[House Hearing, 105 Congress]
[From the U.S. Government Publishing Office]



 
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





                     U.S. GOVERNMENT PRINTING OFFICE
40-482                       WASHINGTON : 1997
________________________________________________________________________
For Sale by the Superintendent of Documents, U.S. Government Printing Office
Internet: bookstore.gpo.gov  Phone: toll free (866) 512-1800; (202) 512-1800  
Fax: (202) 512-2250 Mail: Stop SSOP, Washington, DC 20402-0001





              COMMITTEE ON GOVERNMENT REFORM AND OVERSIGHT

                     DAN BURTON, Indiana, Chairman
BENJAMIN A. GILMAN, New York         HENRY A. WAXMAN, California
J. DENNIS HASTERT, Illinois          TOM LANTOS, California
CONSTANCE A. MORELLA, Maryland       ROBERT E. WISE, Jr., West Virginia
CHRISTOPHER SHAYS, Connecticut       MAJOR R. OWENS, New York
STEVEN H. SCHIFF, New Mexico         EDOLPHUS TOWNS, New York
CHRISTOPHER COX, California          PAUL E. KANJORSKI, Pennsylvania
ILEANA ROS-LEHTINEN, Florida         GARY A. CONDIT, California
JOHN M. McHUGH, New York             CAROLYN B. MALONEY, New York
STEPHEN HORN, California             THOMAS M. BARRETT, Wisconsin
JOHN L. MICA, Florida                ELEANOR HOLMES NORTON, Washington, 
THOMAS M. DAVIS, Virginia                DC
DAVID M. McINTOSH, Indiana           CHAKA FATTAH, Pennsylvania
MARK E. SOUDER, Indiana              TIM HOLDEN, Pennsylvania
JOE SCARBOROUGH, Florida             ELIJAH E. CUMMINGS, Maryland
JOHN SHADEGG, Arizona                DENNIS KUCINICH, Ohio
STEVEN C. LaTOURETTE, Ohio           ROD R. BLAGOJEVICH, Illinois
MARSHALL ``MARK'' SANFORD, South     DANNY K. DAVIS, Illinois
    Carolina                         JOHN F. TIERNEY, Massachusetts
JOHN E. SUNUNU, New Hampshire        JIM TURNER, Texas
PETE SESSIONS, Texas                 THOMAS H. ALLEN, Maine
MIKE PAPPAS, New Jersey                          ------
VINCE SNOWBARGER, Kansas             BERNARD SANDERS, Vermont 
BOB BARR, Georgia                        (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             EDOLPHUS TOWNS, New York
BENJAMIN A. GILMAN, New York         DENNIS KUCINICH, Ohio
DAVID M. McINTOSH, Indiana           THOMAS H. ALLEN, Maine
MARK E. SOUDER, Indiana              TOM LANTOS, California
MIKE PAPPAS, New Jersey              BERNARD SANDERS, Vermont (Ind.)
STEVEN SCHIFF, New Mexico            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








                            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
    Williams, Melanie, project director, Mississippi Delta 
      Futures Healthy Start, prepared statement of...............   125








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 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 under-served 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.
    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.
    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 African-
American 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:]
    [GRAPHIC] [TIFF OMITTED] T0482.001
    
    [GRAPHIC] [TIFF OMITTED] T0482.002
    
    [GRAPHIC] [TIFF OMITTED] T0482.003
    
    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:]
    [GRAPHIC] [TIFF OMITTED] T0482.004
    
    [GRAPHIC] [TIFF OMITTED] T0482.005
    
    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.

  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 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.
    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 community-based 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, post-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?
    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:]
    [GRAPHIC] [TIFF OMITTED] T0482.006
    
    [GRAPHIC] [TIFF OMITTED] T0482.007
    
    [GRAPHIC] [TIFF OMITTED] T0482.008
    
    [GRAPHIC] [TIFF OMITTED] T0482.009
    
    [GRAPHIC] [TIFF OMITTED] T0482.010
    
    [GRAPHIC] [TIFF OMITTED] T0482.011
    
    [GRAPHIC] [TIFF OMITTED] T0482.012
    
    [GRAPHIC] [TIFF OMITTED] T0482.013
    
    [GRAPHIC] [TIFF OMITTED] T0482.014
    
    [GRAPHIC] [TIFF OMITTED] T0482.015
    
    [GRAPHIC] [TIFF OMITTED] T0482.016
    
    [GRAPHIC] [TIFF OMITTED] T0482.017
    
    [GRAPHIC] [TIFF OMITTED] T0482.018
    
    [GRAPHIC] [TIFF OMITTED] T0482.019
    
    [GRAPHIC] [TIFF OMITTED] T0482.020
    
    [GRAPHIC] [TIFF OMITTED] T0482.021
    
    [GRAPHIC] [TIFF OMITTED] T0482.022
    
    [GRAPHIC] [TIFF OMITTED] T0482.023
    
    [GRAPHIC] [TIFF OMITTED] T0482.024
    
    [GRAPHIC] [TIFF OMITTED] T0482.025
    
    [GRAPHIC] [TIFF OMITTED] T0482.026
    
    [GRAPHIC] [TIFF OMITTED] T0482.027
    
    [GRAPHIC] [TIFF OMITTED] T0482.028
    
    [GRAPHIC] [TIFF OMITTED] T0482.029
    
    [GRAPHIC] [TIFF OMITTED] T0482.030
    
    [GRAPHIC] [TIFF OMITTED] T0482.031
    
    [GRAPHIC] [TIFF OMITTED] T0482.032
    
    [GRAPHIC] [TIFF OMITTED] T0482.033
    
    [GRAPHIC] [TIFF OMITTED] T0482.034
    
    [GRAPHIC] [TIFF OMITTED] T0482.035
    
    [GRAPHIC] [TIFF OMITTED] T0482.036
    
    [GRAPHIC] [TIFF OMITTED] T0482.037
    
    [GRAPHIC] [TIFF OMITTED] T0482.038
    
    [GRAPHIC] [TIFF OMITTED] T0482.039
    
    [GRAPHIC] [TIFF OMITTED] T0482.040
    
    [GRAPHIC] [TIFF OMITTED] T0482.041
    
    [GRAPHIC] [TIFF OMITTED] T0482.042
    
    [GRAPHIC] [TIFF OMITTED] T0482.043
    
    [GRAPHIC] [TIFF OMITTED] T0482.044
    
    [GRAPHIC] [TIFF OMITTED] T0482.045
    
    [GRAPHIC] [TIFF OMITTED] T0482.046
    
    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.
    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 pre-term 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 high-risk women into care earlier. This evaluation 
influenced the State to continue to provide case management 
services when it was an area under review.
    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:]
    [GRAPHIC] [TIFF OMITTED] T0482.047
    
    [GRAPHIC] [TIFF OMITTED] T0482.048
    
    [GRAPHIC] [TIFF OMITTED] T0482.049
    
    [GRAPHIC] [TIFF OMITTED] T0482.050
    
    [GRAPHIC] [TIFF OMITTED] T0482.051
    
    [GRAPHIC] [TIFF OMITTED] T0482.052
    
    [GRAPHIC] [TIFF OMITTED] T0482.053
    
    [GRAPHIC] [TIFF OMITTED] T0482.054
    
    [GRAPHIC] [TIFF OMITTED] T0482.055
    
    [GRAPHIC] [TIFF OMITTED] T0482.056
    
    [GRAPHIC] [TIFF OMITTED] T0482.057
    
    [GRAPHIC] [TIFF OMITTED] T0482.058
    
    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 high-risk 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.
    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.
    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:]
    [GRAPHIC] [TIFF OMITTED] T0482.059
    
    [GRAPHIC] [TIFF OMITTED] T0482.060
    
    [GRAPHIC] [TIFF OMITTED] T0482.061
    
    [GRAPHIC] [TIFF OMITTED] T0482.062
    
    [GRAPHIC] [TIFF OMITTED] T0482.063
    
    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 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.
    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:]
    [GRAPHIC] [TIFF OMITTED] T0482.064
    
    [GRAPHIC] [TIFF OMITTED] T0482.065
    
    [GRAPHIC] [TIFF OMITTED] T0482.066
    
    [GRAPHIC] [TIFF OMITTED] T0482.067
    
    [GRAPHIC] [TIFF OMITTED] T0482.068
    
    [GRAPHIC] [TIFF OMITTED] T0482.069
    
    [GRAPHIC] [TIFF OMITTED] T0482.070
    
    [GRAPHIC] [TIFF OMITTED] T0482.071
    
    [GRAPHIC] [TIFF OMITTED] T0482.072
    
    [GRAPHIC] [TIFF OMITTED] T0482.073
    
    [GRAPHIC] [TIFF OMITTED] T0482.074
    
    [GRAPHIC] [TIFF OMITTED] T0482.075
    
    [GRAPHIC] [TIFF OMITTED] T0482.076
    
    [GRAPHIC] [TIFF OMITTED] T0482.077
    
    [GRAPHIC] [TIFF OMITTED] T0482.078
    
    [GRAPHIC] [TIFF OMITTED] T0482.079
    
    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 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 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 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 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.
    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 high-risk 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.

 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:]
    [GRAPHIC] [TIFF OMITTED] T0482.080
    
    [GRAPHIC] [TIFF OMITTED] T0482.081
    
    [GRAPHIC] [TIFF OMITTED] T0482.082
    
    [GRAPHIC] [TIFF OMITTED] T0482.083
    
    [GRAPHIC] [TIFF OMITTED] T0482.084
    
    [GRAPHIC] [TIFF OMITTED] T0482.085
    
    [GRAPHIC] [TIFF OMITTED] T0482.086
    
    [GRAPHIC] [TIFF OMITTED] T0482.087
    
    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.
    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:]
    [GRAPHIC] [TIFF OMITTED] T0482.088
    
    [GRAPHIC] [TIFF OMITTED] T0482.089
    
    [GRAPHIC] [TIFF OMITTED] T0482.090
    
    [GRAPHIC] [TIFF OMITTED] T0482.091
    
    [GRAPHIC] [TIFF OMITTED] T0482.092
    
    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 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 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:]
    [GRAPHIC] [TIFF OMITTED] T0482.093
    
    [GRAPHIC] [TIFF OMITTED] T0482.094
    
    [GRAPHIC] [TIFF OMITTED] T0482.095
    
    [GRAPHIC] [TIFF OMITTED] T0482.096
    
    [GRAPHIC] [TIFF OMITTED] T0482.097
    
    [GRAPHIC] [TIFF OMITTED] T0482.098
    
    [GRAPHIC] [TIFF OMITTED] T0482.099
    
    [GRAPHIC] [TIFF OMITTED] T0482.100
    
    [GRAPHIC] [TIFF OMITTED] T0482.101
    
    [GRAPHIC] [TIFF OMITTED] T0482.102
    
    [GRAPHIC] [TIFF OMITTED] T0482.103
    
    [GRAPHIC] [TIFF OMITTED] T0482.104
    
    [GRAPHIC] [TIFF OMITTED] T0482.105
    
    [GRAPHIC] [TIFF OMITTED] T0482.106
    
    [GRAPHIC] [TIFF OMITTED] T0482.107
    
    [GRAPHIC] [TIFF OMITTED] T0482.108
    
    [GRAPHIC] [TIFF OMITTED] T0482.151
    
    [GRAPHIC] [TIFF OMITTED] T0482.109
    
    [GRAPHIC] [TIFF OMITTED] T0482.110
    
    [GRAPHIC] [TIFF OMITTED] T0482.111
    
    [GRAPHIC] [TIFF OMITTED] T0482.112
    
    [GRAPHIC] [TIFF OMITTED] T0482.113
    
    [GRAPHIC] [TIFF OMITTED] T0482.114
    
    [GRAPHIC] [TIFF OMITTED] T0482.115
    
    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 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:]
    [GRAPHIC] [TIFF OMITTED] T0482.116
    
    [GRAPHIC] [TIFF OMITTED] T0482.117
    
    [GRAPHIC] [TIFF OMITTED] T0482.118
    
    [GRAPHIC] [TIFF OMITTED] T0482.119
    
    [GRAPHIC] [TIFF OMITTED] T0482.120
    
    [GRAPHIC] [TIFF OMITTED] T0482.121
    
    [GRAPHIC] [TIFF OMITTED] T0482.122
    
    [GRAPHIC] [TIFF OMITTED] T0482.123
    
    [GRAPHIC] [TIFF OMITTED] T0482.124
    
    [GRAPHIC] [TIFF OMITTED] T0482.125
    
    [GRAPHIC] [TIFF OMITTED] T0482.126
    
    [GRAPHIC] [TIFF OMITTED] T0482.127
    
    [GRAPHIC] [TIFF OMITTED] T0482.128
    
    [GRAPHIC] [TIFF OMITTED] T0482.129
    
    [GRAPHIC] [TIFF OMITTED] T0482.130
    
    [GRAPHIC] [TIFF OMITTED] T0482.131
    
    [GRAPHIC] [TIFF OMITTED] T0482.132
    
    [GRAPHIC] [TIFF OMITTED] T0482.133
    
    [GRAPHIC] [TIFF OMITTED] T0482.152
    
    [GRAPHIC] [TIFF OMITTED] T0482.134
    
    [GRAPHIC] [TIFF OMITTED] T0482.153
    
    [GRAPHIC] [TIFF OMITTED] T0482.135
    
    [GRAPHIC] [TIFF OMITTED] T0482.154
    
    [GRAPHIC] [TIFF OMITTED] T0482.136
    
    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.
    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: 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:]
    [GRAPHIC] [TIFF OMITTED] T0482.137
    
    [GRAPHIC] [TIFF OMITTED] T0482.138
    
    [GRAPHIC] [TIFF OMITTED] T0482.139
    
    [GRAPHIC] [TIFF OMITTED] T0482.140
    
    [GRAPHIC] [TIFF OMITTED] T0482.141
    
    [GRAPHIC] [TIFF OMITTED] T0482.142
    
    [GRAPHIC] [TIFF OMITTED] T0482.143
    
    [GRAPHIC] [TIFF OMITTED] T0482.144
    
    [GRAPHIC] [TIFF OMITTED] T0482.145
    
    [GRAPHIC] [TIFF OMITTED] T0482.146
    
    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 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 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.
    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 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 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.
    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:]
    [GRAPHIC] [TIFF OMITTED] T0482.147
    
    [GRAPHIC] [TIFF OMITTED] T0482.148
    
    [GRAPHIC] [TIFF OMITTED] T0482.149
    
    [GRAPHIC] [TIFF OMITTED] T0482.150
    
    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 risk-taking 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 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 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.
    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.
    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 African-American 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 interested 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.]

                                   - 
