about health in general. Secondly, research is
needed on the reasons for the disparity reflected by the burden of disease data
generated by cancer surveillance. Thirdly, that research is particularly needed
on the medically under-served, a category which cuts across race and ethnicity.
Four, as currently constituted neither the Office of Special Populations
Research at NCI or the Office of Research on Minority Health at NIH have the
authority, budget or other support mechanisms to effectively coordinate,
stimulate and facilitate research for minorities and medically under-served
groups.
And five, the target for reducing cancer mortality would be
achieving the lowest rates of cancer mortality for selected cancers seen among
different populations. And I'll elaborate briefly on each of those points. The
first one about surveillance, the critical first step is to pinpoint exactly
what differences exist among racial and ethnic groups as well as socio-economic
groups. By legislation, the National Cancer Institute's Surveillance,
Epidemiology and End-Results program is charged with this responsibility as far
as cancer is concerned, and monitoring incidents, mortality and survival rates.
It's the closes thing we have to a national report, but it's severely limited in
a few areas.
Several groups are not adequately covered in the SEER
program. In order for it to be most effective, the committee recommended it
should be expanded to include those populations not covered, such as lower-
income or poverty level whites, especially those living in rural areas, for
example Appalachia; Hispanics of all national origins; African-Americans living
in rural communities, particularly the South; and the American Indian
population. Furthermore, the results should be correlated with the state cancer
registries that are being developed under the CDC program of the National
Program Cancer Registries.
As far as disparities are concerned, we
believe NCI should give consideration to the magnitude of cancer problems in
different ethnic groups. The research needs of these groups and of medically
under- served groups to be identified primarily on the burden of disease, which
is found in each of these populations. Without setting boundaries to begin with
of race and ethnicity, let's look at the burden of disease which is found by an
adequate surveillance program. This was the gist of one of our recommendations.
Thirdly, while a disproportionately large share of African- Americans
and Hispanics live at or below the poverty level, poor whites, particularly the
rural poor, constitute the largest group of poverty-level individuals. According
to data from the US Bureau of the Census, in 1996 there were approximately 10
million African- Americans, approximately 7 million Hispanics - these
individuals suffer from rates of disease and disability as high or in some cases
higher, than racial and ethnic minorities, and should be a high priority in
NIH's research efforts.
In so far as the Office of Research on Minority
Health is concerned, we believe NIH needs to formulate a blueprint or
coordinated plan for addressing questions related to minorities and the
medically under-served. Within NCI the Office of Special Populations Research is
charged to serve as the director's eyes and ears on the research needs of
minority groups, low-income and low- literacy populations, blue-collar workers
and other populations considered to be at a higher risk for cancer.
But
this office lacks the authority and the resources to coordinate an extensive
program of research among ethnic minorities. Similarly, the Office of Research
on Minority Health, which is to coordinate the studies on ethnic minority health
problems, but it's impact also is limited by the size of it's budget and it's
lack of authority over NIH research programs. It has no involvement,
furthermore, with the medically under-served who are not recognizable by race or
ethnicity. That office should more actively coordinate, plan and facilitate
cancer research relevant to ethnic minorities and medically under-served
populations across NIH centers and institutes.
In so far as reducing
cancer mortality by achieving the lowest rates of cancer mortality for selected
cancers, what we mean by this is that there are low rates for some cancers. For
example, prostate cancer among Chinese --high rates among African-Americans. We
suggested that it would be important to look at those populations that have low
rates of cancer, as well as looking only at the populations that have high rates
of cancer.
My more extensive remarks have been submitted to the
committee. I would like to point out two particular things, though, that may be
relevant. One of them is that there's been much discussion about various rates
of diseases beyond cancer in minority populations. A few months ago the
Lexington-Herald Leader produced a supplement which relates to health disorders
in Appalachian or Eastern Kentucky, a 99 percent rural, white population. And
you'll find on reading this that the rates for diabetes, hypertension, coronary
heart disease and some cancers are almost as high, and in some cases higher,
than rates that have been reported for recognizable minorities. I think this may
be an important thing for the group to find, and in addition, there may be some
reprints of specific issues which perhaps I could add to the committees files
later.
But the bulk of my testimony really relates to the IOM committee
report. Thank you very much.
REP. GREENWOOD: thank you very much sir for
your testimony. Dr. Cohen.
DR. JORDAN COHEN: Thank you Mr. Chairman and
members of the committee. My name is Jordan Cohen, I'm president of the
Association of American Medical Colleges which represents US medical schools and
major teaching hospitals in our country, medical students, residents and
faculty. The Association is pleased to endorse the Health Care Fairness Act,
HR-3250, and we commend the committee for holding this hearing.
We must
do more as a country to find solutions to these existing critical disparities in
health status and access to quality health care among significant segments of
our nations population. While it is important that everyone involved in
providing health care to patients work to eliminate health disparities, medical
schools and teaching hospitals have the unique responsibility both to integrate
the knowledge of these disparities into the education of physicians and the
delivery of health care, and to ensure that these problems are high on the
research agenda.
Historically, the AAMC has taken a leadership role in
addressing issues related to inequalities and disparities in medicine. We have
played an active role in enhancing the diversity of those providing health care
and assisting our member institutes in advancing teaching and education and
evaluation of cultural competence. AAMC supports the establishment of the center
for Research on Minority Health at the National Institutes of Health, and the
development of a comprehensive research plan for all minority health research at
the NIH in consultation with other NIH institutes and centers.
The
causes of health disparities are complex and include a mix of socio-economic,
cultural and behavioral factors, as we learned from Dr. Satcher earlier today.
Few if any diseases are unique to particular racial or ethnic groups. But
patterns of prevalence, as we've heard, and of severity differ widely in various
racial and ethnic populations. Research on minority health issues should be
incorporated into the mission of each of the NIH institutes and centers,
building upon the scientific and clinical expertise that resides in their
programs.
The bill also authorizes the submission of the centers budget
directly to the President and to Congress. Traditionally, the association has
not supported the creation of such a separate budget bypass for specific areas
of research. However, the critical need to enhance the research efforts to
address minority health disparities is sufficient, in our view, to justify
making an exception in this case to our long standing policy opposing bypass
budgets.
AAMC has consistently and strongly advocated additional funding
for the NIHs efforts to attract and retain more under-represented minorities
into careers in bio-medical and behavioral research. AAMC supports the
establishment of centers of excellence for research as another positive
initiative to achieve a more diversified research work force. We also believe
that any institution with a well documented and sustained commitment to
addressing issues of minority health should be eligible for these awards.
The association is especially pleased with the provisions in Title 4 on
medical education, which will enable health professional schools to enhance and
expand existing programs to address cultural competency. In particular, we note
that the legislation would provide support for increased curricular and faculty
development for cultural competency at all levels of health professions
education, including continuing education. In conclusion, we believe that the
disparities in health status is a function of race and ethnicity are among the
most pressing challenges that confront our nation. AAMC thanks the subcommittee
for holding this hearing to examine these issues and urges Congress to move
forward in considering and passing HR-3250. Thank you very much.
REP.
GREENWOOD: Thank you Dr. Cohen very much for your testimony. Dr. Schulman.
DR. KEVIN SCHULMAN: Mr. Chairman thank you and Mr. Brown and other
members of the committee, thank you very much for inviting me to appear before
the committee today. I want to try and provide a framework and a rationale for
the medical education sections of the Health Care Fairness Act, especially
section 201 which refers to grants for medical education curriculum development.
The medical literature has carefully documented racial and ethnic
differences and the use of medical therapies for patients with many conditions.
And you've heard a lot on this today. One point to emphasize here is that these
differences in treatment have been shown to result in differences in patient
survival, in and of themselves. One issue not addressed by this entire body of
literature is whether physicians were contributing to these differences by
making different treatment recommendations based on patients race and sex. We
explored this concept directly in a major study published last year in the New
England Journal of Medicine.
We assessed physicians treatment
recommendations for similar patients who differed from each other only on the
basis of race and sex. We included eight patient-actors in the experiment, four
black, four white; four male, four female. Their pictures are included in the
testimony I submitted to the committee. Overall, we found that for identical
patients, physicians were less likely to refer blacks compared to whites and
women compared to men for cardiac catheterization. And that the lowest referral
rates were for black women.
Further, we were able to show that these
results were not influenced by patient personality.
In addition, the
physicians rated the black patient actors as being of lower socio-economic
status than the white patient actors, despite the fact that all patients had
identical job descriptions, lived in the same locations, dressed in the same
clothing, and had the same health insurance. In this carefully controlled
experiment we were able to demonstrate that a patient's characteristics
influenced physician recommendations for cardiac catheterization.
The
social psychology literature suggests that all of us characterize new
individuals when we meet them using an automatic or subconscious process. These
characterizations incorporate societal attitudes and stereotypes into a label
that we attach to other people. The absence of bias indicates an ability to
consciously override these automatic characterizations when relating to other
people.
Our experiment suggests that a brief interview with a new
patient my not yield sufficient information to override these automatic
characterizations. These subconscious characterizations may then contribute to
physicians treatment recommendations for identical patients observed in our
study. The implications of our study is a disturbing one, that physicians are
contributing to disparities in health care between blacks and whites in this
country.
This is not to say that physicians actions are responsible for
all or even a majority of the racial disparities in medical treatment that have
been observed. In fact, we cannot assess the relative contributions of the many
factors shown to effect differences in procedure utilization across patient
race. In addition, we haven't assessed the many different races, we haven't
looked at Hispanics or other races in our experiment.
However, any
contribution by physicians to these disparities cannot be tolerated, as Mr.
Coburn said this morning. While disturbing, these results also offer us hope. As
Thurgood Marshall said, what you have to do, white or black, you have to
recognize that you have certain feelings about the other race, good or bad, and
get rid of them. But you can't get rid of them until you recognize you have
them.
The medical education section of the Health Care Fairness Act
offers an opportunity to directly address this issue. The legislation allows us
to develop new educational programs that target the subconscious biases that
seem to explain the reversible component of the disparities in health care
between blacks and whites. Finding the optimal method of implementing such a
sensitive curriculum, is an issue of major concern that will be addressed by the
research effort called for in this legislation.
The public will not be
assured that the health care system is truly blind to race until we are able to
show that these training programs are effective. Hence the importance of the
evaluation component of these grants. These evaluation efforts will allow us to
understand what works in developing cultural competency curricula and to rapidly
disseminate effective programs to other sites.
In this increasingly
multi-cultural society the issue of how to ensure that patient characteristics
no longer influence clinical decision-making is of critical importance in
designing medical school, residency and continuing education curricula, and
ensuring appropriate clinical practice. Thank you very much for asking me to
present today.
REP. BILIRAKIS: Thank you very much Doctor. Dr. Anne
Peterson, health commissioner for the Commonwealth of Virginia. Welcome doctor.
DR. ANNE PETERSON: Thank you Mr. Chairman Mr. Chairman and members of
the committee. I am the state health commissioner for Virginia, and perhaps am
bringing a different perspective, some of which - the questions came up earlier
today that I hope to be able to address.
Virginia is both recognizing
many areas of racial disparity and beginning to address them in some very
significant ways. We established an Office of Minority Health in 1992 and we are
developing partnerships between the private and public sector to establish goals
to improve the health of all Virginians, with a focus on eliminating
disparities.
And Dr. Satcher spoke about the Healthy People 2010.
Virginia has set eliminating disparities as part of our Healthy People 2000
goal. So we've been looking at that for quite a while already. We have a major
initiative within that office on access to care, and on June 21st we have a
forum on access to care for minority health this summer.
One area, and
this was the one I was asked to address today, is where minorities have clearly
been disproportionately effected is HIV AIDS. While African-Americans comprise
only 20 percent of Virginia's population, they account for almost two-thirds of
the reported HIV cases in Virginia, and over half of the reported AIDS cases.
Minority females have been particularly hard hit by this disease. Although
African-American women account for only 20 percent of the female population in
Virginia, they represent over three-quarters of the female HIV cases in
Virginia, and almost three-quarters of all the female AIDS cases.
While
these statistics are alarming, we are making progress. By careful analysis of
the HIV reporting data, Virginia was one of the first states to recognize that
HIV and AIDS were disproportionately effecting the minority community. As a
result of that early recognition of the minority disparity trend, Virginia has
initiated efforts to directly address this disparity and we are already
beginning to see some results.
Analysis of Virginia's surveillance data
does not show that racial or gender disparities for the length of time between
HIV diagnosis and AIDS. In other words, minority males and females are
progressing from initial HIV diagnoses to sickness at a similar rate as whites.
The number of AIDS deaths for minorities is also decreasing. After peaking in
1995, AIDS deaths have decreased substantially for both African-Americans and
whites.
Initially, the deaths decreased more markedly for whites than
African-Americans. With the addition of the 1999 data, the reduction of deaths
among African-Americans were comparable to those of whites. This may indicate
that more minorities were able to access appropriate and timely care.
Providing anti-viral treatment to pregnant women with HIV infection has
also significantly decreased the transmission of HIV to their newborns. This is
particularly important to minority health since of the para-natal HIV cases
reported in Virginia from 1995 to 1999, 79 percent of the babies were
African-American. Since 1995 when Virginia law required that all physicians
encourage pregnant women in their care to receive HIV testing, and if indicated
treatment, over 90 percent of the HIV infected pregnant women have been tested.
In 1991 ninety-one percent of the infected mothers were treated with anti-
retroviral medication and pre-natal transmission has decreased from 20 cases in
1992 to two so far this year.
In closing, while Virginia has addressed
disparities among minorities with HIV and AIDS, we are also focusing on primary
prevention and other sexually transmitted diseases. An example is our syphilis
elimination project which uses a two-pronged approach of community involvement
to assist prevention and education, and trained public health staff to identify
and treat the disease. The National Centers for Disease Control and Prevention
recently conducted a site visit to Danville, Virginia and plans to use our
efforts as a model for other states to follow.
So I would just say that
as you look at research and as we get data on health disparities and understand
the risk factors, we then can as this example shows, focus our resources and
begin to make a difference in closing the disparity gap. Thank you for this
opportunity.
REP. BILIRAKIS: Thank you very much Dr. Peterson. Dr. John
Harley, MD, Ph.D., is the member and program head of the Oklahoma Medical
Research Foundation out of Oklahoma City. Welcome Dr. Harley and please proceed
sir.
DR. JOHN HARLEY: Thank you Mr. Chairman and ranking member and
committee members. I have two initiatives that I'll mention that are going on in
my laboratory. First is a lupus multi-plex registry and repository. It's a
national collection of pedigree of multiple members of lupus. We facilitate the
work of many scientists by providing them with data and materials from these
families.
And secondly, I act as principle investigator on a study of
genetic linkage of lupus in African-Americans. I understand that this is the
only study funded by the NIH that specifically concentrates on the genetic
linkage in African-Americans.
The OMRF was chartered in 1946 as a
private, non-profit bio- medical research institute which employs over 400
scientists, physicians, technicians, administrative and support personnel.
The OMRF focuses on several critical areas of research: cancer, heart
diseases, diabetes, Alzheimer's and Parkinson's disease as well as lupus and
other auto-immune diseases.
I am pleased to discuss a subject that's
vital for Oklahoma, the Health Care Fairness Act, HR-3250. Because Oklahoma,
which means Land of the Red Man in Choctaw language, is home to 263,000 Native
Americans, the second highest number of Native Americans in any state in the US,
we have instituted a bio-medical research center built for Oklahoma, the Native
American Biomedical Research Center. This center will address many of the same
issues the Health Care Fairness Act addresses, including the dramatic disparity
in the incidences of many diseases in our native American population.
Oklahoma is blessed with the rich and ancient traditions that spring
from our Native American heritage. In fact, we not only have one of the largest
populations of Native Americans in the country, but also among the most diverse,
with over 100 separate tribal groups represented. Unfortunately, we also have
particularly serious problems from the numerous and severe medical conditions
that effect this population.
For example, it is especially true that the
high incidences of auto-immune diseases in Native Americans. These are diseases
where the immune system turns on itself and attacks one's own body. Diseases and
disorders thought to have an auto-immune origin include rheumatoid arthritis,
lupus, Type 1 diabetes or juvenile diabetes, multiple sclerosis, squariderma
(ph) and others.
In some groups of Native Americans, these diseases are
especially common. There is great scientific interest at the present time in the
genetics of auto-immune diseases, despite of the fact that research in this area
is one of the traditionally under-funded in the US. Oklahoma's medical
investigators have special opportunities to contribute to the solution of the
seemingly over-whelming problems through research and genetics. Indeed,
scientists at OMRF have done some of the most significant work in the field of
auto-immunity and appreciate the opportunity for discovery and for helping solve
the serious problems that these diseases pose in selective groups of Native
Americans.
In my personal experience in the rheumatic disease clinic at
one of the state's Indian health service hospitals, the specter of auto- immune
diseases and their clinical presentations are very different in Native Americans
compared to what we know from Americans of European extraction. I am concerned
that the very definitions of what the diseases are must be changed to
accommodate how differently the find expression in Native-Americans.
Accordingly, this also implies that different therapeutic management is likely
to be warranted among the affected Native-Americans.
Auto-immune
diseases effect different populations in different ways. In Native-Americans for
example, rheumatoid arthritis is found in as many as 7 percent of some groups,
which is more than five times more frequent than found in European Americans.
Lupus is another example of high incidences of auto-immune diseases in certain
Native- American populations. In the Oklahoma Sioux, this appears to have an
incidence of about five-fold greater than that found in European Americans.
Other smaller groups, such as the Apache tribe also have a dramatically high
incidence.
Working on the genetic problems of Native-Americans has a
number of advantages. First, the gene pool is different from that found in
European Americans or in African-Americans. There are also, of course, major
differences between Native-American groups. Second, Native-Americans offer the
opportunity to apply newer genetic approaches, using an isolated population
strategy or a genetic admixture. These approaches have a much greater prospect
of success than do the much larger and more expensive studies performed in the
out-bred American population.
For example, squariderma (ph) is found at
a rate of about 1 in 200 of the Oklahoma Choctaw, about 50 times the rate found
in both non-Choctaw Native-Americans in Oklahoma and in European-Americans. One
of these new genetic approaches was used to identify two regions of the human
genome which contain genes that appear to dramatically increase the risk of
squirederma (ph) in the Oklahoma Choctaw. The advances in scientific technology
have been revolutionary in the area of genetics. This technology is being joined
with research excellence in numerous bio-medical scientists at OMRF, the
University of Oklahoma Sciences Center and other research facilities in the
state to address in a major way the genetics of auto-immune disease in our
Native- American populations.
Our opportunities then are not only to
advance medical knowledge, but also to help provide a solution to these serious,
life-long, often debilitating and sometimes fatal diseases in particularly
effected tribal groups. The Oklahoma Medical Research Foundation proposes to
build a unique genetic unit focusing upon disease processes in Native-
Americans, with an initial and special emphasis on auto-immune disorders. We
propose to bring together all the necessary ingredients that will result in
important progress and that will contribute to solving these problems for
affected Native-Americans in Oklahoma, as well as for all of mankind.
The NIH Center for Research on Minority Health will facilitate funding
of OMRF's Native-American Research Center. In addition, the new center will
accelerate studies into dramatic disparities among incidences of many diseases
among all of our minority people. Medical breakthroughs and scientific advances
that originate from studies focusing on minority populations, will likely be
very beneficial to all Americans. OMRF's mission statement is that more live
longer, healthier lives. With an NIH center focusing on minority health, we can
better do our best to ensure that OMRFs goals of longer health care lives are
achieved for all.
REP. BILIRAKIS: I'd like to thank you doctor. Dr.
Elena Rios is president of the National Hispanic Medical Association located
here in Washington, D.C. Doctor please proceed.
DR. ELENA RIOS: Thank
you Congressman, Congressmen and guests, I am deeply honored to join you today
in support of the Health Care Fairness Act, HR-3250, which has the strong
potential to create knowledge and innovation, medical and health services
research, cultural competence training for health professions, and civil rights
monitoring, which I believe will tremendously decrease the disparities in health
that face all of the minorities represented today in the United States.
I'm representing two critical national Washington, D.C.-based
organizations, the National Hispanic Medical Association, which represents
30,000 licensed Hispanic physicians in the United States; and the Hispanic
Serving Health Profession Schools Inc., which was established in 1996 by the
Department of Health and Human Services in response to the White House's
Educational Excellence for Hispanic Education Initiative, which represents 20
medical schools from across the United States with 9 percent Hispanic student
enrollment.
We also work closely with the Hispanic Health Coalition
which represents 30 national organizations. And I'm here today to urge you to
take up the challenge to pass HR-3250 and make America healthier. During my
brief presentation I just wanted to focus on three issues: the current health
status of Hispanics; the need for research in cultural competence in medical
services for Hispanics and all Americans; and to provide you with our
recommendations to improve the bill.
In terms of the Hispanic health
status, let me just start by saying that Hispanics really are the population in
the United States right now. The current US Census estimates of 32 million do
not include the 4 million from Puerto Rico or the 3.5 million that the INS
estimates has current residence from Hispanic backgrounds. I know that by the
year 2050 the projects say that one in every four Americans will be Hispanic.
Indeed, the United States is soon to become the second largest Spanish-speaking
country in the world.
Hispanics are a heterogeneous group from 20
countries. That's a lot of different cultures to deal with, even among the
Hispanics. The socio-economic factors, as we know, determine the lifestyle of
people in this country, and the Hispanics have - one out of three Hispanics are
below the poverty level: the median income of $23,000 versus
the $41,000 for non-Hispanic whites.
And in 1998,
Hispanics continued to have the lowest educational attainment, with
Mexican-Americans have 50 percent high-school dropouts. In terms of access to
health care, Hispanics have very, very poor socio-economic status and very poor
access to health care. The numbers of uninsured in the United States has
increased to 44 million and are increasing at a faster rate as we heard earlier
due to a myriad of factors. But Hispanics are the largest group of uninsured in
the United States: two out of five Hispanics, according to a recent Commonwealth
Fund introduced at our National Hispanic Medical Association annual conference.
And there will be more work in this area by several different
organizations looking at strategies to eliminate the disparity in the insurance
rates of Hispanics. Hispanics are also the least likely to be linked to regular
sources of care, as we heard earlier.
What I'd like to just focus on now
is the need for medical research. We heard a lot about this earlier, but I think
in order to understand the disease pattern that effects Hispanics, factors that
lead to decreasing barriers for Hispanics to access to care; factors that can
increase outreach to Hispanics for health promotion programs and treatment
services in physical and mental health, and research programs that can train
Hispanic health profession students to become researchers, we critically need to
increase bio-medical and health services research that targets all the major
population groups fairly and equitably. This bill should promote support for
research, not only bio-medical institutions, but by community-based agencies and
non-profit entities that target all the minority communities in the country.
There has been minimal federal support for Hispanics to be included in research,
and we urge you to increase research with the passage of this bill.
In
terms of the need for cultural competence curriculum, cultural competence has
been defined as a set of academic and interpersonal skills that allow
individuals to increase their understanding and appreciation of cultural
difference and similarities within, among and between groups. This requires a
willingness and an ability to draw on community-based values, traditions and
customs, and to work with knowledgeable persons of and from the community in
developing focused interventions, communications and other supports. There is an
urgent need to adopt legislation like HR-3250 that promotes health professions
cultural competence curriculum given the growing diversity in the United States'
population.
We believe that successful strategies for increasing to
health insurance must include cultural competence standards for health
professions education, as well as for the whole health system, the facilities,
the standard services, language services, etcetera. There is definitely a
critical need for cultural competence training for the future health workforce
of the country, and as well as for the current workforce to help eliminate
health disparities, as we heard earlier.
We believe that there are
important principles that enhance the cultural competence of the physician in
the physician-patient relationship, including: respect for values; respect for
health and illness beliefs; respect for family dynamics and decision-making;
cultural awareness, assimilation, and acculturation levels; the role of
traditional healers; the role of the pharmacist in our communities; Spanish,
using the language Spanish; elimination of biases; awareness of Hispanic
sub-groups, nuances, language and diet. We believe that more patients from the
Hispanic community and other ethnic communities would access services if they
were provided in a culturally competent manner.
In terms of
recommendations, for research we just really thought that the research endowment
program is only one program that could be developed by this bill. Another
important aspect is the actual development of consortia among bio-medical
institutions and partnership development with community-based organizations and
health professional associations to enhance minority research.
In terms
of the Centers of Excellence for Research Training, we just thought it was
important to commend the bill for having the Health Resources and Services
Administration's Centers for Excellence mentioned, but these are separate from
the new NIH Centers of Excellence that are to be completed.
REP.
BILIRAKIS: Doctor please summarize.
DR. RIOS: Okay, in terms of the
cultural competence curriculum, as I said earlier, we really understand the
importance of the Hispanic physicians and other physicians from our communities
being able to share their expertise in developing curriculum for the rest of the
country. And in terms of the coordination of the cultural competence curriculum,
I just wanted to mention that there is the Office of Minority Health which has
done a great job in developing the Center for Cultural and Linguistic Competence
in health care that could coordinate all of the curriculum mentioned in the
bill.
In summary, I'd just like to say that we commend the efforts of
the committee and we look forward to working with you all in developing more of
the bill.
REP. BILIRAKIS: Thank you doctor. Mr. Ignatius Bau, director
of health policy, Asian-Pacific Islanders American Health Forum, located out of
San Francisco, California. Welcome Doctor - Mister, I guess it's mister, and
please proceed sir.
MR. IGNATIUS BAU: Thank you and good afternoon.
Thank you for the opportunity to testify here in support of HR-3250. I want to
underscore the remarks made by Congressman Underwood earlier this morning, which
highlighted many of the points I'm going to make and which I will not repeat.
We are a national organization that focuses on improving the health of
Asian-Americans and Pacific Islanders. And we work with health providers,
community health centers, and community-based organizations in the diverse
Asian-American and Pacific Islander communities on both health care as well as
health promotion and health prevention programs. As Congressman Underwood said
this morning, we are a very diverse community. We're not a single community, but
many, many communities coming from over 50 countries and speaking over 100
different languages and dialects.
And as a diverse community, we have
very diverse health needs and diverse health statuses. The heterogeneity in our
community is reflected in the fact that on the one hand we have stereotypes and
images of very successful Asian-American doctors and business-people. But on the
other hand we know that Southeast Asian women have the highest rates of cervical
cancer among all Americans, and at the same time have the lowest rates of
screening for both breast and cervical cancer.
We know that native
Hawaiians consistently suffer much, much worst health than their counterparts in
the state of Hawaii. We know that hepatitis-b and tuberculosis hit
Asian-Americans and Pacific Islanders harder than any other racial and ethnic
group. And we know that although one-quarter of Asian-Americans and Pacific
Islanders in the aggregate are uninsured, over 40 percent of Korean-Americans
are uninsured, mainly because they're in small businesses and unable to afford
health insurance on their own.
Therefore we whole-heartedly support this
bill, 3250, including the elevation of the Office of Research on Minority
Health, to a national Center on Research for Minority Health and Health
Disparities. Our organization and others have worked with the Office of Research
on Minority Health, and we know much as they have done with us in our community,
they need the grant making and the direct authority in order to be able to make
sure that the research that we need in our communities, to document these health
disparities, and more importantly to document interventions that will be
effective in addressing these health disparities, are in fact funded and placed
in the community where they belong.
We also applaud and very much want
to focus on the bill's efforts to collect more complete race and ethnicity data
when it comes to health status. This is one of the top priorities of
Asian-Americans and Pacific Islanders. Without this data, it's difficult to talk
about the diversity of our communities and the diversity of health statuses in
our communities, because when we're asked "Well how do you design your program?"
we need to know what languages and what cultures to tailor those programs so
that they can reach the communities that are most affected.
Therefore we
very much support the efforts that have been made in the bill, and would urge
even more efforts to clarify and to even mandate more complete race and
ethnicity data regarding health. Like others on this panel, we support the
bill's training curricula, particularly for cultural competency. And we also
support, along with Dr. Satcher's highlighting it, the media campaign for the
Office of Civil Rights. We think that it's very important that the office
continue to be supported in its efforts to ensure that the health of all
Americans are protected by our civil rights laws.
So in summary, this is
long overdue legislation that would go a long way to address many of the health
disparities in the Asian- American and Pacific Islander and well as the other
minority communities in this country, which will go a long way to advancing the
health of all Americans.
Thank you.
REP. BILIRAKIS: Thank you
very much Dr. Bau. The chair recognizes Dr. Coburn.
REP. COBURN: Thank
you Mr. Chairman. I just want to touch on one thing with Dr. Rios. Did I hear
you say that you, maybe it was an implication, that the federal government ought
to be setting the curricula for the cultural competency.
DR. RIOS: No,
the way the bill - no.
REP. COBURN: I understand what the bill says, but
what did you say? Would you say that again?
DR. RIOS: No, we're
supportive of the way the bill is written that government should encourage
cultural competency curricula -
REP. COBURN: Absolutely.
DR.
RIOS: -- that there is a need for mainstream society to learn more about how to
deal with our culture.
REP. COBURN: Absolutely.
DR. RIOS: What I
mentioned was a definition of cultural competency.
REP. COBURN: I just
wanted to clarify that it's not your testimony that the government ought to be
establishing - the health care professionals, who are minorities and know those
cultural characteristics are to be the ones.
DR. RIOS: I think the
community organizations and the schools need to develop the curricula.
REP. COBURN: Doctor Peterson I want to ask you some questions, and I'm
very interested in your testimony on HIV. Is it your thought that the disparity
is now declining in Virginia because you have a program of HIV and AIDS
notification - partner notification and reporting?
DR. PETERSON: I think
it makes a difference. Virginia is one of the first states to have made HIV
reporting so that in the packet of data that you have, if you look at pages 9
and 10 and compare them, you can see that in 1990 we could recognize there was a
trend to a racial disparity in the HIV. We couldn't see that in our AIDS data.
And so, actually it was '90 for HIV and '93 and '94 for AIDS.
That meant
that as we used our Ryan White dollars we could begin to focus resources in our
minority population years earlier than in other states. So having the data,
knowing for all of your different sub-populations - and I would agree with many
others on the panel that we need to have that data - did allow us to focus. It
has not taken care of all of the disparity in the HIV AIDS situation, but I
think what we try and tease out is access to care, the kinds of things that
system wide, we can address, it looks like we're doing pretty well because we've
been able because we've been able to focus early.
REP. COBURN: So
basically Virginia is re-focusing their dollars where the disease is and in
Virginia it happens to be moving into minority populations. But where-ever it
moves, you would be able to focus the dollars that way.
DR. PETERSON:
Right, and working in collaboration with consortiums and local groups, who then,
in that close partnership, can deal with cultural competency as well. But yes we
have and one of the maps shows the AIDS cases in the graph for the hot spots,
and we have our resources focused there.
REP. COBURN: And you do have
partner notification law in Virginia?
DR. PETERSON: Yes.
REP.
COBURN: And did you recall hearing the testimony of Dr. Satcher that he believes
in the CDC's position, the name-based reporting and partner notification>
DR. PETERSON: Yes and I would agree completely. On partner notification,
that is how we do all of our sexually transmitted diseases. It make sense for
communicable disease control. We've been doing it for a very long time with our
HIV names reporting and we have had no objections to it. We safeguard
confidentiality very, very carefully.
REP. COBURN: Has there ever been a
break in confidentiality?
DR. PETERSON: No, there has not been.
REP. COBURN: When you report to the CDC on HIV infections, and somebody
contracts it heterosexually, do you report that as a heterosexual transmission?
DR. PETERSON: We do, Virginia has a slightly different reporting scheme
than CDC.
REP. COBURN: Then let me ask you the question, when the data
is received by CDC how do they classify it?
DR. PETERSON: They probably
put it in their other.
REP. COBURN: Other meaning no identifiable risk.
Does that make sense to you as the commissioner of public health, that they
would -
DR. PETERSON: What we're trying to do, and made the decision a
number of years ago, is to identify for each person what is the mode that they
contracted the disease, and therefore if it's heterosexual transmission, since
it's now in the heterosexual population, we wanted to be able to track that. And
so we do it a little differently. We know that this is a debate, that they are
going back to the CDC because they don't want to go in the same direction as
Virginia.
REP. COBURN: Dr. Friedell I have a couple of questions. We had
a little private discussion when I was introduced to you an hour or so ago in
terms of human papilloma virus. The House passed yesterday a bill which requires
the CDC to now track and develop tools and educational information for the
American public on human papilloma virus. And I know, as you related to me, the
significant increase you're seeing in cervical cancer in the community that you
serve.
One of the things that concerns me as you talked about cervical
cancer and prostate cancer and these other things, is the reports that are out
there now that there is a positive correlation between HPV exposure and prostate
cancer. And when we see the prostate cancer, what it is in this country, and we
see a sexually transmitted disease that now has a correlation with it, what's
your experience now in how we handle HPV in terms of a communicable disease, and
what we should be doing? And do you have any comments for this committee in
regard to that?
DR. FRIEDELL: I don't really have any experience insofar
as prostate cancer and HPV. I have a fair amount of experience - the idea of
human papilloma virus infection with cancer of the cervix -- my point has been
that cancer of the cervix is at a higher rate in the Appalachian population of
Eastern Kentucky. In fact, our own data show that recently - I'm also the
director of the Cancer Registry - that the incidence of invasive cervical cancer
in Eastern Kentucky, in Appalachian Kentucky, a real poor population - is
exactly the same as in our African-American population.
In terms of HPV
and its function, I don't know that we have any reporting mechanism for the
definition of HPV itself. And until we get a more reliable test, I think in the
longer range, most people believe that recognizing human papilloma virus in
certain strains - I think it's 16, 18 and 31 particularly - that perhaps
developing a vaccine is the most effective way to deal with that particular
problem as part of the cervical cancer problem.
REP. BILIRAKIS: I know
that this is a subject that Dr. Coburn is very knowledgeable in and wants to
continue on, but our trouble is that we have probably an hours worth of votes to
take starting now. And I really don't want to make these good people wait until
we return. So possibly maybe we can hustle right on through. Mr. Brown.
REP. BROWN: Thank you Mr. Chairman. Mr. Bau tell me a little bit about
tuberculosis.
Why is it more common among Asian-Americans? What
nationalities especially, does it hit just the poor who are here, and is there
much multi-drug resistant TB among Asian-Americans in this country?
MR.
BAU: From what I know, a lot of tuberculosis is from folks who are coming from
other countries where tuberculosis is much more prevalent, and so even though we
do immigration screening for that, a lot of that - and Dr. Peterson could
probably speak to it as well - means that we then need both culturally
appropriate as well as linguistically appropriate programs to follow up and make
sure that people continue to stay on their medications. And also the conditions
in which tuberculosis continues to spread, where's there's over- crowding,
where's there's not good ventilation. Again, when you've got new immigrant
populations coming in, how these situations in which, again, those kinds of
situations do exist, then that also leads to the spread, even, again, to the
best efforts.
So again, a lot of it is targeting the efforts and I think
Dr. Peterson could also speak to the fact that funding for it's control was at a
really good level and then it fell dramatically, several years ago. And so
again, part of the resurgence that we see is directly correlated to the amount
of funding that goes into those programs.
REP. BROWN: Dr. Peterson are
we doing directly observed treatment well in Virginia?
DR. PETERSON: We
are doing directly observed treatment for cases that are infectious. The
resource funding issue is a limiting factor for skin test positive but
non-infectious cases and doing directly observable therapy. And I would
reiterate that in Virginia our cases are foreign-born at this point and one of
our measures of success is finding them and treating them early and making sure
that we don't have any cases that are transmission within the US. And Virginia
has been very successful with that. It's getting harder to do.
REP.
BILIRAKIS: Dr. Cohen, your organization, AMC has traditionally opposed set-aside
programs for research that are not reviewable by research management. We've had
a policy here in the Congress, frankly, of not adding to disease related
research dollars. Not directing NIH, in other words, how they should spend those
research dollars, even though we sometimes are unhappy about some of the
decisions they make. And we let them know that, but we still hesitate to direct
that. And yet this legislation, as you know, allocates funds directly to the
proposed center. Comment quickly.
DR. COHEN: Well I think the decision
we came to was that the urgency of this matter was such that we were willing to
forego that traditional objection to bypass budgets, which we will continue to
have a strong policy against. We feel that the balance here has shifted because
of the urgency of this issue.
REP. BILIRAKIS: It's the urgency then.
DR. COHEN: Yes sir.
REP. BILIRAKIS: Well I have so much more but
I don't want to - the Chair's going to recognize Mr. Whitfield.
REP.
EDWARD WHITFIELD (R-KY): Mr. Chairman thank you and I understand you're going to
release this panel so that they don't have to -
REP. BILIRAKIS: Yeah,
we're going to finish up.
REP. WHITFIELD: Well I would first of all ask
unanimous consent that Dr. Friedell be able to admit into the record an article
from the Lexington Herald relating to incidences of cancer within the state of
Kentucky, and particularly in Appalachia.
REP. BILIRAKIS: Without
objection, and to add to that, there's a package here which has been cleared
through the Minority National Alliance of State and Territory AIDS Directors,
the data and testimony of the Bureau of HIV-AIDS in Florida, etcetera, etcetera.
I would ask unanimous consent that that be made a part of the record. And it has
been cleared.
REP. WHITFIELD: Mr. Chairman if I may make one statement
and I'll say this quickly. I read Dr. Friedell's testimony and I think that
everyone on this panel would agree that we are very much concerned about the
programs for research and health prevention, prevention of disease in
minorities. But I think it's also important, and Dr. Friedell pointed this out
very well, that we be concerned about all under-served populations, whatever
their ethnicity might be. And there are, as a matter of fact, more poor white
people under-severed in the country than there are blacks, Hispanics, Native
Americans put together. And this bill focuses entirely on minorities, which is
important. But I think also, as we move forward in this legislation, must focus
on the medically under-served as well. So with that -
REP. BILIRAKIS:
Mr. Strickland.
REP. TED STRICKLAND (D-OH): Yeah I just want to make one
quick statement. We only have a couple of minutes left, but I'm going to echo my
colleagues comments. I believe we need to focus on minority health. I believe
the statistics are alarming and unacceptable that you have talked about. I also
believe, talking to Dr. Friedell and others, that correlation is not necessarily
causation. And race and ethnicity may not be the primary causative factor, it
may be under- served medically populations and poverty related conditions. And
so I hope that this bill is not so limited that it leaves out a whole mass of
citizens who rightfully should be considered as being under-served. And with
that I will yield.
REP. BILIRAKIS: I appreciate that Mr. Strickland.
Very quickly, and I don't know how much time we have, we don't have very much.
But if the center -- the elevation of the office to a center is probably the
stumbling block maybe, because of the fact that it bypasses - the dollars bypass
the director etcetera. And unless we get their approval I don't know really how
much hope there will be.
So I would ask you about the other provisions
of this bill, the Titles II, Title III, Title IV, Title V and what not. Is there
a lot of - do you feel that there's a lot to be gained by those titles and can
be gained from a constructive basis, whether or not at this time the elevation
takes place for the center?
WITNESSES: (Respond in affirmative).
REP. BILIRAKIS: You all do then, thank you. Well ladies and gentlemen,
we really appreciate it. We apologize for your waiting so long. Some of you have
had this experience before and know what it's like up here. Also we do ask you
if you'll be willing to answer any written requests to you. You've been an awful
lot of help. Thank you so much.
This hearing is adjourned.
END
LOAD-DATE: May 16, 2000 
