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40–482 CC 1997

THE HEALTHY START PROGRAM: IMPLEMENTATION LESSONS AND IMPACT ON INFANT MORTALITY

HEARING

BEFORE THE

SUBCOMMITTEE ON HUMAN RESOURCES

OF THE

COMMITTEE ON GOVERNMENT

REFORM AND OVERSIGHT

HOUSE OF REPRESENTATIVES

ONE HUNDRED FIFTH CONGRESS

FIRST SESSION

MARCH 13, 1997

Serial No. 105–11

Printed for the use of the Committee on Government Reform and Oversight

(

(II)

COMMITTEE ON GOVERNMENT REFORM AND OVERSIGHT

DAN BURTON, Indiana, Chairman

BENJAMIN A. GILMAN, New York

J. DENNIS HASTERT, Illinois

CONSTANCE A. MORELLA, Maryland

CHRISTOPHER SHAYS, Connecticut

STEVEN H. SCHIFF, New Mexico

CHRISTOPHER COX, California

ILEANA ROS-LEHTINEN, Florida

JOHN M. MCHUGH, New York

STEPHEN HORN, California

JOHN L. MICA, Florida

THOMAS M. DAVIS, Virginia

DAVID M. MCINTOSH, Indiana

MARK E. SOUDER, Indiana

JOE SCARBOROUGH, Florida

JOHN SHADEGG, Arizona

STEVEN C. LATOURETTE, Ohio

MARSHALL ‘‘MARK’’ SANFORD, South

Carolina

JOHN E. SUNUNU, New Hampshire

PETE SESSIONS, Texas

MIKE PAPPAS, New Jersey

VINCE SNOWBARGER, Kansas

BOB BARR, Georgia

——— ———

HENRY A. WAXMAN, California

TOM LANTOS, California

ROBERT E. WISE, JR., West Virginia

MAJOR R. OWENS, New York

EDOLPHUS TOWNS, New York

PAUL E. KANJORSKI, Pennsylvania

GARY A. CONDIT, California

CAROLYN B. MALONEY, New York

THOMAS M. BARRETT, Wisconsin

ELEANOR HOLMES NORTON, Washington,

DC

CHAKA FATTAH, Pennsylvania

TIM HOLDEN, Pennsylvania

ELIJAH E. CUMMINGS, Maryland

DENNIS KUCINICH, Ohio

ROD R. BLAGOJEVICH, Illinois

DANNY K. DAVIS, Illinois

JOHN F. TIERNEY, Massachusetts

JIM TURNER, Texas

THOMAS H. ALLEN, Maine

———

BERNARD SANDERS, Vermont

(Independent)

KEVIN BINGER, Staff Director

DANIEL R. MOLL, Deputy Staff Director

JUDITH MCCOY, Chief Clerk

PHIL SCHILIRO, Minority Staff Director

SUBCOMMITTEE ON HUMAN RESOURCES

CHRISTOPHER SHAYS, Connecticut, Chairman

VINCE SNOWBARGER, Kansas

BENJAMIN A. GILMAN, New York

DAVID M. MCINTOSH, Indiana

MARK E. SOUDER, Indiana

MIKE PAPPAS, New Jersey

STEVEN SCHIFF, New Mexico

EDOLPHUS TOWNS, New York

DENNIS KUCINICH, Ohio

THOMAS H. ALLEN, Maine

TOM LANTOS, California

BERNARD SANDERS, Vermont (Ind.)

THOMAS M. BARRETT, Wisconsin

EX OFFICIO

DAN BURTON, Indiana, HENRY A. WAXMAN, California

LAWRENCE J. HALLORAN, Staff Director and Counsel

DORIS F. JACOBS, Associate Counsel

ROBERT NEWMAN, Professional Staff Member

R. JARED CARPENTER, Clerk

RON STROMAN, Minority Professional Staff Member

(III)

C O N T E N T S

Page

Hearing held on March 13, 1997 ............................................................................ 1

Statement of:

Coyle, Thomas, assistant commissioner, Baltimore City Health Department, Maternal and Infant Care and Special Projects, accompanied

by Bernard Guyer, chairman, Department of Maternal and Child

Health, Johns Hopkins School of Hygiene and Public Health; Melanie

Williams, project director, Mississippi Delta Futures Healthy Start,

accompanied by Robert Pugh, executive director Mississippi Primary

Health Care Association; Barbara Hatcher, project director, District

of Columbia Healthy Start Program; and Juan Molina Crespo, project

director, Cleveland Department of Public Health ...................................... 106

Nora, Audrey H., Director, Maternal and Child Health Bureau, Health

Resources and Services Administration, Department of Health and

Human Services, accompanied by Thurma McCann, Director, Division

of Healthy Start, Maternal and Child Health Bureau; James S. Marks,

Director, National Center for Chronic Disease Prevention and Health

Promotion, Centers for Disease Control and Prevention, Department

of Health and Human Services, accompanied by Mary Anne Freedman,

Director, Division of Vital Statistics, National Center for Health Statistics, Centers for Disease Control and Prevention; Duane Alexander,

Director, Institute of Child Health and Human Development, National

Institutes of Health, Department of Health and Human Services; and

Lisa Simpson, Acting Administrator, Agency for Health Care Policy

and Research, Department of Health and Human Services ..................... 12

Letters, statements, etc., submitted for the record by:

Alexander, Duane, Director, Institute of Child Health and Human Development, National Institutes of Health, Department of Health and

Human Services, prepared statement of ..................................................... 76

Barrett, Hon. Thomas M., a Representative in Congress from the State

of Wisconsin:

Prepared statement of ............................................................................... 9

Statement from the Milwaukee Healthy Women and Infants Project .. 5

Coyle, Thomas, assistant commissioner, Baltimore City Health Department, Maternal and Infant Care and Special Projects, prepared statement of ........................................................................................................... 107

Crespo, Juan Molina, project director, Cleveland Department of Public

Health, prepared statement of ..................................................................... 178

Guyer, Bernard, chairman, Department of Maternal and Child Health,

Johns Hopkins School of Hygiene and Public Health, prepared statement of ........................................................................................................... 117

Hatcher, Barbara, project director, District of Columbia Healthy Start

Program, prepared statement of .................................................................. 151

Marks, James S., Director, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Department of Health and Human Services, prepared statement

of ..................................................................................................................... 61

Nora, Audrey H., Director, Maternal and Child Health Bureau, Health

Resources and Services Administration, Department of Health and

Human Services, prepared statement of ..................................................... 17

Simpson, Lisa, Acting Administrator, Agency for Health Care Policy and

Research, Department of Health and Human Services, prepared statement of ........................................................................................................... 84

Stokes, Hon. Louis, a Representative in Congress from the State of Ohio,

prepared statement of ................................................................................... 195

Page

IV

Letters, statements, etc., submitted for the record by—Continued

Williams, Melanie, project director, Mississippi Delta Futures Healthy

Start, prepared statement of ........................................................................ 125

(1)

THE HEALTHY START PROGRAM: IMPLEMENTATION LESSONS AND IMPACT ON INFANT

MORTALITY

THURSDAY, MARCH 13, 1997

HOUSE OF REPRESENTATIVES,

SUBCOMMITTEE ON HUMAN RESOURCES,

COMMITTEE ON GOVERNMENT REFORM AND OVERSIGHT,

Washington, DC.

The subcommittee met, pursuant to notice, at 10:10 a.m., in room

2247, Rayburn House Office Building, Hon. Christopher Shays

(chairman of the subcommittee) presiding.

Present: Representatives Shays, Snowbarger, Towns, Kucinich,

and Barrett.

Also present: Representatives Cummings, Thompson, and Stokes.

Staff present: Lawrence J. Halloran, staff director and counsel;

Doris F. Jacobs, associate counsel; Robert Newman, professional

staff member; R. Jared Carpenter, clerk; Ronald Stroman, minority

professional staff; and Ellen Rayner, minority chief clerk.

Mr. SHAYS. Good morning. I would like to call this hearing to

order and welcome our witnesses and our guests to what is a very

important hearing.

Every child deserves a healthy start. That caring principle motivated President Bush in 1989, to make the effort against infant

mortality a national priority. Part of that initiative was the

Healthy Start Program, a 5-year demonstration begun in 1991 to

test innovative, locally driven approaches to reach pregnant women

and improve the health of their babies.

Since then, Healthy Start projects in 22 communities have

planned their strategies, formed their community organizations,

and provided a variety of services to expectant mothers. Through

this fiscal year, Congress appropriated and the Department of

Health and Human Services, HHS, spent more than $500 million

on Healthy Start.

Now the test is over, and it is time to find out what worked and

what did not. It is time to analyze as objectively as possible, the

impact of Healthy Start initiatives on the leading causes of infant

mortality: low birth weight, birth defects, and Sudden Infant Death

Syndrome. It is time to determine what Healthy Start demonstrated about the effectiveness and sustainability of community

action to improve the health of infants at risk.

Toward that end, HHS is conducting a formal evaluation of the

15 original Healthy Start projects. The study will measure the program’s performance in terms of infant mortality data, infant health

2

records, maternal health records, and public health statistics. The

$5 million study will be completed in late 1998 or early 1999.

But the Department believes that enough is already known to

justify expansion of the program to 30 more localities. The President’s fiscal year 1989 budget requests $96 million for replication

of nine successful Healthy Start infant mortality reduction strategies.

The request raises important oversight questions: On what basis

did the Department declare the program a success? Can reductions

in infant mortality rates be linked directly to Healthy Start initiatives prior to completion of a national evaluation? On what empirical data can communities rely to replicate the successes and avoid

the missteps of Healthy Start? Can HHS manage an expanded program effectively?

As much as anyone, I want the answers to confirm that we have

found locally supported approaches reduce infant mortality. But

the decisions affecting the lives of 30,000 babies each year should

be based on facts, not hopes or theories. Federal policies and programs to fight infant mortality must be based on sound research

and current data, not anecdotal information and purely local evaluation. When it comes to the care of vulnerable infants, good intentions are no substitute for good health outcomes.

We ask the HHS public health agencies involved in the fight

against infant mortality to address these concerns. We also invite

Healthy Start project directors to describe their work, to bring local

solutions to a national problem.

Your testimony today is an important part of the subcommittee’s

Healthy Start evaluation. We are very grateful that you came, and

we are eager to begin this hearing. And we welcome all of you.

With that, I would like to call on Ed Towns, who is the ranking

member of this subcommittee, and I would say without hesitation

an equal partner in this process, in this hearing, and in all of the

other hearings that we have conducted. Mr. Towns.

Mr. TOWNS. Thank you very much, Mr. Chairman.

Millions of our children are in grave risk because of infant mortality and low birth weight, particularly in our under-served and

minority communities.

In 1992, the infant mortality rate was 8.5 deaths per 1,000

births, one of the highest rates of infant mortality among industrialized nations. African-American infants die at a rate more than

twice the rate for white infants, with 17.6 infant deaths per 1,000

births, a rate seen in some of the poorest Third World countries.

We are, however, making progress. Since 1970, the infant mortality rate has been cut in half. But the rate is still much too high,

particularly in economically disadvantaged neighborhoods. That is

why programs like Healthy Start are so important.

Healthy Start was developed by Dr. Louis Sullivan, former Bush

administration Secretary for the Department of Health and Human

Services. Dr. Sullivan recognized that a one-size-fits-all-approach to

infant mortality and low birth weight would not work in underserved areas. Dr. Sulllivan designed Healthy Start to allow local

health care providers and community residents to develop individual programs that work best in their communities.

3

For example, the Bedford Healthy Start Program in my district

provides prenatal care, substance abuse prevention, treatment for

adolescent drug abuse, a pregnancy program, immunization, of

course, nutrition education and counseling, and primary medical

care for children.

While a 5-year study to evaluate the success of Healthy Start

will not be complete until next year, data from the Healthy Start

target areas suggest that the program has helped reduce infant

mortality and other pregnancy problems.

According to information that I received from Healthy Start in

New York City from 1990 to 1995, infant mortality dropped 43 percent in the Bedford target area compared to a 24 percent decline

city-wide. The overall decrease in the other New York Healthy

Start target areas was 40 percent.

According to Senator Arlen Specter in testimony that he provided

last year in the Senate on the Healthy Start Program, the results

of Healthy Start have been extraordinary.

In Pittsburgh, infant mortality has declined 20 percent, and an

estimated 61 percent decline for women who have taken advantage

of the Healthy Start Program.

Additionally, Gen. Colin Powell has announced that Healthy

Start will be a major part of the Corporation of National Service

that Presidents Bush, Carter, and Ford will unveil in the coming

weeks.

Two days ago, members of my staff visited the Baltimore Healthy

Start Program, and talked to health care providers, community

leaders, and with women and men who are participating in the program. Everyone they talked with said that the program is well-run,

and is dramatically improving pre- and post-natal health care for

the women and children in the program. They came back excited.

Like any other program, Healthy Start can be improved. It is my

sense that HHS should exercise better oversight over the operations of the program. But this federally-funded, locally-administered program appears to be cost effective.

According to the Office of Technology Assessment, $8 billion was

expended in 1987 for the care of low birth weight babies. HHS has

estimated that reducing the number of children born of low birth

weight by 82,000 births could save between $1.1 million and $2.5

million a year. We are talking about saving money.

If Healthy Start can continue to play a role in reducing infant

mortality and low birth weight babies, and help to improve the

quality of life for poor women and children in our country, it deserves our strongest support.

The program witnesses that we will hear from today are on the

front lines battling infant mortality in communities across this Nation, communities where Healthy Start has made the difference between life and death for thousands of poor American children.

I am hopeful that we will learn enough from their comments to

dramatically improve the life expectancy for our country’s poorest

children.

Thank you very much, Mr. Chairman. And I yield back.

Mr. SHAYS. I thank the gentleman.

Mr. Snowbarger, vice chairman of the subcommittee.

Mr. SNOWBARGER. I have nothing at this time. Thank you.

4

Mr. SHAYS. Mr. Barrett.

Mr. BARRETT. Thank you, Mr. Chairman. I do have a statement,

if I could, please.

Thank you for holding this hearing on the Healthy Start demonstration program. I am a strong supporter of Healthy Start. The

program in my district is called the Milwaukee Women and Infants

Project. And it has achieved good and solid results in my community by getting pregnant women into prenatal care.

Milwaukee was approved as a Healthy Start site, because we

were experiencing alarming infant mortality and low birth weight

baby rates. The problems that Healthy Start addresses are typical

in my community. And the problems are particularly striking for

our African-American community.

For example, in Milwaukee, the average low birth weight for

1988 through 1990 was 14.7 per 1,000 births, with the AfricanAmerican rate being 18.3. By 1994, the infant mortality rate had

decreased by 8 percent for white infants. However, the IMR for

non-white infants increased by 20 percent.

I am proud to say that our Milwaukee Healthy Start Program

currently reports zero infant deaths among its client population. In

addition, it reports a 22 percent increase in the number of women

enrolling in prenatal care during their first trimester, and substantial increases in health, immunization, and nutritional access for

infants and their mothers.

Mr. Chairman, with the subcommittee’s consent, I would like to

enter a statement from the Milwaukee Healthy Women and Infants

Project into the subcommittee’s record.

Mr. SHAYS. Without objection.

[The information referred to follows:]

5

6

7

8

Mr. BARRETT. Again, I am a strong supporter of Healthy Start.

When you look at the babies, who could not be? Healthy Start

projects are the type of community-based, locally-designed, and locally-controlled programs that many of my colleagues assert all

programs should be.

For that reason, I am puzzled as to why the effectiveness of these

projects would be called into question even before a Federal study

is completed.

Healthy Start is a good investment. Look at the communities and

talk to the clients. The results are evident.

I must also express puzzlement about portions of the Department

of Health and Human Service’s current funding decisions for the

Healthy Start Program. The Healthy Start Program in my district

is in the category of projects termed ‘‘special projects.’’ It is my understanding that the Department proposes to severely under-fund

special project sites.

When the Healthy Start demonstration began in the Bush administration in 1991, Milwaukee was one of seven projects deemed

approved, but not funded. Milwaukee and six other projects were

federally funded beginning in 1994. Milwaukee has been funded at

a level of $1 million annually.

It is my understanding, however, that the seven special project

programs will be limited to a maximum of $500,000 under phase

II of Healthy Start. My community’s Healthy Start project is telling

me it will not be able to operate at this funding level, ending services for many of my constituents.

In fact, I have been informed that the so-called ‘‘special projects’’

have always been restricted in access to funding, and have never

had the opportunity to apply for the higher funding levels available

for the original sites, and for the proposed new sites.

Today, I hope to receive an explanation about the criteria for

such administrative funding decisions, because my district needs

Healthy Start. I do not want to close it down, because it works.

Thank you.

[The prepared statement of Hon. Thomas M. Barrett follows:]

9

10

11

Mr. SHAYS. I thank the gentleman.

If I could, I would like to get some housekeeping out of the way,

if I can.

I ask unanimous consent that all members of the subcommittee

be permitted to place any opening statement in the record, and

that the record remain open for 3 days for that purpose. Without

objection, so ordered.

And I also ask unanimous consent that all witnesses be permitted to include their written statements in the record. Without

objection, so ordered.

We have two panels that will be coming before us. The first is

comprised of officials from the U.S. Department of Health and

Human Services. And then we will be having providers in the local

communities who will come and testify about their programs.

At this time, I would like to call Audrey Nora, Director of Maternal and Child Health Bureau, Health Resources and Services Administration, accompanied by Thurma McCann, Director of Division of Healthy Start, Maternal and Child Health Bureau. Also, I

would call James Marks, Director of the Chronic Disease Center,

Centers for Disease Control and Prevention; Duane Alexander, Director of the Institute of Child Health and Human Development,

National Institutes of Health; and Lisa Simpson, Acting Administrator, Agency for Health Care Policy and Research.

If you would all just come and stand, as we do swear our witnesses in, even Members of Congress. This is a policy that we have

for everyone.

[Witnesses sworn.]

Mr. SHAYS. For the record, everyone has responded in the affirmative. I hope we can fit you at that table. We probably need a table

a little wider. I am sorry for that. The important thing is that you

have enough space to put your documents down, and have a mike

that picks up your voice.

Let me from the outset just apologize and just state for the

record. I chair the task force on the Budget Committee on Health

Care, and we are making our preliminary decisions on what we are

going to report to the full House. And the meeting is now.

I want to weigh in on the very issues that we are talking about

in a positive way. So that should give me some license to leave.

I will say that one of the issues that I would like responded to

from all participants, is, although I will not be here: it is my understanding that this program was intended to be a program to see

the effect of local initiatives. But it was a local-based and local

community effort, and that ultimately we would see programs. And

it was the expectation, I thought, and the expectation of others,

that they would ultimately be self-financing, that we would then

seed additional programs. I would love, for the record, the responses. So I’ve really asked a question up front that I hope others

will address.

We are going to start in the order that I called you, which would

be Dr. Nora first and then Dr. Marks, then Dr. Alexander, and

then Dr. Simpson, in that order. This will be chaired by Vince

Snowbarger, who is the vice chairman of the subcommittee.

Mr. SNOWBARGER [presiding]. Dr. Nora.

12

STATEMENTS OF AUDREY H. NORA, DIRECTOR, MATERNAL

AND CHILD HEALTH BUREAU, HEALTH RESOURCES AND

SERVICES ADMINISTRATION, DEPARTMENT OF HEALTH AND

HUMAN SERVICES, ACCOMPANIED BY THURMA MCCANN, DIRECTOR, DIVISION OF HEALTHY START, MATERNAL AND

CHILD HEALTH BUREAU; JAMES S. MARKS, DIRECTOR, NATIONAL CENTER FOR CHRONIC DISEASE PREVENTION AND

HEALTH PROMOTION, CENTERS FOR DISEASE CONTROL

AND PREVENTION, DEPARTMENT OF HEALTH AND HUMAN

SERVICES, ACCOMPANIED BY MARY ANNE FREEDMAN, DIRECTOR, DIVISION OF VITAL STATISTICS, NATIONAL CENTER FOR HEALTH STATISTICS, CENTERS FOR DISEASE CONTROL AND PREVENTION; DUANE ALEXANDER, DIRECTOR,

INSTITUTE OF CHILD HEALTH AND HUMAN DEVELOPMENT,

NATIONAL INSTITUTES OF HEALTH, DEPARTMENT OF

HEALTH AND HUMAN SERVICES; AND LISA SIMPSON, ACTING ADMINISTRATOR, AGENCY FOR HEALTH CARE POLICY

AND RESEARCH, DEPARTMENT OF HEALTH AND HUMAN

SERVICES

Dr. NORA. Mr. Chairman and members of the subcommittee, I

am Dr. Audrey H. Nora, Director of the Maternal and Child Health

Bureau, Health Resources and Services Administration. I am accompanied this morning by Dr. Thurma McCann, the Director of

the Maternal and Child Health Bureau’s Division of Healthy Start,

who is sitting on my right.

Mr. SNOWBARGER. Dr. Nora, if I could interrupt, before we get

into the substance of the testimony, I want to point out, both to the

panel and to my colleagues up here, we don’t have lights this morning on the timing, and our timing is going to be held over here by

a flip chart.

We will try to be generous with the time and understand that

it is a little difficult to see that while you’re testifying, but I apologize for the inconvenience.

I’m sorry, Dr. Nora. Go ahead.

Dr. NORA. OK. Thank you. I am pleased to share with you our

efforts to reduce infant mortality in the United States through

Healthy Start. In my testimony today, I will highlight the progress

Healthy Start has made toward improving maternal and infant

health in 22 communities across the country, and describe how the

Department plans to buildupon what we have learned.

In short, we are convinced that the Healthy Start Program is

having a positive impact on reduction of infant mortality and morbidity in the areas where the program exists, and we are now planning to replicate these successful efforts in other parts of the country.

Infant mortality, which is defined as the death of babies before

their first birthday, is a public health tragedy. Thanks to an intensified national commitment to babies, to giving babies a healthy

start in life, the preliminary estimate for the U.S. infant mortality

rate is at a historic low of 7.5 deaths per 1,000 live births in 1995,

and the proportion of mothers getting early prenatal care is at a

record high of 80.2 percent in 1994.

We have also seen declines in some of the risk factors for low

birth weight and infant mortality. Teen births dropped for the

13

fourth straight year in 1995, and smoking among pregnant women

has been decreasing in recent years. Nevertheless, when compared

to other developed countries, the United States continues to have

unacceptably high infant mortality rates with significant disparities among racial and ethnic groups.

In 1991, based on findings by a White House Task Force on Infant Mortality, President Bush recommended that actions be taken

to address persistently high infant mortality rates in this Nation,

particularly those associated with ethnic and racial populations.

Healthy Start began as a demonstration program in late 1991,

with funds appropriated initially under Public Law 102–27, ‘‘the

Dire Emergency Supplemental Appropriations Act of Fiscal Year

1991,’’ and has been renewed annually since then, in Labor HHS

appropriations bills.

The Healthy Start Program was built on the premise that residents of local communities would best know how to overcome these

barriers. Thus, new, community-based strategies were needed to

attack the causes of infant mortality and low birth weight, especially among high-risk populations.

The National Institutes of Health, the Centers for Disease Control and Prevention, the Agency for Health Care Policy and Research, and many other Federal agencies participated with HRSA

in the development of the Healthy Start conceptual framework.

They continue to be our allies in addressing health issues affecting

our Nation’s mothers, infants, children, and their families.

Applicants for Healthy Start grants were sought among both

urban and rural communities with infant mortality rates at least

one-and-a-half times the national average. In late 1991, 15 applicants—13 urban and 2 rural—were awarded planning grants.

The initial grants supported year-long, comprehensive planning

activities through fiscal year 1992. The projects began serving clients in fiscal year 1993.

The overall goal was to reduce infant mortality in the project

areas by 50 percent over a 5-year period, focusing on five principles

which would assure early prenatal care and appropriate supports

for families. These five principles include: innovation, community

commitment and involvement, increased access to health care,

service integration, and personal responsibility.

In late 1994, seven additional communities—five urban and two

rural—received Healthy Start special project grants. These communities also had infant mortality rates greater than one-and-a-half

times the national average for infant mortality. The goal for these

projects was to significantly reduce infant mortality rates in the

target areas over a 2-year period.

In 1993, HRSA entered into a contract with Mathematica Policy

Research to conduct an independent, extensive cross-site evaluation

of the 15 original Healthy Start projects. This national evaluation,

managed by HRSA’s Office of Planning and Evaluation, consists of

both process and outcome analyses.

The process evaluation will detail the individual characteristics

of the 15 original projects, their health and social service infrastructures, organizational characteristics, and descriptive information about the type and scope of local interventions.

14

The outcome evaluation entails a quantitative analysis of the

overall success of the Healthy Start Program through assessment

of multiple program outcomes, such as infant mortality rates, low

birth weight incidence, and improved maternal and infant health,

using client-specific data as well as secondary data sources.

The national evaluation is a 5-year effort with a final report due

in 1998. Comparisonsites to the Healthy Start communities will be

selected in order to demonstrate the comparative impact of Healthy

Start interventions on communities.

While we await the completion of the Mathematica evaluation,

results from similar national studies and the impact of communitybased service interventions and outcomes from a number of local

evaluations at current Healthy Start demonstrationsites are providing useful information.

A recent cross-site successful program to reduce infant mortality

in the South was conducted by the School of Public Health, University of North Carolina. The evaluative program, called Healthy Futures/Healthy Generations, used interventions similar to Healthy

Start’s. It was sponsored, from 1988 to 1993, by the Southern Governors Association, and was co-funded by the Robert Wood Johnson

Foundation and the Maternal and Child Health Bureau.

The evaluation compared data from 11 Southern States participating in the Healthy Futures/Healthy Generations program with

six States who were not participating, and it attempted to determine if a broad set of perinatal interventions had assisted participating States to reduce infant mortality and expand access to

health care services.

Many of the Healthy Futures/Healthy Generations interventions

were very like those developed by Healthy Start projects, and included public awareness campaigns for prenatal care services, risk

screening protocols, increased obstetric personnel and training of

those personnel, improved management of high-risk mothers and

newborns, and improved identification and followup of high-risk infants.

Major findings from this evaluation include: improved health outcomes of mothers and infants; enhanced perinatal health care systems; increased utilization of public and private resources, and

other efforts which served as a catalyst for a wide range of infant

mortality reduction activities. Substantial decline in infant mortality in the South occurred during the Healthy Futures/Healthy

Generations period, compared to the pre-program period. For example, at the conclusion, the infant mortality rate was 10 compared

to 11.3 infant deaths prior to beginning the program and these infant mortality declines were substantially greater for black populations in the South. There were also increases in the percentage

of women who sought prenatal care during their first trimester.

There was an increase of .3 percent in the South compared to a .4

percent decrease in early prenatal care nationwide.

Our knowledge of successful community-driven approaches for

Healthy Start grantees has been greatly enriched by timely information from 14 of the 15 original projects. Each of the seven special projects has also been required to conduct a local evaluation.

The local evaluations have looked at interventions, such as outreach services, infant mortality reviews, prison initiatives, postVerDate 11-MAY-2000 10:16 Jun 13, 2002 Jkt 010199 PO 00000 Frm 00018 Fmt 6633 Sfmt 6602 W:\DISC\40482 pfrm01 PsN: 40482
15

partum surveys, community ethnographic studies and studies of

special populations, such as adolescents and male partners.

The Healthy Start initiative also features an aggressive national

and local public information and education component that raises

awareness of infant mortality and promotes prenatal care and

other healthy behaviors. A new set of public service advertisements, released in February, urges women to avoid putting their

babies’ health ‘‘on the line’’ by seeking early and regular prenatal

care.

The campaign features toll-free numbers for English-speaking

callers and Spanish-speaking callers. For the first time, just by

calling the hotline, women can reach either their own States’ maternal and child health office or a local Healthy Start site, whichever is closer.

Over the 4 operational years of fiscal year 1993 through 1996, information we have learned from the Healthy Start projects has

been distilled into nine models of infant mortality reduction strategies which support the concept of community-based service integration.

Mr. SNOWBARGER. Dr. Nora, we’re going to have to ask you to

sum up quickly here. We have tried to be generous with the time,

and we’re going to be running late if we allow everyone the same

amount of time. Thank you.

Dr. NORA. OK. Thank you. The Maternal and Child Health Bureau and its Division of Healthy Start has provided guidance and

oversight to the 22 Healthy Start projects.

Our management of the Healthy Start initiative extends to assisting the grantees in developing and implementing programs and

strategies to reduce infant mortality, closely monitoring performance, providing and arranging for the provision of technical assistance, facilitating community consortium development, mediating

conflicts, and promoting communication with State Title V agencies.

While the overwhelming majority of Healthy Start sites have experienced minimal problems in the development of consortia, local

conflicts have emerged in a few sites. Federal regulations allow

HRSA to take corrective action where grantees exhibit serious deficiencies or, ‘‘exceptions,’’ in business management or unsuccessful

performance in administrative and programmatic management.

Currently, three grantees fall into this ‘‘exceptional’’ category.

They are Birmingham, Detroit, and Northwest Indiana.

The Mississippi Delta Futures Project was selected as one of the

seven special projects in late 1994. Its project area covers eight

counties in the Delta Region. Since inception, the project has experienced difficulties in reaching cohesions within the multi-faceted

communities of the project area, establishing effective communications among all stakeholders and timely compliance with grant requirements.

Intensive technical assistance from both Federal staff and private sector resources has been provided. In spite of these efforts,

it has been necessary to reduce funding to this project during this

fiscal year.

Mr. SNOWBARGER. Dr. Nora, could you conclude fairly quickly

here?

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Dr. NORA. Yes. Yes. I will.

In conclusion, with encouragement from the Congress, HRSA has

established three objectives to operationalize the Healthy Start initiative: No. 1, operationalize successful Healthy Start models

through replication; No. 2, establish a peer mentoring program;

and No. 3, disseminate nationally information which we have

learned.

In closing, I would like to emphasize that we are confident that

Healthy Start will continue to be a vital component of the administration’s comprehensive national strategy to increase access to prenatal care and to help families care for their infants.

We know that early and continuous prenatal care makes a difference. If children are indeed our future, Healthy Start is a strategic investment in that future.

This concludes my testimony.

[The prepared statement of Dr. Nora follows:]

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Mr. SNOWBARGER. Thank you, Dr. Nora. Dr. Marks.

Dr. MARKS. Thank you, Mr. Chairman. Good morning. I am Dr.

James Marks from the National Center for Chronic Disease Prevention and Health Promotion at the Centers for Disease Control.

I am pleased to be here to discuss some of our agency’s activities

related to infant mortality and prenatal care, including the National Vital Statistics System. I will summarize my written testimony on this work and also discuss the timeliness and accuracy of

the data, and some of our other activities in this area.

As Dr. Nora has mentioned, the infant mortality rate in the

United States has declined steadily over the last quarter century,

reaching 7.5 deaths per 1,000 live births in 1995, the lowest rate

ever recorded. Slightly over 30,000 infants die in the United States

each year, with the leading causes of death being birth defects, disorders related to prematurity and low birth weight, Sudden Infant

Death Syndrome, and Respiratory Distress Syndrome.

However, the relatively poor international ranking of the United

States in infant mortality and the large differential in infant mortality among the U.S. population subgroups presents cause for concern.

The vital statistics system maintained by CDC’s National Center

for Health Statistics is the source of the Nation’s official vital statistics. These statistics are provided through State-operated registration systems and are based on vital records filed in the State

offices. Detailed annual birth and death data are available for the

United States as a whole, for States, for counties, and cities of

greater than 100,000.

CDC believes this State data on low birth weight and infant mortality to be highly accurate. All of the States have adopted laws requiring registration of live births and deaths, and CDC relies on information provided by the States to complete the national files. An

example: the States were able to link about 98 percent of all infant

death records to their corresponding birth certificates, one of the

ways that they are encouraged to check on completeness of registration.

With regard to timelines, the vital statistics system is in transition, with a shift toward electronic collection and transmission of

data. This is dramatically improving timeliness. In 1995, almost 70

percent of births were registered electronically, although most

States were still processing a paper legal record.

In October 1996, CDC released preliminary data for calendar

year 1995, including preliminary infant mortality rates, by cause of

death and race. This was an almost 12-month improvement over

previous data releases.

CDC is working further with the States to continue to improve

timeliness of vital statistics in general, and especially timeliness of

the linked birth and death data.

In addition to collecting the vital statistics, CDC conducts epidemiologic research into the risks and causes of infant mortality

and supports the States to gather and better use their data to assess their infant health problems and target their resources. I will

now describe some of this work in a little detail.

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For example, one measure that is of great importance is that of

early prenatal care, defined as having the initial prenatal visit

within the first 3 months of pregnancy.

In 1994, about 80 percent of all women received early prenatal

care, but there is substantial variation among our largest cities,

with the cities that have the lowest rates averaging slightly over

50 percent, and those with the highest rates having over 80 percent

of women receiving early prenatal care.

Another way that we use vital statistics is in examination of ethnic and racial disparities in infant mortality. As you have heard,

African-American infants have over twice the rate of infant mortality as do white infants.

It is found that this is principally due to the very low birth

weight rate, which contributes to almost two-thirds of the disparity

and the concomitive higher mortality of those very small infants.

Although these very low birth weight infants represent only a

tiny fraction of all the births in the United States—about 2.3 percent of the births to African-Americans and only .8 percent among

whites—because of their high mortality, they account for this excess.

Further, when you look at the risk of death to college-educated

African-American women, compared with college-educated white

women, we find that the excess remains. We would assume, for

these college-educated groups, that access to quality care would be

much more nearly equal than for the population as a whole, yet the

excess remains.

Therefore, CDC has begun to examine the psychological, social,

cultural, and environmental factors that may contribute to preterm delivery, using a community participatory approach in Harlem and Los Angeles. We are working with the communities to understand how they view the infant mortality and the risks and protective factors influencing maternal health and pregnancy outcomes.

CDC also works heavily in the area of birth defects, the leading

cause of infant mortality, where it is surveillance and epidemiologic

capabilities have enabled us to conduct research that has led, for

example, to show that the consumption of the vitamin, folic acid,

could prevent 50 to 70 percent of cases of neural tube defects, a

very serious birth defect.

Our efforts, along with those of others, contributed to the FDA’s

decision to require fortification of the food supply with low levels

of folic acid.

I would now like to just briefly mention our work with the States

and communities.

The Maternal and Child Health Epidemiology Program is collaborative between CDC and HRSA. We support about 15 States to

increase their analytic capability through the assignment of epidemiologists and support for specific analytic projects.

For example, Georgia evaluated the efficacy of prenatal care case

management funded by Medicaid and found that it does get highrisk women into care earlier. This evaluation influenced the State

to continue to provide case management services when it was an

area under review.

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The other is the Pregnancy Risk Assessment Monitoring System,

or PRAMS, which is an ongoing population-based surveillance system designed to identify and monitor selected material behaviors

and experiences that occur before, during, and after a pregnancy.

Again, in fiscal year 1996, we funded 15 States for this. It is designed to supplement data from vital records and asks a sample of

women who have recently delivered about their behaviors and experiences, such as access and use of care, alcohol use, smoking, violence during pregnancy, et cetera.

An example of how this was used: in Oklahoma, they found that

half of all women with Medicaid coverage, who had their first prenatal visit after the first trimester, indicated that they began care

as early as they wanted to. Thus, awareness of the importance of

prenatal care remains a barrier to receiving early prenatal care,

particularly among women with Medicaid coverage.

In conclusion, continued progress in reducing the Nation’s infant

mortality rate and eliminating the racial and ethnic differences in

pregnancy outcomes will occur if the national, State, and local commitment to improving birth outcomes also continues. It is increasingly clear that infant mortality is a problem that needs broad community-based, as well as medical interventions. The Healthy Start

demonstration projects and the complementary work that we are

engaged in at CDC we hope will contribute to reducing infant mortality in the future.

Thank you. I will be pleased to respond to any questions you

might have.

[The prepared statement of Dr. Marks follows:]

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Mr. SNOWBARGER. Thank you, Dr. Marks. Dr. Alexander.

Dr. ALEXANDER. Mr. Vice Chairman, members of the subcommittee, I thank you for the opportunity to testify here today. I

am Duane Alexander, Director of the National Institute of Child

Health and Human Development at the National Institutes of

Health.

The Congress charged my institute, the NICHD, with supporting

and conducting biomedical and behavioral research on maternal

and child health, the population sciences, and medical rehabilitation. When my institute was founded in 1962, it was given a special mandate to address the significant problem of infant mortality

in the United States, which was actually on the rise at the time.

Since then, the U.S. infant mortality rate has declined by 70 percent.

NICHD-supported research advances have played a major role in

that reduction, particularly improvements in preventing and treating Respiratory Distress Syndrome and the ‘‘Back-to-Sleep’’ campaign aimed at reducing the risk of Sudden Infant Death Syndrome.

Since 1990, three major research findings have significantly affected and accelerated the continuing decline in the U.S. infant

mortality rate.

First is the development and use of surfactant to treat newborns

afflicted with Respiratory Distress Syndrome. Our research had

previously revealed that infants with RDS lacked surfactant, a surface factor that keeps the insides of the lungs from sticking together and makes breathing easier.

The development and administration of surfactant has markedly reduced deaths due to RDS and saves almost $90 million a year in

medical costs.

To illustrate the significance of this advance, in 1963—the year

after NICHD was founded—President Kennedy’s infant son Patrick

was born prematurely and died of Respiratory Distress Syndrome.

Despite all his advantages, his doctors and his parents could only

watch helplessly as Patrick struggled to breathe, because the cause

of RDS was not yet understood and there was no treatment.

Now, with surfactant treatment, new respirators, better isolettes,

and advanced intravenous fluid therapy, all developed through research, premature babies have a far better chance to live. When

Patrick was born, an infant with RDS, at his weight and gestational age, had a 95 percent chance of dying. Today, an infant at

that weight and age has a 95 percent chance of living.

Second, in 1994, an NICHD-supported Consensus Development

Conference concluded that use of antenatal steroids to treat women

in preterm labor would result in a 50 to 60 percent reduction in

the baby’s risk of death or suffering complications.

As a result of our targeted dissemination of the recommendations

from that consensus panel, the use of antenatal steroids in highrisk women has increased from 15 percent of such patients to about

60 percent, potentially saving the lives of several thousand very

low birth weight infants each year, plus as much as $160 million

annually in medical expenditures.

Further increases in the application of these recommendations

will result in additional savings in both infant lives and costs.

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The third and perhaps most dramatic research finding that has

reduced infant mortality in the United States in the 1990’s is the

realization that placing infants on their backs to sleep, rather than

the common practice of on their stomachs, reduces the risk of Sudden Infant Death Syndrome.

For many years, SIDS had been the leading cause of death in infants from between 1 month and 1 year of age. Deaths due to SIDS

have fallen by more than 30 percent nationwide in the past 3

years. Some States are reporting reductions of over 60 percent in

SIDS deaths.

Such declines can be traced to the success of the research-based ‘‘Back-to-Sleep’’ campaign designed to encourage back sleeping for

infants.

The ‘‘Back-to-Sleep’’ campaign is led by NICHD with the Maternal and Child Health Bureau and the American Academy of Pediatrics, in collaboration with SIDS parents and professional groups.

Since the campaign began, it is estimated that 1,600 fewer babies

a year die of SIDS.

Despite these major research advances and their direct impact on

reducing infant mortality, the rate of death during the first year

of life is still too high, and remains an important public health

problem for the Nation. We continue to support a major research

program on reducing infant mortality and anticipate that our expenditures in this area during this current fiscal year will exceed

$94 million.

Recognizing that obstetric and neonatal practice was hampered

by a lack of clinical trials of sufficient size to give clear indications

rapidly of the effectiveness of various treatment approaches, several years ago we established two networks for multisite clinical

trials in maternal-fetal medicine and neonatology.

These networks develop common protocols, conduct the trial, and

present the results jointly. To date, these networks have successfully identified both effective and ineffective interventions and

widely disseminated the results for clinicians.

Our infant mortality research effort is placing special emphasis

on the leading cause of infant mortality, birth defects, and the

problems of prematurity, especially low birth weight. For some

time, we have explored questions about possible links between maternal infections and premature birth.

Using the most promising lead we have at the present time for

reducing prematurity, our maternal-fetal medicine network

launched a clinical trial in August 1996 to determine whether

screening pregnant women for a marker of bacterial vaginosis

called fetal fibronectin, and treating them with an antibiotic to

eliminate this infection would reduce the rate of premature delivery.

This large-scale clinical trial is based on evidence that bacterial

vaginosis triggers premature labor and on small studies suggesting

that antibiotic treatment markedly lowers that risk.

Because large numbers of women, particularly African-American

women, have this common infection and are unaware of it, the development of an inexpensive and easy means of eliminating it could

have a major impact on the incidence of prematurity and infant

mortality.

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Mr. Vice Chairman, our Institute is proud of its record in helping

to reduce the rate of infant mortality in our country, and remains

committed to continuing to contribute to this effort in the future.

I will be glad to respond to any questions that you or members

of the subcommittee have.

[The prepared statement of Dr. Alexander follows:]

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Mr. SNOWBARGER. Thank you, Dr. Alexander. Dr. Simpson.

Dr. SIMPSON. Good morning, Mr. Vice Chairman and members of

the subcommittee. It is my pleasure to be here. I’m Lisa Simpson.

I’m the Acting Administrator of the Agency for Health Care Policy

and Research.

I take particular pleasure in being able to testify here this morning, both as a pediatrician, as my colleagues, but also a former director of maternal and child health for the State of Hawaii.

There are three major points that I would like to leave you with

today from our Agency’s perspective.

First, that we share the Healthy Start Program’s goal of trying

to reduce infant mortality and to do that through research. However, our research programs have never directly assessed the effectiveness of the Healthy Start Program.

The second point is that health services research, which is the

research that we sponsor, has contributed to our understanding of

the effectiveness and cost-effectiveness of interventions to improve

low birth weight outcomes.

Third, many clinical services today, whether used for pregnant

women, children, or adults, and are considered the standard of

practice, actually lack a strong evidence or scientific base, and to

create that scientific base and to use it to promote evidence-based

practice is a key strategy for improving clinical care in this country.

The Agency’s research emphasis, which stems from our legislative mandate, has been on issues and conditions which are common, costly, and for which there is substantial variation in practice.

Perinatal care, which is the care of a mother before delivery and

of herself and her baby after delivery, is clearly one of these issues.

Let me give you some examples.

Each year in this country, the costs of hospital admission for childbirth exceed $20 billion. Each year, the incremental costs of

low birth weight are close to $4 billion. To put this in perspective,

the annual direct costs of low birth weight continue to exceed the

cost of AIDS.

AHCPR has a series of studies underway on perinatal care.

Projects include studies of the management of childbirth and patient outcomes, variations in practice related to prenatal care, and

strategies to improve the outcomes for very low birth weight infants.

In 1992, the Agency funded a comprehensive 5-year research

project to investigate the components of obstetrical care. The

project, which is titled the Low Birth Weight Patient Outcomes Research Team, or PORT, is headed by Dr. Robert Goldenberg, a national authority on low birth weight at the University of Alabama.

This project is now in its last year, and has already yielded several key findings, and my written testimony includes several highlights from this project, but let me just mention one or two, because I think they exemplify how health services research complements the biomedical and epidemiologic research that are conducted by other agencies in the Department.

One of the most important and, frankly, controversial findings of

this study is the lack of evidence for the effectiveness of prescribing

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bed rest for pregnant women considered to be at risk for a number

of adverse perinatal outcomes.

In fact, there is not much consensus about when bed rest should

be used, for whom, or for how long, and yet a growing body of research is showing that bed rest may, in some cases, actually be

harmful. Still, almost 20 percent of pregnancies are recommended

bed rest today.

So there is clearly a gap, a critical gap, between what we know

from research and what is going on day-to-day in clinical practice.

Another important finding from this study is that high-risk babies have an increased chance of survival, with no significant increase in cost, if they are delivered in hospitals with a high volume

of deliveries in specialized neonatal intensive care units, or NICUs.

This finding is from California, and it is my understanding that

the California Children’s Service, which oversees neonatal intensive care in that States’s Medicaid population, is already looking to

these results to recommend revisions for their State guidelines on

neonatal intensive care.

Overall, this study has already produced 77 published articles

and abstracts in leading peer review journals on these key findings.

Mr. Vice Chairman, I respectfully request that a cumulative bibliography of these articles be submitted for the record.

Other findings from this study have influenced the practice recommendations that have been disseminated by the Centers for Disease Control and Prevention and the National Institutes of Health.

For example, this study’s findings on cost effectiveness of the maternal screening and treatment for the prevention of a disease neonatal Group B streptococcal sepsis were used by the Centers for

Disease Control in formulating their recently released screening

and treatment recommendations.

Other findings from Dr. Goldenberg’s study were also used by the

National Institutes of Health in what Dr. Alexander just mentioned, their consensus development conference on the use of

corticosteroids for fetal maturation and improving birth outcomes.

But health services research also goes beyond looking at the clinical services themselves to examine how you organize and finance

health care services and to determine which of these approaches result in improved quality, better outcomes, and lower costs.

For example, our researchers have estimated that, in 1987,

health care expenditures for infants totaled $12.6 billion and were

greater on a per capita basis than those of any other age group

younger than 65.

The source of this type of data is the agency’s Medical Expenditure Panel Survey, which collects detailed information on the use

and payment for health care services from a nationally representative sample of Americans. Many questions remain unanswered

today about the many changes in the health care system, such as

the impact of managed care and what will happen to the delivery

of services at the community level.

This survey, or MEPS, is one source of information that will be

able to shed some light on these questions in the years ahead. Because this survey is now an annual survey, we will be able to provide you with much more current data on a yearly basis, beginning

in 1998.

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To conclude, Mr. Vice Chairman, there are a number of interventions being used today to reduce the rate of infant mortality, and

there is wide agreement that prenatal care is a key strategy, but

we need to continue to build the science base behind these clinical

interventions.

We need to give policymakers, physicians, patients and, increasingly, purchasers and health plans information on which specific

interventions are the most effective and the most cost effective in

reducing low birth weight and infant mortality.

While our agency is helping to bridge some of the gaps in this

area, in other words, between what is known about effective treatment and the use of these treatments in everyday practice, a lot

of work remains.

I am pleased to say that we are one of the Federal agencies collaborating with the others at the table and private sector groups

in sponsoring a conference this fall that is going to bring together

national experts on preterm, and really try to chart the course for

research for the next decade in this area.

Thank you.

[The prepared statement of Dr. Simpson follows:]

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Mr. SNOWBARGER. Thank you very much. We will now go to questioning for the panel, and I would like to begin by reminding panelists—maybe that’s the best way to do it—reminding panelists of

the chairman’s question before he left. This may really just be for

Dr. Nora. I’m not sure. If others want to respond, that’s fine.

My understanding was his question was concerning the legislation that was passed about the nature of the programs, maybe beginning at the Federal level but, sooner or later, becoming local

programs that were self-financed.

Dr. Nora, could you respond to the chairman’s concern?

Dr. NORA. Yes. I would be happy to. We refer to this as sustainability. And, in the third year of the program, we sponsored a national conference addressing this issue.

All of the grantees participated in it, as did some of our other

Federal partners. The private sector was involved. The State Title

V maternal and child health directors were included, as well as

local interest groups.

The grantees have been working on sustainability since that

time. We likewise anticipate that Federal funding will not continue

forever.

Mr. SNOWBARGER. Those of you who have been around the committee before know that I like to take advantage of my freshman

status and claim ignorance on a lot of things.

Mr. TOWNS. Only this year. [Laughter.]

Mr. SNOWBARGER. I know. I know. Like I said before, I’m going

to take advantage of it.

I am not so sure we are concerned, necessarily, about Federal

funds running out, but it seems to me that there is a need to expand this to other areas and, rather than expand the program as

a whole, I would think there would be a desire to establish programs in certain geographic areas and then move on to continue

expanding the program nationwide.

Is that the course this is taking? Do we find any of the programs

that are anywhere near self-sustaining at this point?

Dr. NORA. Well, our intent is to expand the area into approximately 30 other geographic areas, which would address the criteria

that have been identified. In addition, those communities must

have one-and-a-half times the national average of infant mortality

rates to be eligible.

We anticipate that many of the current existing Healthy Start

sites would serve as mentors to assist the new sites in using the

kinds of interventions that have been successful.

Mr. SNOWBARGER. I guess the question still is: is anybody coming

close to sustainability at this point? What steps have been taken

in that direction with any of the programs?

Dr. NORA. I would like to ask Dr. McCann to provide more detail

on the sustainability.

Mr. SNOWBARGER. That would be fine.

Dr. MCCANN. I guess as a result of the conference that Dr. Nora

mentioned, as well as many of the efforts that are going on locally,

there are several of the Healthy Start Programs which have been

able to find other funding for the currently funded interventions.

As a result, when we are starting this next phase which we are

calling replication, and asking these current grantees to mentor, we

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have given them the option of applying for whatever model they

wish to mentor, so that those that they have found other funding

for they would not be coming in to ask requests for Federal funding.

In that way, we feel that they will be able to sustain many of

the existing interventions and models that are currently going on,

as well as getting support from us to help them with those that

they have not currently found funding for.

Mr. SNOWBARGER. So all of the programs that we currently have

in place will continue to receive funding?

Dr. MCCANN. Some funding.

Mr. SNOWBARGER. Some funding.

Dr. MCCANN. But not to the level that it will fund all of the

interventions that they currently have supported.

Mr. SNOWBARGER. OK. I’m not sure who to address this question

to, but one of the questions that came up as I was listening to all

of you speak is trying to get a handle on how infant mortality, low

birth weight, et cetera—it seems like it has been going down nationwide.

Do we have some comparison between how programs in these cities have fared versus the nationwide averages, as they have gone

down?

Dr. NORA. We have some results from the local evaluations that

would give us some information on that. Dr. McCann, do you have

the details?

Dr. MCCANN. Yes. We have trends that we have been following

among all of our grantees, in terms of what their infant mortality

rates are, but we are not attributing those infant mortality rate

drops entirely to the Healthy Start Program, because we plan to

wait for the outcomes of the national evaluation to really point that

out to us in a much more technical manner.

However, through the local evaluations, many of our grantees are

reporting outcomes which suggest that they have increasing enrollment in the first trimester, that they are seeing more women during their pregnancy for prenatal care, that low birth weight seems

to be declining in many of the sites and, you know, they have identified which clients have received case management or outreach,

and those clients whom have been case-managed have reduced low

birth weight rates.

So we are beginning to start to see some declining numbers within the specific population that is affected through the Healthy Start

Program, but we cannot report that the decreases are entirely due

to the Healthy Start Program right now.

Mr. SNOWBARGER. You don’t have any basis for saying that the

reductions are greater where the programs are in place than they

would be nationwide?

Dr. MCCANN. We can’t say that, no.

Mr. SNOWBARGER. Dr. Marks, do you have any basis for answering that question?

Dr. MARKS. No. Really, the evaluation being done by

Mathematica will allow that to be looked at more thoroughly, in

that, in many of the cities, the Healthy Start has selected certain

areas of the cities so, overall city statistics might not adequately

reflect what is going on in the Healthy Start areas. But the data

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that we have from Vital Statistics is being made available for the

evaluation, as they need it.

Mr. SNOWBARGER. If I can follow through on one question, that

has to do with the statistical analysis here by Mathematica, apparently they were brought on board in 1993. I understand that this

is going to be a 5-year study and we’ll study the first full implementation here.

Is there any provision, though, in their contract or in your arrangements with them, for interim reports, so that we have some

preliminary findings before the end of 1998? If I understand this

correctly, we’re talking about this program ending, in theory, in

September 1997, and it’s going to be a full year, a year and 3

months later, before we can find out whether or not the program

has been successful.

Dr. NORA. Well, it’s certainly true that the national evaluation

will not be available until 1998, but I think there is some preliminary evidence in the local evaluations that are showing changes in

the communities where these programs are located. I think you will

hear about some of those from the next panel.

Mr. SNOWBARGER. All right.

Dr. MCCANN. In addition, there are reports that are being released that have begun earlier.

As Dr. Nora reported, there are not only outcome portions for the

national evaluation, but there is also process analysis going on that

some of these reports are being prepared at present, they are undergoing the process that is set in place for review by the grantees

and other professionals prior to being released. So some reports are

available.

We also have what we refer to as special reports that have been

completed. One has been done on the outreach workers in Healthy

Start; another has been done on the adolescent services in Healthy

Start. Those reports are out and available at this point in time.

Mr. SNOWBARGER. Thank you. Mr. Towns.

Mr. TOWNS. Thank you very much. Let me make certain I’m

hearing you right.

In your testimony, you indicated in Pittsburgh the rate of infant

deaths for pregnant women receiving case management and home

visiting is 7.8 per 1,000 birth rate, 50 percent lower than the rate

of 15.6 for women not participating in the Healthy Start Program,

but also living in the housing development.

Now, what do you mean by that?

Dr. MCCANN. Well, what you’re reading are data that are reported by the grantees in their applications that they present to us

on an annual basis, which really provides an opportunity for us to

monitor the progress of the project.

There are other kinds of interventions going on in each of the

Healthy Start communities, other than the Healthy Start interventions.

By looking at comparisonsites, which will be part of the contract

with Mathematica, we would be able to tell more directly exactly

what impact the Healthy Start Program has had on these communities, and that’s the part of the evaluation that we are awaiting.

But, in the meantime, the grantees have taken a very close look

at their specific interventions, such as the one that you’re referring

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to in Pittsburgh, where they have taken a look at their case managed population and just taken a look at what’s going on with infant mortality and low birth weight.

Mr. TOWNS. So, in other words—I mean, let me just make sure

I fully understand—you say there are reasons for me to be excited

about this?

Dr. MCCANN. There are reasons for you to be excited about it.

We are very happy about it.

Mr. TOWNS. OK.

Dr. MCCANN. We think that it’s pointing in the right direction,

and we are awaiting the comparisonsite evaluation by

Mathematica to support what we’ve seen preliminarily.

Mr. TOWNS. OK. That’s very clear. Let me just sort of ask a general question to, I guess, all of you. If we were to eliminate local

community-based programs, like Healthy Start, what would be the

impact of the underserved communities currently benefiting from

the program? What would happen? We’ve seen enough to be able

to make a general assessment, haven’t we?

Dr. NORA. Well, we feel that Healthy Start was the glue that

pulls together the services that are existing within the community,

and we feel that it has strengthened the foundation that is there

and has made the community more aware of what needs to be

done; so we feel that it is important to be able to bring this about.

In many of the projects, for example, there have been efforts to

integrate the services from across agencies, such as WIC, the Infant Feeding Program, enrolling women in Medicaid, and the outreach services that you mentioned earlier.

So it’s an effort to pull all of these together to address the problems of the entire woman and her pregnancy and the baby.

Mr. TOWNS. Thank you. Dr. Marks, I think you mentioned in

terms of working with the community.

Dr. MARKS. Yes.

Mr. TOWNS. I think I heard you say that. What do you mean by

that, when you say working with the community?

Dr. MARKS. Sure. We’ve used the community approach in a lot

of areas, and not just in the infant mortality area, but we have the

projects that I mentioned in Harlem and in Los Angeles.

One of the issues in working with the community is find out

how—as I mentioned before, we found that Medicaid women in

Oklahoma got care as early as they wanted. We need to find out

what are the sort of, the local issues that have people not getting

the care when it is available to them, what are the issues that they

see are important as barriers to care, whether it’s transportation,

whether it’s being encouraged and helped to change behaviors that

contribute to poor infant outcomes.

What we are doing in ours is to spend a lot of time with focus

groups and working with the community to see how they frame the

issues of infant and mothers’ health, and then whether we can, in

fact, by what we learn by talking with them, modify the systems

that exist in their communities so that they are more responsive

and more specific for the kinds of concerns that they have.

In those discussions, we spend time saying what we know about

the medical risks, what we know about the behavioral risks, so

that they understand what we do know, but especially in the area

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of the gap between African-Americans and white Americans infant

health.

Whenever we do that analysis on just the medical factors, we can

explain some of that gap, but not all of it, so we have to look for

other interventions, and we think that some of that may come from

the community and what they perceive as the issues and problems

that they have to deal with.

Mr. TOWNS. Thank you very much, Mr. Chairman. I yield back.

Mr. SNOWBARGER. Thank you. Let me just try to close up this

panel with some questions about coordination between the agencies

that we have here.

We’ve heard research telling us new ways to deal with problems,

to what extent is Healthy Start, you know, monitoring those

changes and implementing those changes within their communities, to what extent does the CDC monitor what Healthy Start

may be doing.

Is there any coordination or interfocus here between the groups

about how we’re dealing with these infant problems in high-risk

areas, I guess is the best way to put it?

Dr. NORA. I think one very clear example is Sudden Infant Death

Syndrome and the ‘‘Back-to-Sleep’’ campaign. All of the Federal

agencies participated in this, and we continue to work together on

this campaign and share expenses; and I think it’s made a lot of

difference as far as infants dying with sudden infant death.

Maybe Dr. Alexander would like to add something else.

Dr. ALEXANDER. Yes, I think that the SIDS experience is an excellent example of agencies working together. The epidemiologic

findings clearly indicated that sleep position was associated with

Sudden Infant Death Syndrome and that back was safer. All of us

worked together in putting together the ‘‘Back-to-Sleep’’ campaign.

In addition, the Centers for Disease Control worked together

with us in the research community to develop a protocol for a death

scene evaluation that helps in establishing the cause, that SIDS is,

in fact, the attributable cause of death or not.

All of us have worked cooperatively in developing materials and

getting the message out, and this message has been picked up, it

is my understanding, in the Healthy Start sites and implemented

very effectively in those communities where Healthy Start exists.

Mr. SNOWBARGER. Thank you. Are there any more questions?

[No response.]

Mr. SNOWBARGER. If not, I thank the panel for coming this morning and for presenting their testimony. And just to assure, I can’t

remember who it was that asked, but all of your written testimony

will be included in the record. So thank you.

I think I would like to call the next panel forward: Thomas

Coyle, Melanie Williams, Barbara Hatcher, and Juan Molina

Crespo as well, by the way, as Dr. Guyer and Robert Pugh.

I apologize for letting you sit down first. We need to swear you

in, so if you could, all stand and raise your hand.

[Witnesses sworn.]

Mr. SNOWBARGER. I would like to recognize one of our colleagues,

Representative Cummings, at this time.

Mr. CUMMINGS. Thank you very much, Mr. Chairman and our

ranking member. Thank you.

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Mr. Chairman, I would like to introduce two esteemed guests

from my congressional district of Baltimore, and make some brief

remarks regarding the Healthy Start Program.

Historically, the 7th Congressional District of Baltimore has experienced an exceedingly high rate of infant mortality. Many highrisk areas in the city had twice the national average of infant

deaths. However, with the implementation of the Healthy Start

Program in 1993, Baltimore has drastically reduced the number of

babies born with low birth weights and severely reduced the number of infant mortalities.

The Healthy Start staff, in conjunction with the Mayor’s Office

and the surrounding community, are committed to ensuring that

all babies have a strong and healthy beginning, by providing important prenatal care to high-risk mothers who need it most.

Our city’s infant mortality rate has dropped 31 percent since the

implementation of the Healthy Start Program. In the two neighborhoods where Baltimore’s Healthy Start Centers are located, the infant mortality rate has been slashed by a staggering 61 percent.

The Baltimore example is truly a success story.

We have targeted the program services to the poorest areas of

the city, which are at the highest risk. The staff is mostly comprised of community residents who have been hired and trained

through the program, thereby providing important employment opportunities to the community.

I might add, Mr. Chairman and members of the committee, I

have had an opportunity to meet many of those people who work

in the program. They are very dedicated. They give much of their

time and effort, going beyond the normal 8-hour day, to assist people in lifting themselves up and lifting their children up.

Mr. Chairman, this program is working, and I decry any attempt

to reduce its funding level.

I would now like to recognize Dr. Bernard Guyer and Mr. Thomas Coyle. I am very pleased that they are able to testify as to the

merits of the Healthy Start Program in Baltimore.

Dr. Guyer is chair of the Maryland Commission on Infant Mortality Prevention, and professor and chair of the Department of

Maternal and Child Health of the Johns Hopkins University School

of Public Health and Hygiene.

Mr. Coyle is currently the assistant commissioner for maternal

and infant care and special projects, of the Baltimore City Health

Department. He is responsible for all maternal and infant programs managed by the Baltimore City Health Department. He also

serves as project director for the Federal Healthy Start Program.

I am so proud of the work that these gentlemen do on behalf of

so many. Mr. Chairman, I thank you for the opportunity to be here

with them and I look forward to hearing their testimony.

Mr. SNOWBARGER. Thank you, Representative Cummings. And,

with that, Mr. Coyle, we will turn the microphone over to you.

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STATEMENTS OF THOMAS COYLE, ASSISTANT COMMISSIONER,

BALTIMORE CITY HEALTH DEPARTMENT, MATERNAL AND

INFANT CARE AND SPECIAL PROJECTS, ACCOMPANIED BY

BERNARD GUYER, CHAIRMAN, DEPARTMENT OF MATERNAL

AND CHILD HEALTH, JOHNS HOPKINS SCHOOL OF HYGIENE

AND PUBLIC HEALTH; MELANIE WILLIAMS, PROJECT DIRECTOR, MISSISSIPPI DELTA FUTURES HEALTHY START, ACCOMPANIED BY ROBERT PUGH, EXECUTIVE DIRECTOR MISSISSIPPI PRIMARY HEALTH CARE ASSOCIATION; BARBARA

HATCHER, PROJECT DIRECTOR, DISTRICT OF COLUMBIA

HEALTHY START PROGRAM; AND JUAN MOLINA CRESPO,

PROJECT DIRECTOR, CLEVELAND DEPARTMENT OF PUBLIC

HEALTH

Mr. COYLE. Thank you, Congressman, and good morning, Mr.

Vice Chairman and members of the subcommittee.

We welcome the opportunity to be here today to testify about the

National Healthy Start Program. I have submitted my testimony

earlier this week, and we will try to summarize that today.

I am joined here on my left by Dr. Bernard Guyer, who Congressman Cummings has already introduced. I had listed out all of Dr.

Guyer’s titles and several other things, but I’m going to have to

pass on this, since the Congressman has already done that.

Because our time is limited, and because the focus of this hearing is on evaluation, and because Baltimore City has dramatic results in terms of the local evaluation, I am asking Dr. Guyer,

whose department has overseen this evaluation for over 6 years, to

do most of the testimony.

Bernie.

[The prepared statement of Mr. Coyle follows:]

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Mr. SNOWBARGER. Dr. Guyer.

Dr. GUYER. Thank you, Mr. Vice Chairman. I am pleased to be

asked to come here today by Tom Coyle and the Baltimore Healthy

Start Project. This is a wonderful collaboration between faculty at

Johns Hopkins and our colleagues in the Baltimore City Health Department.

I have a handout that I put on the table with some of these earlier results, for the committee. Let me just summarize briefly the

findings.

This committee is obviously very well-informed on issues of infant mortality and low birth weight, and I won’t go into any of the

background to that. What I want to provide you with is some early

evidence of the evaluation from the Baltimore Healthy Start

Project.

These data come from more than 600 women who participated in

the Baltimore Healthy Start Project during their pregnancies, and

they are compared to more than 500 women who became known to

the Baltimore Healthy Start Project, but only after they delivered

their babies.

In summary, the data show that the women who did not have

the Healthy Start services prenatally were more than twice as likely to have a low birth weight baby, more than three times as likely

to have a very low birth weight baby, and more than twice as likely

to have a pre-term delivery.

Clearly, there is something going on with exposure to the

Healthy Start interventions during the pregnancy that gives these

women advantages over those who get to Healthy Start after the

baby is born.

The faculty at Johns Hopkins has been taking a careful look at

this data, trying to dissect it and understand what factors account

for these kinds of differences. But one thing that they have done

immediately was to look at women who are substance abusers in

both groups—those who get Healthy Start services before the baby

is born, during pregnancy, and those who only become available

afterwards. These findings hold up even among women who are

substance abusers.

I do not have hard answers for you on the causes and the difference that Healthy Start makes, but I want to point you in a particular direction that I think is important from the Baltimore experience. Now, we know that low birth weight is an important precursor of infant mortality.

It is influenced by a whole set of medical factors, but it is also,

as often is said, it is a social problem, and the Healthy Start intervention in Baltimore, in particular, provides social support, housing, job preparation, education, case management to these women,

and it may be that what we are seeing among the Baltimore

Healthy Start participants is the added benefit of all those intensive services in reducing low birth weight.

We have had very few studies in the past that have made this

level of intensive investment in these high-risk pregnancies to try

to see whether they could have these kinds of effects on the difficult outcomes like very low birth weight and low birth weight.

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There are lots more analysis that need to be done with these

data to be able to come up with definitive findings, but the early

findings are very positive. Thank you.

[The prepared statement of Dr. Guyer follows:]

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Mr. SNOWBARGER. Thank you, Dr. Guyer. Mr. Coyle, does that

complete your testimony?

Mr. COYLE. Yes.

Mr. SNOWBARGER. Thank you. With that, I would like to call on

another of our colleagues, Representative Thompson, at this time.

Mr. THOMPSON. Thank you, Mr. Chairman, and other members

of this subcommittee. I am happy to come and introduce someone

to you who is project director for our Delta Futures Healthy Start

Initiative in Mississippi and one of the few rural projects we have

across the country. But my support for this project is 100 percent.

They operate presently in the 2d District of Mississippi, which for

the record is the State with the highest infant-mortality rate. It

ranks No. 1.

And I am honored to introduce Ms. Melanie Williams, the distinguished project director of the Delta Futures Healthy Start Initiative. Ms. Williams has done outstanding work administering this

program in Mississippi and is due much credit for its success. A licensed, master-level social worker of 10 years, she has demonstrated extensive leadership and administrative ability through

the development and implementation of innovative programs dealing primarily with maternal and child-health issues.

I also again want to say that my experience with this project indicates that it is an excellent project, Mr. Chairman, and I hope

from the testimony that you will receive from Ms. Williams and

others here you will see that it is well worth the investment.

And, once again, I would like to thank the committee for allowing

me to introduce Ms. Williams, and I present Ms. Williams to you

at this point.

Mr. SNOWBARGER. Thank you, Representative Thompson. Ms.

Williams.

Ms. WILLIAMS. Mr. Vice Chairman and members of the subcommittee, thank you today for the opportunity to address your organization about Delta Futures, and I bring you greetings from the

Mississippi Delta. Delta Futures was funded in 1994 as one of the

seven special projects added to the Healthy Start Initiative. We

began with an infant mortality rate of 15.5 percent, which was a

3-year average over 1998 to 1990.

The project was formed around two primary goals: one, to reduce

the infant mortality rate by 20 percent; and the second, to establish

community-based groups and organizations that could provide

input and guidance into program planning and implementation.

We attacked the infant mortality rate problem by developing a

number of strategies that we have implemented throughout our

eight-county project area. We have worked to develop programs

that enhance existing clinical services by providing prenatal care

providers to areas where those types of services did not exist. We

worked to reduce risk for pregnant and parenting women by promoting healthy deliveries and enhancing parenting skills.

We have also worked to provide facilitative services that help to

provide better access to prenatal care services by providing transportation and child care for women who are trying to access prenatal care services.

We have provided a great deal of training and education that

helps to raise public awareness. We have developed public service

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announcements, brochures, and videotapes that are made available

to a wide variety of community groups and organizations throughout the project area.

A lot of our efforts have focused on programs that target adolescents and the gateway problem of teen pregnancy. We have worked

to develop efforts that boost self-esteem among young people and

encourage them to delay sexual activity until they are ready for

that responsibility.

Our infant mortality rate has dropped 10.6 percent in 1995,

which was a decline of 30 percent. I am not certain that we can

target Delta Futures with that full responsibility for that decline.

Our project has only been in existence for 2 years, and many of our

programming efforts focus on more long-term outcomes.

The second component that we worked on was the development

of community-based groups and organizations that can help to provide input into program planning and implementation; this has

been the most challenging and rewarding component of our project.

We believe that communities best know how to solve their own

problems, and it is simply our job to help them determine what

their needs might be and to help them craft strategies that they

think will work in their communities.

This has not been without its share of conflict. Sometimes communities tell us things that we do not necessarily want to hear, or

want to implement strategies that we know cannot work or cannot

be done. They may come to the table with their own agenda and

their own ideas that may not necessarily relate to infant mortality

reduction.

We have worked very hard to increase the capacity of our communities and to build infrastructure and to encourage collaboration

among existing groups and organizations. We have been successful

in developing an RFP process that has put over $840,000 back into

local community-based organizations for the development of infant

mortality reduction strategies.

We have worked to provide training in leadership development,

consortium building and maintenance, and conflict resolution to

these local groups and organizations.

The Division of Healthy Start has been very helpful to Delta Futures with implementation of this initiative. Through site visits

and technical assistance during critical periods of our implementation, the Division has demonstrated a commitment to fostering successful achievement of project goals.

It should be noted, however, that while expansion of infant mortality prevention initiatives to new communities is important, it is

equally important to assist currently funded Healthy Start projects

to sustain and continue effective services as well.

Healthy Start should balance use of available funding for both

the maintenance of service levels for current projects and seeding

of new projects. Delta Futures is a unique Healthy Start initiative,

inasmuch as it is only one of three rural projects. Our experience

has been that expectations or objectives oftentimes are somewhat

ambitious for rural communities.

Many systems and organizations that are readily available in

urban areas often do not exist in rural communities. Much of Delta

Futures’ efforts have focused on building infrastructure and

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strengthening communities’ capacities to meet the challenges of

dealing with these complex issues. Because of these challenges, our

progress oftentimes seems slow or fraught with conflict.

We are strengthened, however, by the ever increasing commitment, enthusiasm, and willingness of the communities we serve to

reduce infant mortality, and as a result of our efforts we believe

that not only will we have successfully reduced infant mortality in

the Delta, but we will also improve communities’ ability to address

many other issues that affect the quality of life for its residents.

[The prepared statement of Ms. Williams follows:]

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Mr. SNOWBARGER. Thank you very much, Ms. Williams.

I apologize to the panel. We have been called to the floor for a

vote, so we will take a recess. Until we get back, we would ask

those that want to continue on the panel here, and, Mr. Towns, if

we can get back as quickly as possible so we do not inconvenience

these panelists any more than necessary. We will stand in recess.

[Recess.]

Mr. SNOWBARGER. OK, we are ready to begin again. Mr. Towns.

Mr. TOWNS. Thank you, Mr. Chairman. I want to thank all of the

panel members for coming here today to present your testimony. I

would also like to introduce Dr. Barbara Hatcher, who is the

project director for the District of Columbia Healthy Start Program.

Dr. Hatcher, Representative Eleanor Holmes Norton has asked me

to commend you, on her behalf, for your excellent service.

Ms. HATCHER. Thank you very much. Good morning, Mr. Vice

Chairman and other honorable members of the subcommittee. I am

Dr. Barbara J. Hatcher, project director for the District of Columbia Healthy Start project. I am here today with Carol Coleman, a

resource mother in our project.

I am pleased to have this opportunity to share what we have

learned in the District of Columbia. There are many lessons

learned from our experience with Healthy Start. I would like to

take just a few minutes to summarize three major lessons learned

from this demonstration effort.

From a practical standpoint, we have learned about dealing with

communities and people in communities. We know the importance

of taking the services to the community and getting community

‘‘buy-in.’’ For example, we have hired and trained community residents and provided them with some marketable skills.

This was not an easy or simple task. It is important to note that

some of our staff from Wards 7 and 8 are ex-offenders, former substance abusers, and former welfare recipients. We also have a

cadre of community residents also working on this problem. We

have learned what it takes to prepare those who have never

worked or have not worked in a long time.

Besides new skill development, we know we must help individuals improve their self-esteem, self-worth, and life skills. The hiring and training of community residents is a small but important

economic and community development effort. It is important to the

individual and the total community.

Because of efforts like Healthy Start, Wards 7 and 8 are beginning to change. Given our practical and hands-on experience, we

can assist new communities to design appropriate training programs. This not only has applicability for Healthy Start but for

new welfare reform efforts at the State level.

We have learned about working in communities and addressing

the infant mortality problem holistically. We have clearly learned

that Medicare alone cannot reduce infant mortality. We are helping

to redefine health care to be an inclusive concept viewed within the

community context and on a continuum.

Health care in depressed and low-income communities means

more than prenatal care. It includes what health professionals call

‘‘enabling services,’’ such as social case management, smoking cessation, substance abuse counseling and treatment, and an array of

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preventive and educational services. We can guide new communities as they attempt to redesign their system of care.

While we must continue to validate our data scientifically, we

have also learned more about the association of substance use with

poor pregnancy outcomes. Our infant mortality review and case

management data strongly suggest that substance use is a marker

for poor pregnancy outcome. We believe that data such as this from

Healthy Start can help researchers pose and examine new research

questions.

However, the lack of scientific rigor does not diminish what we

have to share with others. We can help new communities learn efficient and effective techniques for finding substance abusers,

screening for substance use, working with families affected by substance use, and designing a system of care for those very complex

cases.

I would like to take a few minutes to address sustainability. We

are trying to sustain our efforts but must compete with public safety, public works and welfare funding in the District. As the total

dollars decrease in the District and we change to a system of managed care, sustainability is not assured and will, of course, be more

difficult. Infant mortality is on the District’s health policy agenda,

and we hope to be able to influence funding decisions.

In closing, these are only a few of the lessons we have learned.

We hope this is helpful and thank you for the opportunity. I will

be open for questions.

[The prepared statement of Ms. Hatcher follows:]

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Mr. SNOWBARGER. Thank you, Dr. Hatcher.

OK. I am going to call on Juan Molina Crespo, please.

Mr. CRESPO. Good morning, Mr. Chairman, members of the committee. My name is Juan Molina Crespo, and I am the project director of the Greater Cleveland Healthy Family/Healthy Start

Project, which is the Healthy Start Initiative in Cleveland, OH. On

behalf of Michael R. White, mayor of the city of Cleveland, I would

like to thank this committee for the opportunity to provide testimony regarding our project.

Mr. Chairman, with your permission, sir, I did bring a poster

that I would like to put on the easel.

Cleveland is 1 of the 15 original Healthy Start sites. Healthy

Start services have been available in 15 designated neighborhoods

in the city of Cleveland since October 1992, and since that time we

have seen steady progress. We have seen a dramatic drop in infant

deaths among the women who actively participate in the Healthy

Start Project, from a high of 20.2 deaths per 1,000 births in 1993

to 11.3 per 1,000 births in 1995.

In calendar year 1996 alone, 1,852 pregnant women were enrolled in the Cleveland project. Each one of those women then received the help and support they needed to ensure a healthy birth.

The rate of infant deaths for the population of women who live in

the project neighborhoods but who did not enroll in the project rose

from 21.5 in 1993 to 25.7 deaths per 1,000 in 1995.

We know that when we are able to find and enroll pregnant

women, outreach, indeed, works to reduce infant mortality. Overall

stats show that in 1990, the infant death rate in the Project area

was 22.4 deaths per every 1,000 live births. In 1995, that number

was reduced to 20.8.

The impact of the program can also be seen in the decrease in

low birth weights among infants born in the Project area. Low

birth weight is defined as an infant who is born weighing less than

2,500 grams. Low birth weight is often a precursor of severe health

problems for the baby, which can often lead to death.

In 1990, the rate of babies born at this weight in the Project area

was 148 for every 1,000 live births. In 1995, in the Project area,

we have seen that rate drop to 121.3 for every 1,000 live births.

In order to reduce infant mortality and address the problems leading to infant death, it is imperative for a woman to enter prenatal

care early in her pregnancy and to continue that care on a prescribed schedule up to delivery.

In 1991, the percentage of women living in the Project area who

delivered without having any prenatal care at all was 8.9 percent.

By 1995, that figure had been reduced to 3.8 percent. In 1990, 48

percent of women living in the project area who delivered received

an adequate level of prenatal care; that figure was raised to 50.2

by 1995.

Our Project in Cleveland was carefully designed to achieve these

types of results, and began with a focus on four goals, sir. The first,

of course, was the reduction of infant mortality in the city of Cleveland by 50 percent within 5 years.

Second, the Project was to create support for a system-wide collaboration and integration among the social and medical systems

in the community.

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Next, the Project sought to empower the community through

entry-level job opportunities, as well as volunteer leadership development.

Finally, the Project was meant to test and refine new strategies

for addressing infant mortality, and identify those which work and

develop ways to sustain them and their effects.

The Healthy Start Initiative funding launched the creation of a

community-wide consortium to systemically address the problem of

infant deaths. Now well-established after 5 years, the Healthy

Start Consortium is made up of community residents, project participants, medical and social service providers, nonprofit agencies,

community-based organizations, clergy, and educators.

The Consortium has provided an unprecedented opportunity for

citizens and the public and private sectors to work collaboratively

to solve a major public health problem.

Healthy Start Initiative funding in Cleveland has also allowed

for the creation of a research team devoted solely to investigating

the causes of infant death in the city of Cleveland. The results of

this research have revealed that the leading cause of death in our

community is prematurity, followed by Sudden Infant Death Syndrome, birth defects, and infections, such as sexually transmitted

diseases.

Taken together, these factors account for two-thirds of the infant

deaths in Cleveland. Armed with this information, the Consortium

began to focus its energies on the prevention of these specific problems. The focal points of the Consortium’s educational programs

were narrowed to the signs and symptoms of preterm labor, the

prevention of sexually transmitted diseases, and appropriate sleep

positioning for newborns to prevent SIDS.

These programs have been aimed at the general public through

a public information campaign. Outreach workers have also received extensive training on these issues in order to educate project

participants one on one.

As the demonstration phase of the Healthy Start Initiative draws

to a close, we are in a position to analyze the public health lessons

learned. In Cleveland, our success rests largely on the consortium

structure, which has allowed a high level of communication

amongst providers and community to better address the needs.

Also, we have learned that the causes of infant death in our community may most often be traced to high-risk situations in which

a pregnant woman may find herself. You may remember that in

December 1994, there was a discovery of pulmonary hemosiderosis

that was found in Cleveland, and members of the CDC dispatched

a team to be able to do the appropriate investigation of hemosiderosis.

The team that was dispatched by CDC from Atlanta was met by

our outreach workers. They were allowed into the homes where the

cases had been found, so we see that the outreach team which has

been developed in Cleveland has gone beyond the Healthy Start

box, and it has ramifications for other public health initiatives in

the city of Cleveland.

With these lessons in mind, the Greater Cleveland Healthy Family/Healthy Start Consortium’s vision for the future is the provision

of supportive services to the highest risk women in the community:

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those who struggle with chemical dependency, those who reside in

homeless shelters, domestic violence shelters, those who are incarcerated, as well as the teens and the women who have fallen

through the cracks of the health care safety net in our communities.

Therefore, I would respectfully urge this committee to recommend the continued funding of the Healthy Start Initiative at

the community level. Channeling this money through any other

agencies, either State or Federal, would dilute the effects of the

program and halt the real progress being made to reduce infant

deaths.

In Cleveland, we believe the people most qualified to combat the

issues of infant mortality are the people who face those problems

on a daily basis. Thank you.

[The prepared statement of Mr. Crespo follows:]

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Mr. TOWNS [presiding]. Thank you very much. At this point, I

would turn to a gentleman from Cleveland who knows a lot about

Cleveland. In fact, he was the mayor of Cleveland.

Mr. KUCINICH. Thank you very much, Mr. Chairman, members

of the committee. I certainly want to welcome our visitors from

Cleveland and let Mr. Crespo know that I appreciate the work that

you are doing in our city on this program.

In my view, Healthy Start presents possibilities for saving the

next generation and for saving succeeding generations. It is a part

of our responsibility as lawmakers and as policymakers to be sure

that our policies are going to enable babies to grow, to blossom in

a healthy way, and I know this is what this program is about.

And I have a few questions, if I may, with permission of the

Chair, to ask relative to the program in Cleveland, so that perhaps

you can help us understand precisely where those benefits are and

enable us to develop policies that will be consistent with the needs

of the people of not only our community, but others who are affected by this program.

With respect to the data that has been provided to the committee, one document cited Profiles, Attachment No. 1. It says that

Cleveland has seen a reduction of infant mortality among women

enrolled in Healthy Start from 22.4 out of 1,000 births in 1991 to

16.33. And in another document, which is the Health and Human

Services Fiscal Year 1998 Justification, Attachment 3, it says there

has been a reduction in infant mortality from 22.4 to 13.5 per thousand. Still, in another document provided by the city of Cleveland,

as well as cited in your testimony, it says that infant mortality

among women enrolled in the program is now at 11.3 deaths per

1,000 births.

Could you help to establish what is the correct infant mortality

rate per 1,000 births for women enrolled in the Healthy Start Program today?

Mr. CRESPO. Thank you, Congressman, yes. The data that you

referred to earlier is earlier data. The most current data that we

have, as of January 1997, for the women enrolled living in the

project area and enrolled in our Healthy Family/Health Start Program is 11.3 deaths per every 1,000.

Mr. KUCINICH. So, then, it would be fair to say, then, that over

the course of the program the infant mortality rate has actually

been cut in half, from 22.4?

Mr. CRESPO. That is correct, for the women enrolled in the

project——

Mr. KUCINICH. Right. I understand that——

Mr. CRESPO [continuing]. The infant mortality rate has been reduced by approximately 50 percent.

Mr. KUCINICH. Mr. Chairman and members of the committee,

this is, I think, a striking testimony to the effectiveness of a program when you can actually cut infant mortality rates by one half.

There are certain challenges, which, as you know, are out there to

the whole idea of Healthy Start, and some people would say that

the decrease in infant mortality rate could not be directly attributed to Healthy Start. But even though let’s suppose for the sake

of discussion that the decreases in the IMR cannot be directly attributed to Healthy Start, aren’t there intangible benefits which

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are not measurable by the statistics which accrue to the community?

Mr. CRESPO. I think that in terms of the spillover effect that we

have that this project has been able to provide to the community

is one of dignity to a population where historically we have not

been able to do that. When we speak about empowering the community and bringing them to the table to develop the strategies

and help us administer a project that is going to save the babies

in our community, I think that is something that is very valid and

certainly is something that speaks to the future generations, like

you indicated earlier.

So there are a lot of things. In terms of the job training, the

skills development, our outreach workers, for the most cases, this

was their first real job. I mean, they were one step away themselves from being a participant in this project. We have been able

to not only bring them on as indigenous outreach workers, those

folks that are recognized by the community as a leader in that community and to train them, but also in many cases they have moved

on to other jobs.

A good example of that, sir, is the recent flurry of HMO activities

all over this country. We have had our outreach worker army raided, to some degree, by HMOs because they know that the members

that they are trying to reach are, for the most part, the same participants that our outreach workers have access to.

So we have developed a mechanism that is now being used by

at least three HMOs in Cleveland to be able to access those difficult members. And as we all know, if we continue to get them in

prenatal care early, that means higher profit margins for the

HMOs.

Mr. KUCINICH. Mr. Chairman, is there time for a couple of more

questions?

Mr. SNOWBARGER [presiding]. Well, let’s see. Make them short.

Go ahead.

Mr. KUCINICH. OK. According to Lolita McDavid, who I know you

are familiar with at Cleveland Rainbow Babies and Children’s hospital, says that for every $1 spent on prenatal care, we save $3 in

later cost for babies that are born too soon or too small. And

through this program, have you done any studies which estimate

how many dollars have been saved by getting women, particularly

high-risk women into early prenatal care?

Mr. CRESPO. Sir, I have not done that study, but let me try to

respond this way. I have taken a walk through the intensive care,

perinatal unit at Metro Health Hospital, and every baby—those

million-dollar babies that are lying there—and some of them never

get a chance to go home—we feel that those are our babies, and

if we can continue to reduce the number of babies, the number of

million-dollar babies that are in that intensive care unit, then we

think that all the dollars that are spent with respect to Healthy

Start are dollars well spent.

Mr. KUCINICH. Thank you, Mr. Chairman. I want to thank you.

I just would like to conclude by saying this, that Cleveland has this

wonderful facility at Metropolitan General Hospital, where we care

for babies that are born prematurely for a number of reasons, and

this is what he is talking about. There are babies that effectively

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require $1 million in care because they have not received—their

mothers perhaps have not received the kind of care which this program can provide.

So I view life as a seamless web, and these newborn children are

certainly part of that, in the essence of it, and so I am strongly in

favor of this program, and I hope that we will get support from

members of the committee and the Congress to continue. Thank

you very much.

Mr. SNOWBARGER. Thank you. I do not know how many of you

were in the room before Chairman Shays left, but he left us with

a question that probably you can answer better than those on the

first panel. It was his understanding, as this Healthy Start Program was put into place initially, that there were really two hopes

for these programs. One is that they would be very much controlled

locally, and the second is that they would be at some point in time

where they would be self-financed and self-sustaining.

I believe that Dr. Hatcher addressed that, to some extent, in her

testimony, but could the others of you respond to the sustainability

question, please?

Mr. COYLE. Yes. I would like to. We, in Baltimore, never understood that.

Mr. SNOWBARGER. Well, it is important for us to know that.

Mr. COYLE. We understood that that was supposed to be the

strategy. We did not understand how that would ever work. The reverse would be true for us. We would think that the strategy would

be if you took 15 sites and did this kind of intensive intervention,

looking for real models that work, that you would then continue a

few of the best sites and let the rest of the sites go—that is what

our view of what a demonstration project ought to be—so that

those sites that have done this would continue and be able to put

that kind of information and technical assistance and research out

to the rest of the country.

We are working very aggressively to find dollars to sustain our

program, and we hope to do that, but if anybody knows the foundation situation these days and the whole other cutbacks in State

government, as well as the Federal level, where one would think

that you could sustain a program at $7 or $8 million is hard to understand.

We are committed to sustaining our program, but I must say we

never understood the model to start with.

Mr. GUYER. Can I just make a quick response?

Mr. SNOWBARGER. Yes.

Mr. GUYER. I think sustainability is a really tough issue for these

programs. In part it is because I think the level of investment that

it takes to have the good outcomes is much higher than any of us

ever anticipated it would be. This is not the level of investment

that providing early prenatal care takes. It is a level of investment

that accounts for all of the social issues related to these poor outcomes as well.

To the extent that there are savings to these programs, those

savings probably accrue to Medicaid, and you did not have anyone

from HCFA here today in your earlier panel. You might want to

think about using savings that accrue to the Medicaid program to,

in fact, sustain these preventive efforts at the community level.

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Ms. WILLIAMS. Mr. Vice Chairman, I neglected in my opening remarks to introduce our executive director, Mr. Robert Pugh, who

is the executive director for the Mississippi Primary Health Care

Association, which is my organization’s grantee, and I believe he

would like to address your question.

Mr. SNOWBARGER. Mr. Pugh.

Mr. PUGH. Thank you, Mr. Vice Chairman and other members of

the committee. Since I have not had the opportunity to say ‘‘good

morning,’’ I will now say good morning or early afternoon and will

say that I am very delighted to have the opportunity to be here

today and to address you.

The issue of sustainability is one in which the Delta Futures

Project in Mississippi is currently developing a strategy around. As

Ms. Williams indicated during her testimony, we are one of the

seven supplemental projects that were funded; therefore, we are

just in our 3d year of Healthy Start.

The issue of sustainability was not very clear at the beginning;

however, the division of Healthy Start has worked very diligently

with us to help begin the process of looking at sustainability. I can

tell you that that issue is a very difficult one for a rural area and

a very economically depressed area like the Mississippi Delta.

Unfortunately, the Medicaid managed care picture in Mississippi

has not moved along as far as it has in some other States. We do

not have operating HMOs. We had hoped that we would be able

to develop a practical sustainability approach through working

with HMOs that would be developing in Mississippi around Medicaid managed care. Unfortunately, this has not happened.

Currently, however, we are working with our State health department to look at ways in which we can identify a sustaining and

recurring source of revenue through providing case management

services to the Medicaid-eligible population through our Medicaid

Division, and we are very, very excited about the possibility of getting that program under way during this 0–3 year to continue not

all of the efforts we are doing under our Healthy Start Project, but

some of the areas around case management that are very important to us.

So it is going to be very difficult to undertake any real sustainability for a program like we have in Mississippi in the near future

in the short run, but we are hopeful that some success can be

reached and can be started.

Mr. SNOWBARGER. Mr. Crespo, do you care to respond?

Mr. CRESPO. Yes, if I may. Thank you. We looked at components

that we had nurtured, if you would, for the first active 4 years of

the project and saw where we were getting the most bang for our

buck, if you would pardon the pun.

We found that clearly outreach was something that needed to be

sustained. How we did that, we moved our outreach team in terms

of the management of that team from two, very good, sort of traditional medical providers to an organization that is called the

Neighborhood Centers Association, which is an umbrella organization of 22 settlement houses in the community. So now the outreach is being managed by them.

They have been able to successfully enter into two contracts with

HMOs to deliver the outreach services that I spoke of earlier. With

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respect to the school teams, we also had outreach workers called

‘‘specialized outreach workers’’ that work solely in the middle and

high schools.

That was given also to the public school system because, again,

the cultures of the organizations where it was really meant to manage could not really understand, I mean, the needs of the kids effectively. So we gave the administration of that over to the school

system. We are expecting that they will be able to sustain components of that within their own structure.

When we talked about the component of the high-risk teen, we

have a high-risk team that goes into the Justice Center for Incarcerated Women in Cleveland. We have worked out a memorandum

of understanding with the Cuyahoga County Justice Center so that

they can again absorb those kinds of models that we know are effective and working.

Last, I just want to bring up the issue of consortium. As you

know, the Consortium is sort of the whole infrastructure that has

to be maintained, and how do you do that? Well, consortia activity,

the community activity with the settlement houses that are doing

the outreach really validate those kinds of efforts. Those are the

kinds of things that bring together community leadership.

Clearly, everyone that comes to the table is not concerned about

infant mortality, but the problems that come to the table are directed and are involved and do have a causal effect on the babies

that are dying in our community. So everyone comes with some solution, although in their mind they may not know that the solution

that they are providing is, indeed, a solution to help combat infant

mortality.

So those are the ways that we are attempting to sustain the successful components that we have seen in Cleveland.

Mr. SNOWBARGER. Is it fair to say that you are sustaining your

program be delegating your outsourcing?

Mr. CRESPO. I think it is fair to say that in Cleveland we need

to look at existing structures and prove to them that we have a

model, show them that we have a model that has had some results,

and we would like for them to help us sustain those, yes.

Mr. SNOWBARGER. Just a real quick yes/no answer on this, because I heard it a couple of places. Do you feel like you are properly

advised concerning the expectations on sustainability? I have one

yes, one no, obviously. You really kind of mention—— Mr. COYLE. I do not want to be misunderstood. What I was saying is the Federal Government 2 or 3 years ago started asking each

of the sites to get ready for sustainability, so there is no question

that the Federal Government gave the signal. In my mind, they did

what they were supposed to do. What I was saying to you is that

it would seem to me if you develop models that work, if you took

a model in cancer or AIDS and it was working, you would not come

to the point where, OK, it is working; now we are going to put it

out of business.

I said I had trouble with the idea of how to do that. Let me just

make one important point here. Baltimore is committed to raising

significant dollars for sustainability, but what is going to happen

in Baltimore is if we do this, because people believe in the infrastructure that we have, we are going to move away from infant

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mortality because if you are dealing with managed care organizations or foundations or others, a lot of them want you to do something, but it is not infant mortality driven.

So I have explained to the feds earlier that, yeah, we can raise

a lot of sustainability money, but it is not going to help necessarily

reducing infant mortality and low birth weight because the dollars

that we will get will not be targeted for that. So there is a real dilemma here.

Mr. SNOWBARGER. Dr. Hatcher.

Ms. HATCHER. Yes. I would just like to add and supplement what

has been said. I think the Federal Government was very clear with

us regarding the sustainability, but what has happened to us, there

is a changing with health care reform, welfare reform, and all these

changing systems, it is just very hard to begin to look at sustainability. I mean, to actually do it, not to look at it. You can look at

it, you can plan, but you have a lot of people competing for a

shrinking pot.

Mr. SNOWBARGER. Does anybody else care to respond? I apologize.

Mr. CRESPO. Mr. Chair, with my experience, I think that the direction that we received from Washington in terms of sustainability

has been fairly clear.

Mr. SNOWBARGER. Thank you. Mr. Towns.

Mr. TOWNS. Thank you very much, Mr. Chairman. Mr. Chairman, we have been joined by one of our senior, senior, senior Members in Congress, and I am referring to his service. [Laughter.]

An outstanding and highly respected Member, Congressman Lou

Stokes from Cleveland. At this time, Mr. Chairman, I would like

to yield to him.

Mr. STOKES. Thank you very much, Mr. Towns and Mr. Chairman. It is a pleasure to be here, even if I have to withstand these

attacks on me. [Laughter.]

But I want to say for me it is a special pleasure to be here, first,

because this committee has been so instrumental in terms of the

promulgation of this particular legislation. I have had occasion to

come here before the subcommittee and testify, and I really commend you for the interest and concern that you have taken in this

whole matter. I am pleased to see these outstanding panelists who

are here this morning and want to extend a special welcome to Mr.

Juan Crespo, who is our Healthy Start Program director in Cleveland.

The Healthy Start Program is very important to me. As you

know, former Secretary of the Department of Health and Human

Services, Dr. Louis Sullivan was one of the initiators of this legislation. We included it at the time we put forth the Disadvantaged

Minority Health Improvement Act, which I sponsored in the House

and Sen. Kennedy sponsored in the Senate, historic legislation

which Healthy Start became a part of.

I serve on the Appropriations Subcommittee on Labor, Health,

and Human Services, and Education, Mr. Chairman, where last

year we put up an extensive fight to try and save this program. At

that time, it was felt that we had reached the 5-year mark and perhaps we should move on and do other things.

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And we had some pretty tough fights over on our committee trying to get it funded because we realized that we could show on

graphs the kind of progress that has been made in 15 cities around

the country, major cities. We were able to show what was happening in infant mortality prior to the initiation of this legislation

and how the graph would show in a very vivid way how we had

made some inroads on this whole infant mortality problem.

So, I am hoping that we can get this program reauthorized and

funded, and let us continue making the progress that has been

made.

I have a statement which I will submit for the record, and I appreciate the opportunity to be here with you, Mr. Chairman and

Mr. Towns.

[The prepared statement of Hon. Louis Stokes follows:]

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Mr. SNOWBARGER. Thank you, Representative Stokes.

Mr. Towns, do you want to do some questioning?

Mr. TOWNS. Yes. Thank you very much, and let me just say, it

is a pleasure to have you here with us, and we know, in terms of

the work that you have done in the area of health period, and then,

of course, in this particular issue as well, so we are delighted to

have you here.

Let me just move, first of all, to Mr. Coyle and to Dr. Guyer. My

staff had an opportunity to visit your program, and they came back

all excited, and, of course, I must admit, they do not get excited too

often. So evidently you must be doing something very special over

there.

Let me go to the question, though, of why do you think it was

important to include men as part of your Healthy Start Project.

Mr. COYLE. We had a project that preceded Healthy Start, and

that is one of the reasons we were selected, because we had a head

start, something called the Baltimore Project, that had been in

place for 2 years before we started Healthy Start, and so we had

2 years of experience in this business at a much smaller level.

In the first year of Healthy Start, as we were getting to some of

the huge, risk-taking behaviors that our women have in these poor

communities, the realization came to us, which should have come

earlier, that many of these risk-taking behaviors, particularly substance abuse, is directly related to the male partner.

So a lot of their behaviors are affected dramatically by the male

partner they are with, either the father of the child or a significant

other, and we began to believe that if you are going to change risktaking behaviors which are at the heart of reducing infant mortality and low birth weight, you have got to bring the father into

this. And so we created this very special men’s program.

Joe Jones, who is somewhere in the audience, he runs this program. We have had great publicity on this, national publicity on

this men’s program, and what it focuses on is taking the highest

risk men that you all know that are in your communities and insisting that they pay attention to their children.

And so the first focus, when we get these men, is that their first

responsibility is to their children. Once that starts happening, then

we deal with all the other social, economic, and health issues dealing with the men, most of which is around substance abuse, drug

dealing, and those kinds of things. And we have had tremendous

success with getting the men not only to take better care of their

children, but also to really turn their lives around.

But the answer to your question is, we believe you cannot change

the risk-taking behaviors of women if you do not deal with their

male partner simultaneously.

Mr. TOWNS. Thank you very much. Mr. Chairman, what I would

like to do is ask this question, let it go down the line, and that will

be it for me, but I wanted to get a response from all of them on

this issue.

I guess the best way to ask this would be, let’s switch roles, and

thinking in terms of what Congressman Stokes said in terms of the

fights that we have had around here trying to maintain programs

such as this that we know are doing a great job: what should I say

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to my colleagues that do not support these programs in order to

convince them to do so? Arm me. Give me some material.

I tell you what, so I do not miss anybody, why don’t we start

with you, Mr. Crespo, and then we will come right down the line?

Mr. CRESPO. Thank you, Congressman. I think probably the most

relevant thing is that we have seen, in the projects represented

here today among others, have seen that the process objectives are

being met; that is to say that we know that if we enroll them early

in their pregnancy, infant mortality, indeed, is going to be reduced

in that community.

And the spillover effect of that factor alone would have very positive outcomes in terms of the overall makeup of that community in

terms of substance abuse, in terms of school dropout rates, in

terms of other activity that would lend itself to putting together the

community that we need in order for babies to live in it.

So I think that the important thing, sir, is that we need to look

at this project, and we need to get out of the Healthy Start box.

Infant mortality reduction is much more encompassing, and every

facet of society has an impact on it, so the dollars that are spent

here are dollars that are well spent.

Ms. HATCHER. I think that just by reducing low birth rate and

some of the problems that we know occur in our communities, that

costs a lot of money. Not only do you have to spend the $200,000

for a low-birth-rate baby in the neonatal, intensive care unit; that

child is more likely to have other kinds of developmental problems,

so long term, we continue to pay for this.

So in Healthy Start we can reduce the number to have healthier

children from the beginning, I think over the long term there is a

significant reduction in cost. It may cost us $100 or $200—and that

is probably low—I will say $2,000 per case-managed woman, a

woman that we case managed, but if you do not have to spend

$200,000 for that neonatal, intensive care unit, right there you already have some health-care-dollar savings.

I do not think we see it all in the short term; some of it is a

much more long-term effect, and so it is very hard for us to give

the kind of specific data that people may want, but I think we have

to see this as a long-term effect. There are some short-term savings, but there is also the big long-term savings.

Mr. PUGH. Congressman Towns, in response to your question, we

certainly recognize that there are a lot of competing interests and

priorities in this Nation and across the various States and other

communities. The idea of improving pregnancy outcome certainly

can be looked at in a cost-benefit way, just as Dr. Hatcher has

talked about some, but she also made another profound statement

a little bit earlier, when she said it takes more than direct medical

intervention to reduce infant mortality and low birth weight.

The fact of it is, you can judge a nation by how it cares for its

children, and the fact of it is that nothing is more important to our

future in this Nation than raising healthy children and giving

every child that is coming into this country, coming to life, a

healthy start.

And one of the ways that we have known that we have done that

in Mississippi is by increasing community awareness and bringing

the community together around this issue to develop strategies to

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help them solve their own problems in their communities related

to infant mortality, low birth weight, high rates of teenage pregnancy. And we think it is very important that resources be provided to do everything we can in this Nation to raise a healthy, future population for this Nation’s sustainability, and I think that it

is very important that this be given top priority, regardless of the

other competing interests.

And I believe that the Congress can do much in helping to foster

the idea that this is a Nation who cares about its children, that,

indeed, this is a Nation that cares about its future.

Mr. TOWNS. Thank you, Mr. Pugh. Ms. Williams. Oh, you want

to be identified with his statement. Dr. Guyer.

Mr. GUYER. I will just make a brief comment. It is unfortunate

that the timing of the evaluation of this project is not exactly synchronous with the project itself. The experiment is still in the middle, and it would be a shame if what seem to be promising early

results, in fact, are lost because the level of support is not sustained. A few years later we may find out that this was one of the

most successful efforts ever launched by the Federal Government

in this area.

So I would make that argument for sustaining the level of effort

that currently exists.

Mr. TOWNS. Thank you very, very much. Thank all of you for

your testimony and for your comments. You have been extremely

helpful. I yield back to you, Mr. Chairman. I am sorry I went a little over.

Mr. SNOWBARGER. That is fine, Mr. Towns. Let me ask two final

questions. One, Ms. Williams, specifically relates to the Delta Futures Program. In her testimony, Dr. Nora indicated that this

project was one of the problem projects, maybe is the best way to

put it, and I suppose by raising the topic I give you the opportunity

to respond, but really what I was looking for is, are there things

that you have gone through that we can learn how not to do things

perhaps?

Ms. WILLIAMS. I would certainly hope so.

Mr. SNOWBARGER. Do you have any specifics that you can give

us at this point?

Ms. WILLIAMS. I think a lot of the struggles that we have dealt

with deal specifically with rural communities, inasmuch as we are

not always on the same learning curve as urban areas might be,

and we found that people often come—when you have moneys that

are available, everyone is struggling for their share or their piece

of the pie, and conflict is oftentimes just an inherent part of that

process.

And we certainly learned a great deal about how to deal with

and manage conflict and work with those communities and deal

with that, and I think that we have been very successful in that

area.

Mr. SNOWBARGER. One last question, however many of you want

to answer this. I asked the last panel about coordination and cooperation between Federal programs. They were all very self-congratulatory and actually had held a conference together, so obviously they are coordinating their programs.

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Do any of you care to respond to that? Do you find that all of

these child-health-care programs are working in synch and in coordination, or are there problems there?

Mr. CRESPO. Mr. Chairman, I think there is a need for improvement on how that information gets to the community level. That

is not to say, of course, that we are not made aware of certain conferences or funds that are available or initiatives that we may be

able to add our experience to, but at the community level, those decisions are made here; and the way they are brought down sometimes, I think, needs refining. But, overall, I would say, yes, at

least from Cleveland’s perspective, that we are made aware of

those.

Mr. SNOWBARGER. All right. Does anybody else care to respond?

Dr. Hatcher.

Dr. HATCHER. Well, I think they are working together. In the

District of Columbia not only do we have the Healthy Start Project;

we have what is called the National Institutes of Health D.C. Initiative, and that initiative is a research project, but it is looking at

this issue of infant mortality so we can have a better understanding of what is impacting infant mortality and what is unique

about infant mortality here in the District of Columbia.

I think it is particularly important because we are primarily an

African-American community. The disparity in infant mortality is

in our community, and so it provides a unique opportunity for us

to somewhat be a laboratory, even though we do not want to be

studied to death, but a laboratory for what can really work. And

those efforts from NIH are very community based also. We hope

the next level of funding will be more intervention projects that

will kind of support that some of the Healthy Start models were

actually very, very effective, even though we believe our preliminary data says that.

Also, we are very fortunate to have from CDC an epidemiologist

assigned to our office so she can help us look at our data and help

me and other staff have a better understanding of data and to use

that data to really evaluate and design other projects.

Mr. SNOWBARGER. Does anyone else care to respond? Dr. Guyer.

Mr. GUYER. I think Healthy Start has been a somewhat isolated

program since its inception, and I think it would actually benefit

if the Federal agencies all spend some time thinking about what

have they learned from the Healthy Start experience and how the

different kinds of initiatives from the different agencies could interact with each other at the community level.

I think it is hard for community-level people to access all of the

different Federal initiatives. You hear that the District of Columbia

has lots of them. I suspect Mississippi has few of them; so there

is a real unevenness. And I think HCFA also needs to be brought

into that because they have the money, and they are potentially

the ones who will both fund the failures and benefit from the savings.

Mr. SNOWBARGER. Representative Stokes.

Mr. STOKES. Thank you, Mr. Chairman. Once again, let me

thank both you, and your ranking member, Mr. Towns, for inviting

me to participate in this hearing this morning.

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I have two quick questions. As we seek to reauthorize the

Healthy Start Program in its own right and having looked at this

program now for a period of 5 years, in your professional judgment,

are there certain provisions that we ought to put into this legislation to strengthen it? And I hope I am not covering something that

you perhaps have already covered today.

Mr. CRESPO. Congressman, I think that as we look at expanding

this project, the local initiatives, I think, have a lot of experience

and a lot of wherewithal to help shape the future of how infant

mortality reductions projects in this country ought to be run.

I would respectfully recommend, suggest that project directors be

brought in on the discussion when it is about expanding a project

or funding a project, developing new criteria for a project, so that

the Federal Government, the Federal entity charged with it, can

benefit from our experience. And I do not know that that has been

the case. We need to be at the table in terms of offering some direction and some experience.

Mr. STOKES. Last, as directors, do you see any special challenges

facing either Healthy Start Program participants or yourselves as

directors of this program?

Mr. CRESPO. The special challenges, sir, when we—I would like

to answer that by pointing to our young people, and by ‘‘young,’’ I

mean middle school because, for the most part, when we get them

in high school, it is already too late. So we need to start the prevention and the abstinence messages, we need to start them earlier. We need to start them in middle school.

So one of the challenges, sir, is that if this project is not allowed

to continue, we allow—because of it, the Cleveland Public School

System is for the first time beginning to track incidents of sexual

activity and pregnancy in these schools. That has not been available before.

So I would again—that is going to be a big challenge for that

school system and for the Cleveland project to be able to maintain

that kind of information and that kind of data.

Mr. SNOWBARGER. Thank you, Mr. Crespo. Does anyone else have

any comment?

Mr. COYLE. Just two things.

Mr. SNOWBARGER. Sure.

Mr. COYLE. One is—Congressman Towns asked something about

this before—Congressman Stokes—the whole title of paternal child

health in some way needs to be relooked at and redefined. Unless

we can bring, especially in major cities, the African-American male

into this process in a real way, we are going to make very little

progress. And as long as we look at this—and I understand all the

history of maternal and child health, but we have excluded AfricanAmerican males from the whole family process. The welfare system

has done that. A whole range of things have done that.

Until they are active participants in whatever Healthy Start and

whatever other similar projects happen in the United States, we

are not going to make a lot of progress.

Also, I just wanted to say that we did not have the opportunity

at the beginning, but several of our participants, clients in Healthy

Start, who are the heart of the matter, took the time to come down

here today to see what a hearing was like because they are interVerDate 11-MAY-2000 10:16 Jun 13, 2002 Jkt 010199 PO 00000 Frm 00207 Fmt 6633 Sfmt 6602 W:\DISC\40482 pfrm01 PsN: 40482
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ested in that. I would like for them to stand up so that you know

that they came and they wanted to see what this is all about. And

they are the people that make our program work.

[Applause.]

Mr. STOKES. Thank you very much. It is nice to see all of them

attending a hearing of this sort. I am sure it is edifying for them

and a comfort for them to listen to all of the experts testify on

something that is so near and dear to them.

Mr. Chairman, I think you have been very generous—— Mr. SNOWBARGER. Dr. Hatcher, did you care to respond?

Ms. HATCHER. I will just briefly say that I think that we are

going on the right track with trying to strengthen Healthy Start.

If we use the lessons that all of us have learned with 22 projects

and we cannot only tell the next projects, but their communities

need to understand, this is, you know, kind of the background of

infant mortality, so they do not have to start from the beginning.

We can give them some information, and they can go from that

point forward.

Mr. SNOWBARGER. Thank you. I, too, want to thank all the witnesses for their appearance. Mr. Crespo, it was pointed out to me

that you are at the table, but perhaps the table is a little too small

and the time too short to get into all the detail that we need to.

There being no further business before the committee, the subcommittee is adjourned. Thank you again.

[Whereupon, at 12:55 p.m., the subcommittee was adjourned.]

Æ