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April 25, 2002
Mr. Chairman, Senator Frist and members of the Subcommittee, I am pleased to appear before you today to testify about the role of the Department of Health and Human Services in improving the health of women in the United States and to highlight the Administration's plan to make prevention the centerpiece of the Departments activities on this important topic.
INVESTMENT IN WOMEN'S HEALTH
In 2002, the Department of Health and Human Services will spend almost $70 billion on women's health. Just three agencies expend nearly 97% of these funds -- the National Institutes of Health, the Health Resources and Services Administration and the Centers for Medicare and Medicaid Services which is responsible for over $61 billion in spending. From this, we can conclude that the majority of federal expenditures on women's health support medical and public health services and research on diseases and conditions important to women's health. The remaining three percent of this year's budget for women's health is divided among eight other offices and agencies -- the Centers for Disease Control and Prevention, the Administration on Aging, the Administration for Children and Families, the Substance Abuse and Mental Health Services Administration, the Indian Health Service, the Agency for Healthcare Research and Quality, the Food and Drug Administration and the Office of Public Health and Science, which I oversee. In 2002, the Office of Public Health and Science has budgeted over $68 million for women's health.
SUCCESS IN WOMEN'S HEALTH
With strong support from this Committee and others in Congress, the Department of Health and Human Services has contributed to a number of important successes in women's health over the past decade. In 2000, nearly 85% of women over age 18 received a pap smear in the previous three years and 75% of women over 50 received a mammogram. These numbers not only represent the successful achievement of the Healthy People 2000 benchmarks for these prevention services -- but most importantly they also represent saved lives. From 1992-1998, the rate of breast cancer mortality declined by an average of 2.4% each year and a similar rate of decline was seen for cervical cancer. Programs such as the Breast and Cervical Cancer Early Detection Program at CDC have made important contributions to meeting these goals for low-income women across the country. Additionally, the Secretary's and CMS' focus on approving Medicaid waivers for these services means that low-income women in 39 States now have access to these services that didn't just two years ago.
Women are not only living longer, they are living more healthy and productive lives in their later years. This allows them to remain fully engaged with family and friends and continue to make essential contributions to their communities and the nation as they age. Importantly, women today are becoming more informed and are asking for more details about the health issues that affect them. The Department has encouraged this trend, with support from this Committee, by establishing the National Women's Health Information Center and targeting public outreach to at-risk communities through neighborhood partnerships. Both of these efforts are managed through the Department's Office on Women's Health.
FOCUS ON PREVENTION
There is still much work to be done. Chronic conditions such as cardiovascular disease and diabetes are among the most prevalent, costly and preventable of all health problems. Cardiovascular disease and its manifestations such as heart attack and stroke are the leading cause of death for US women. However, consideration of deaths alone understates the burden of cardiovascular disease. Heart disease is the leading cause of disability among working adults. Stroke alone accounts for disability among more than 1 million Americans and almost 6 million hospitalizations each year are due to cardiovascular disease.
Diabetes linked to obesity has reached epidemic proportions in this country. It is the fifth leading cause of death among women. More than one out of every ten women in the U.S. displays signs of pre-diabetes or diabetes. Twenty three percent of all US women display signs of metabolic syndromes that pre-dispose them to developing diabetes and cardiovascular disease -- a number that stands at 35% for Hispanic women. Among African American and Hispanic women in their mid-sixties, nearly one out of every three suffers from diabetes and for Native American women this number may be as high as two out of every three.
The HHS/OWH sponsors a national education campaign to promote healthy behaviors among minority women. The Pick Your Path to Health Campaign (PYPTH) offers practical, culturally appropriate action steps that women can take to improve their health. Through public/private partnerships, the Campaign's materials are distributed to local neighborhood groups and local media that are trusted by minority women. This year HHS/OWH will launch a series of pilot programs in each of the ten HHS regions, in which underserved women will be individually coached to develop their own personal action steps. In 2003, the campaign will be expanded to include rural women and women with disabilities.
The medical care costs of people with chronic diseases such as diabetes and cardiovascular disease account for over 70% of the $1 trillion spent nationally on health care each year. Effective prevention measures exist today to substantially curtail illnesses, disabilities and unnecessary or early deaths caused by these chronic illnesses and other preventable diseases.
THE OFFICE ON WOMEN'S HEALTH
President Bush and Secretary Thompson have made prevention a cornerstone of the nation's health agenda. During the announcement of his candidate for Surgeon General on March 26, 2002, the President reiterated his prevention message, noting, "Simple improvements in diet and exercise would result in dramatic improvements in America's health." The Office of the Surgeon General, the public health service corp, and the Centers for Disease Control and Prevention are key players in the development and implementation of disease prevention strategies. On women's health, the Office on Women's Health in the Office of Public Health and Science will be responsible for seeing that health promotion and disease prevention goals are met for women.
The Office on Women's Health both runs programs that target women and also helps to coordinate the research, health promotion and disease prevention strategies of offices and agencies throughout the Department of Health and Human Services.
As part of implementing the President's and Secretary Thompson's health agenda, the Office on Women's Health is refining its performance goals to focus on activities that will result in measurable reductions in the rate of preventable diseases in women over the next few years. Initially, the office will focus on cardiovascular disease, cancer, diabetes and HIV/AIDS. These diseases were selected because, first, they represent leading causes of morbidity and mortality in women, second, disparities exist between men and women for these diseases -- either in treatment, incidence or prevalence -- and finally, they are all preventable.
THE ACTION PLAN
The keys to achieving these goals is to understand what strategies and interventions work to prevent these diseases in women and to ensure that proven and effective measures are deployed by the Department and replicated throughout the country. The Department, with the Office on Women's Health acting to help coordinate these efforts, will be identifying successful, evidenced-based prevention and treatment strategies, promoting innovations based on new research, replicating successful models and disseminating information about these successful interventions to other public and private partners. Particular attention will be given to those models that successfully address health disparities seen among racial and ethnic minorities.
The Department's effort to reduce cardiovascular disease in women is a helpful illustration of this model. Today, the Agency for Healthcare Research and Quality is supporting work to understand why women are not treated as aggressively for cardiovascular disease as men and to determine which interventions result in the best outcomes for women suffering from cardiovascular disease. The Health Resources and Services Administration is helping to promote quality health care services among health professionals who serve populations of women in need, and CDC and HRSA have joined as partners to implement the WISEWOMAN program which provides low-income women with risk factor screening, intervention services and medical referrals. Finally, the Office on Women's Health supports tailored public outreach, including the "For your heart" public education program and a partnership effort with the Association of Black Cardiologists and African American churches to bring health and prevention messages to women at high risk for cardiovascular disease.
In these efforts -- we capture the essential elements of the Department's vision: research to understand what works and what does not; programs to bring this information to health professionals who are providing medical care and prevention services; and public outreach efforts to inform women about effective health behaviors and medical interventions.
In the future, the Department can do more to coordinate this bench to hearthside translation. For instance, recent exciting studies supported by NIH indicate that there are both protein markers and genetic ones that could help physicians identify women who are at high risk for poor outcomes from cardiovascular disease. If these early findings hold up to additional studies, we would then want to make sure this knowledge is incorporated into other HHS programs on women's cardiovascular disease. Over the next year, the Office on Women's Health will develop mechanisms to track new health and research findings, help promote assessments of their effectiveness and ensure this knowledge is disseminated within and outside the Department.
I will now highlight a few examples of women's health program activities across HHS. Several broad initiatives among the agencies target multiple related health issues and I will cover these first.
During the last 3 years, several Members of Congress have asked DHHS/OWH and other agencies in the Department to review and develop programs to stem the risk of cardiovascular disease in women. The HHS/OWH has collaborated with the American Heart Association in the development of a tailored heart disease prevention interactive website program, accessible through the National Women's Health Information Center, entitled, "For Your Heart." A tailored story and message are given to a woman based upon her self-identified race/ethnicity, behavioral risk factors, and stage in changing these factors.
The OWH also is partnering with the Association of Black Cardiologists (ABC) Center for Women's Health. The initiative will incorporate cardiovascular health education programs in churches with large African American populations, with the ultimate goal of reducing cardiovascular mortality and morbidity among women.
Two years ago, the AHRQ women's program launched an ongoing collaborative research initiative to understand why women receive less aggressive treatment for heart disease than do men, and what is known about the use and effectiveness of diagnostic testing and treatment of heart disease and stroke in women. The initiative involves representatives from several HHS agencies, including the NIH Office of Research on Women's Health (ORWH) and the NHLBI, as well as the HHS OWH. Private sector partners include the American Heart Association, the Jacobs Institute on Women's Health, the Society for Women's Health Research, WomenHeart, and a number of professional organizations.
AHRQ and NIH/ORWH are also co-funding development of an evidence report at Stanford University and the University of California/San Francisco that is systematically reviewing the literature on cardiovascular disease as it specifically relates to women. It will establish a baseline for what is currently known (or not known) about the diagnosis and treatment of women with heart disease, as well as identify gaps in the scientific information on optimum care for women.
AHRQ also is conducting a cardiovascular care study which compares treatments and prevention services provided to men versus women (and minorities) in a large managed care organization. The results will be used to develop better benchmarks for care to women and minorities.
In May 2002, the Food and Drug Administration's Office on Women's Health (OWH) will launch Take Time To Care About Diabetes. This program will be co-sponsored by the National Association of Chain Drug Stores (NACDS) and the American Diabetes Association (ADA). This campaign, following on the success of the award winning campaign "Take Time to Care: Use Medicines Wisely," leverages extensive resources, infrastructure, and visibility through its partnerships with outside organizations, thus greatly enhancing the impact and effectiveness of the effort by FDA and HHS.
The campaign materials will consist of a brochure with background information, key messages, risk assessment questions, and a recipe booklet with meal ideas for diabetics. These materials will be distributed in partnership with local health organizations, pharmacies, senior centers, religious groups, universities, women's groups, and many others. Minority communities will be reached through several professional nursing associations.
Other HHS agencies are providing program assistance to FDA. The National Institutes of Health will supply Community Outreach Kits prepared by the National Diabetes Education Program for use by local organizations; the Centers for Disease Control and Prevention will provide an information pack on Women and Diabetes, covering each stage of a woman's life; the Centers for Medicare and Medicaid Services (CMS) will feature CMS comprehensive information about federal benefits for diabetics on their website; the Indian Health Service will distribute campaign materials through selected Indian Health clinics in urban and reservation areas nationwide; and the Administration on Aging will distribute campaign materials through state units on aging, area agencies on aging, and Indian Tribal Organizations.
The NIH/ORWH supports a number of research grants in the area of Diabetes Prevention. The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) currently has the Diabetes Prevention Program (DPP). This multi-centered randomized trial is designed to determine whether type 2 diabetes can be prevented or delayed in a population of high-risk individuals. Included in the high-risk population are women with a history of gestational diabetes mellitus (GDM) and individuals with impaired glucose tolerance.
The NIH has a very active and well-coordinated program of research on obesity that involves many institutes and centers. Examples of some current research avenues include: the genetic underpinnings of obesity; the molecular and neuroendocrinological regulation of food intake, energy expenditure, and fat storage; epidemiological studies to help understand the etiologies, interrelationships, course, and health effects of overweight and obesity and weight change among children and pregnant women; prevention studies targeted at the population level with special emphasis on high risk populations; and intervention studies including modification of behavior, activity and dietary patterns and the use of pharmacological agents.
The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) has initiated a major education/translation activity focused on the topic of overweight and obesity. This initiative includes a national information service, the Weight-control Information Network (WIN), which provides health professionals and consumers with science-based material on obesity, weight control, and nutrition. WIN provides fact sheets, brochures, article reprints and conference and workshop proceedings. Additionally, a quarterly newsletter for health professionals is disseminated featuring the latest information from NIH and other organizations on obesity and related topics.
CDC, as the nation's "prevention" agency, supports chronic disease programs in State Health Departments, and supports State and Local Departments of Education to establish school-based prevention programs. CDC also supports surveillance to measure disease burden, identifies populations at risk, targets program efforts, and evaluates program effectiveness; educates the public and providers; and invests in research to evaluate and improve programs. CDC's chronic disease program WISEWOMAN provides high blood pressure and cholesterol screening and, in follow-up, intensive dietary and physical activity interventions for high-risk women.
HRSA, the Department's "access" agency, has created the Diabetes, Asthma and Cardiovascular Collaboratives. Education regarding healthy nutrition and regular physical activity are integral parts of these collaborative training and services models. Partnerships with local recreational departments, grocery stores, restaurants and fitness centers are also encouraged in the Collaborative care model.
HRSA's Innovative Approaches to Promoting Positive Health Behaviors in Women program identifies women in communities who may not seek health care and develops interventions for them to stimulate positive health behavior practices.
Violence against women does not discriminate: it spans all racial, age, and economic boundaries. One in four women report that they have been victims of violence or stalking by a spouse, partner, or date. Violence against women is a leading cause of injury for American women between the ages of 15 and 54, increasingly a major public health issue for the United States. These acts of violence take several forms, including spousal and domestic partner violence, sexual assault and abuse, rape, incest, and elder abuse.
Today there is much more awareness that violence against women is a major problem in our country, but this increased awareness has not yet translated into measurable decreases. Almost one-third of American women murdered each year are killed by their current or former partners, often a husband. And sadly, many children suffer or witness abuse in their homes, which can spawn legacies of violence for families across America. Violence at home often spills over into schools and places of work, and it affects people from every walk of life.
The HHS Violence Against Women Steering Committee, under the leadership of HHS/OWH, coordinates the Department's responses to research needs, program implementation, service provision, and crisis intervention. This committee has proposed and coordinated department-wide budget initiatives, hosted seminars, and proposed actions to address evolving needs. They develop the bi-annual HHS Progress Report to the Secretary presented at the National Advisory Council on Violence Against Women. The Council is a presidentially appointed council consisting of experts in the fields of domestic violence and sexual assault; it is co-chaired by the Attorney General and the Secretary of Health and Human Services. The Department's Violence Against Women Steering Committee is instrumental in assuring that the recommendations from the Council are implemented where possible throughout the Department.
One of the major reasons that health care providers give for not screening patients for domestic violence is their belief that they have no ability or training to assist patients who disclose that they are victims of violence. To test this barrier and overcome the reluctance of the health care system to offer screening and intervention programs, even simple ones that refer patients to community social resources, AHRQ is supporting a series of studies to assess the impact of health care interventions on the women they are intended to serve. The Agency's work is also exploring other aspects of providing health care services, including the use of health codes, reimbursement levels, and better use of technologies and information systems. Last year, AHRQ joined with the Family Violence Prevention Fund to develop a HHS Visiting Scholar in Domestic Violence, the first such program to be offered by a HHS agency. The Scholar Program brought a researcher to AHRQ for a year to assist in shaping a long-term research agenda that would be responsive to the needs of the private sector.
On an ongoing basis, HRSA's Area Health Education Centers (AHECs) provide training to primary care professionals in how to identify and treat spousal and domestic partner violence among patients. HRSA also provides support for primary care and clinical specialist programs to prepare nurses at an advanced level to care for women's unique health care needs. Finally, HRSA's Geriatric Education Centers (GECs) provide training to geriatric healthcare professionals to identify types of abuse and neglect in the elderly, assess at-risk patients and their families, and provide case management for victims of violence.
In addition, HHS regional Offices on Women's Health have been active in training health care professionals in identifying, treating and referring patients who are victims of family violence. For example, the Region X Women's Health Committee has been working with the Washington State Department of Health Perinatal Partnership Against Domestic Violence (PPADV), which seeks to train medical providers in identifying patients who are victims of family violence.
MATERNAL ORAL HEALTH
The National Institute of Dental and Craniofacial Research (NIDCR) at the National Institutes of Health (NIH) supports research addressing the link between the mother's oral health and the health of their infants/toddlers on two major areas, dental caries (cavities) and periodontal disease (gum disease).
The NIH/ORWH and the National Institute of Dental and Craniofacial Research (NIDCR) have a study underway that will evaluate whether periodontitis is a risk factor for adverse pregnancy outcomes -- by adding an oral component to the ongoing Project Viva, a prospective study of 6,000 pregnant women, to evaluate this association. Maternal infection during pregnancy has been demonstrated to play an important role in etiology of preterm delivery. Periodontal infection can serve as a reservoir of gram negative anaerobic organisms and their products, and proinflammatory mediators which could target the placental membranes via systemic circulation, thus leading to preterm delivery or fetal growth restriction.
PUBLIC INFORMATION AND EDUCATION
Today's women lead complex lives and are sometimes overwhelmed by the amount of health information and misinformation in the media and on the Internet when they seek details about the health issues that affect them. The Department's National Women's Health Information Center (NWHIC), managed by the HHS Office on Women's Health, provides both internet (www.4woman.gov) and telephone access (1-800-994-WOMAN or TTD: 1-888-220-5446) to reliable noncommercial health information for women. NWHIC offers a single point-of-entry to over 4,000 publications, the vast majority from federal agencies and 1,600 organizations on more than 800 health topics; eight specialty sections, including women with disabilities, healthy pregnancy, violence against women, breastfeeding, young women's health, and a Spanish-language section; 150 frequently asked questions (FAQs); national health education campaigns; a calendar of events; daily women's health news; and online journals and dictionaries. It currently averages over 6 million hits and 350,000 individual visitors to the web site and an additional 3000 phone inquiries per month. Women and their families can trust the information they find on NWHIC about all of their women's health issues.
In my over thirty years in medicine and health research, I -- like each of you -- have seen incredible advances in our understanding of disease and our ability to target interventions to improve health. With Congress' generous support of biomedical and health research, strongly supported by this Administration, we are poised to reap enormous benefits for citizens of our country. However, what we have learned through research must be translated into medical practice and to the actions and activities of individual citizens. The Administration welcomes your focus on women's health and looks forward to working with you to develop targeted but flexible strategies that can continue to achieve the goal of improving the health and welfare of women in the United States.
That concludes my testimony. At this time I would be happy to answer questions from the Subcommittee.
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Last revised: April 30, 2002