Public Health Services: Agencies Use Different Approaches to Protect
Public Against Disease and Injury (Briefing Report, 04/29/94,
GAO/HEHS-94-85BR).

The Public Health Service (PHS) conducts or supports national programs
of health services delivery, disease prevention, health promotion, and
biomedical research through eight PHS agencies. Because agencies'
programs often address the same diseases or conditions, the potential
exists for duplication of effort. Congressional concerns have also been
raised about the expansion of funding for the Centers for Disease
Control and Prevention (CDC), which rose from $587 million to about $1.5
billion between fiscal years 1987 and 1992.  Concerns have likewise been
raised that the scope of CDC's programs and activities today extends
well beyond the agency's early focus on communicable disease.  GAO found
that no PHS agency was duplicating another agency's public health
activities in the programs GAO reviewed.  Also, CDC's programs were
appropriate considering the agency's legislative authority and its
history of prevention and control efforts regarding chronic diseases and
other health conditions.  Public health experts GAO consulted support
CDC's activities.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  HEHS-94-85BR
     TITLE:  Public Health Services: Agencies Use Different Approaches 
             to Protect Public Against Disease and Injury
      DATE:  04/29/94
   SUBJECT:  Disease detection or diagnosis
             Agency missions
             Interagency relations
             Federal/state relations
             Health care programs
             Health care services
             Diseases
             Cancer research
             Public health legislation
IDENTIFIER:  CDC Project DIRECT
             Maternal and Child Health Block Grant
             National Diabetes Information Clearinghouse
             NCI Surveillance, Epidemiology, and End Results Program
             CDC Rocky Mountain Tobacco-Free Challenge Program
             
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Cover
================================================================ COVER


Briefing Report to Congressional Committees

April 1994

PUBLIC HEALTH SERVICES - AGENCIES
USE DIFFERENT APPROACHES TO
PROTECT PUBLIC AGAINST DISEASE AND
INJURY

GAO/HEHS-94-85BR

Public Health Service Agencies


Abbreviations
=============================================================== ABBREV

  ADAMHA - Alcohol, Drug Abuse, and Mental Health Administration
  AHCPR - Agency for Health Care Policy and Research
  ASSIST - American Stop Smoking Intervention Study
  ATSDR - Agency for Toxic Substances and Disease Registry
  CDC - Centers for Disease Control and Prevention
  DIRECT - Diabetes Intervention:  Reaching and Educating Communities
     Together
  EMF - electromagnetic field
  FDA - Food and Drug Administration
  HHS - Department of Health and Human Services
  HRSA - Health Resources and Services Administration
  IAP - Immunization Action Plans
  IHS - Indian Health Service
  NCI - National Cancer Institute
  NIAAA - National Institute on Alcohol Abuse and Alcoholism
  NIDA - National Institute on Drug Abuse
  NIEHS - National Institute of Environmental Health Sciences
  NIH - National Institutes of Health
  NIMH - National Institute of Mental Health
  NIOSH - National Institute for Occupational Safety and Health
  NVPO - National Vaccine Program Office
  PHS - Public Health Service
  SAMHSA - Substance Abuse and Mental Health Services Administration
  SEER - Surveillance, Epidemiology, and End Results Program

Letter
=============================================================== LETTER


B-251677

April 29, 1994

Congressional Committees

The Public Health Service (PHS) conducts or supports national
programs of health services delivery, disease prevention, health
promotion, and biomedical research through eight PHS agencies.\1
Because agencies' programs often address the same diseases or
conditions, the potential exists for the agencies to duplicate each
other's activities.  In an era of budget constraints and competing
fiscal priorities, the Senate and House Committees on Appropriations
want to ensure that they do not fund duplicate programs and
activities. 

Furthermore, the House Committee on Appropriations was concerned
about the expansion of funding for the Centers for Disease Control
and Prevention (CDC) in recent years.  In 5 years, from fiscal years
1987 to 1992, CDC's appropriations rose from $587 million to about
$1.5 billion.  The Committee also was concerned about the broadened
scope of CDC's programs and activities that has extended the agency
beyond its early focus on communicable disease.  CDC evolved from an
office established in the 1940s to control the spread of malaria
during World War II to an agency whose mission is to prevent and
control disease (including chronic disease), injury, and disability
for all Americans. 

This briefing report responds to your directive\2 that we evaluate
the (1) possible duplication of program activities among the PHS
agencies\3 and (2) appropriateness of CDC's programs, particularly
those involving chronic diseases, intentional injury,\4 and the
funding of health services, such as cancer screening.\5 We briefed
your staffs on the results of our review. 

In summary, no PHS agency was duplicating another PHS agency's public
health activities in the program areas that we reviewed.  Also, CDC's
programs were appropriate considering the agency's legislative
authority and its history of prevention and control activities in
chronic diseases and other health conditions.  Public health experts
we consulted support CDC's activities. 


--------------------
\1 The PHS agencies are the National Institutes of Health (NIH),
Centers for Disease Control and Prevention (CDC), Substance Abuse and
Mental Health Services Administration (SAMHSA), Health Resources and
Services Administration (HRSA), Agency for Toxic Substances and
Disease Registry (ATSDR), Indian Health Service (IHS), Food and Drug
Administration (FDA), and Agency for Health Care Policy and Research
(AHCPR). 

\2 Committee on Appropriations, U.S.  Senate (Senate Report 102-397,
Sept.  10, 1992), p.  72, and Committee on Appropriations, U.S. 
House of Representatives (House Report 102-708, July 23, 1992),
p.  53. 

\3 "Activities" refers to public health functions as described by the
Institute of Medicine's Committee for the Study of the Future of
Public Health in its report, The Future of Public Health.  These
include surveillance, which is the collection of data about a
population's health status; epidemiology, which is the study of the
natural history of disease in a population and the factors that
determine its spread; applied research; financial and technical
assistance; resource development; demonstration projects in
communities; health education; and evaluation and assessment. 

\4 Intentional injuries are those resulting from violence-related
acts, such as assaults and homicide. 

\5 We provided information to you on the appropriateness of CDC's
programs and preliminary results of our work on duplication among PHS
agencies (GAO/HRD-93-32R, Aug.  30, 1993). 


   BACKGROUND
------------------------------------------------------------ Letter :1

Many PHS agencies have mandates to address the same public health
issues, such as cancer, diabetes, environmental health,\6 and
immunization.  However, in addressing these health problems, these
agencies have different orientations.  CDC is the main epidemiologic
and health assessment unit for the nation and provides financial and
technical assistance to states and localities, which implement
interventions to prevent and control disease, injury, and disability. 
NIH, which is the leading biomedical research arm of the government,
sponsors research projects across the nation.  HRSA is primarily
concerned with developing health resources and manpower and providing
services to low-income populations and others at risk.  SAMHSA
concentrates on developing programs to prevent and treat alcohol and
substance abuse and to address mental health issues.  HRSA and SAMHSA
establish and support health services for their target populations
through grants and contracts to state and local government agencies
and private health care institutions. 


--------------------
\6 Environmental health includes the toxic and ecological effects of
natural and synthetic chemicals, radiation, and occupation-related
diseases and injuries. 


   SCOPE AND METHODOLOGY
------------------------------------------------------------ Letter :2

In our analyses to determine whether there was duplication among PHS
agencies, we examined the following program elements:  the public
health activities being conducted, their purpose(s), and the
activities' target populations.  To be considered a duplicate program
activity, all three elements had to be the same in two or more
agencies.  If the activity or purpose was the same, or similar, we
considered the programs potentially duplicative, warranting further
analysis.  In analyzing further, we examined other related factors,
such as the activity's goals, time frames, emphases, and distribution
channels (for example, different geographic areas, or community
health centers versus state public health departments).  As agreed
with both the Senate and House Committees on Appropriations' staffs,
we limited our review to program areas with budgets of $1 million or
more. 

The six program areas we reviewed were diabetes, breast and cervical
cancer, immunization, intentional injury, tobacco control (that is,
activities on smoking prevention and cessation and on the use of
smokeless tobacco), and environmental health.  We chose these areas
on the basis of discussions with your staffs and agency officials and
our review of information describing these programs as high-priority
areas that are addressed by more than one PHS agency. 

Our criteria for assessing the appropriateness of CDC's activities
were whether CDC had the (1) legislative authority, (2) historical
role,\7 and (3) organizational capabilities\8 to conduct these
activities.  As the House Committee's staff requested, we interviewed
experts in public health to obtain their opinions on the
appropriateness of CDC programs and activities, considering the
agency's mission.  The 16 experts included commissioners of state
health departments, deans of leading schools of public health, and
directors of health associations. 

In determining whether any duplication of activities existed among
the PHS agencies and in evaluating the appropriateness of CDC's
programs, we visited CDC, NIH, HRSA, and SAMHSA and had extensive
meetings with officials in the program areas that we reviewed.\9 We
also reviewed studies, reports, program plans, and other
documentation on these program areas as well as mission statements
and legislative histories of the agencies and several of their
programs. 

We conducted our work from January to December 1993 in accordance
with generally accepted government auditing standards. 


--------------------
\7 Given the concern about CDC's widened scope of activities, we
agreed with the House Committee on Appropriations to examine
historical precedents for programs within CDC's broad legislative
authority. 

\8 We use the term "organizational capabilities" or capacity to mean
an agency's human resources and established relationships with other
organizations. 

\9 As agreed with the Senate and House Committees on Appropriations,
we did not examine programs at IHS, FDA, AHCPR, and ATSDR. 


   FINDINGS
------------------------------------------------------------ Letter :3

Even though many PHS agencies address the same disease or condition,
we did not find duplicative efforts in the six program areas that we
reviewed--diabetes, breast and cervical cancer, immunization,
intentional injury, tobacco control, and environmental health.  In
each program area, either the public health activities that the
agencies conducted or supported were different or the purpose or
target of the activities was different.  In many cases, the
difference in activities was clear, such as surveillance versus
research. 

In some cases, agencies conducted or supported similar activities,
but they were not duplicative because either the purpose or the
target of the activity was different.  For example, CDC, NIH, and
HRSA provide health education in diabetes.  CDC develops educational
materials and training courses that translate research into public
health practice for practitioners and other community leaders.  NIH
funds diabetes research and training centers.  These centers have
educational and demonstration components with programs to educate
diabetes patients on the use of new and improved methods for managing
diabetes.  On the other hand, HRSA funds the education and training
of health personnel in its effort to guide the development of health
resources.  Overall, no two agencies were conducting the same
activities for the same purpose and target population.  (See sec. 
1.)

CDC's activities in chronic diseases, intentional injury, and funding
of services, such as cancer screening, are appropriate in light of
its mission to prevent and control disease, injury, and disability. 
CDC's legislative authority, its historical roles in preventing and
controlling diseases and other conditions, and its established
relationship with states support the agency's activities.  CDC has
the legislative authority to conduct or support public health
activities in diabetes, breast and cervical cancer, and intentional
injury.  CDC also has a history of involvement in programs to prevent
and control chronic diseases and intentional injury, typically
through funding to state health departments for programs and services
for the public.  CDC's relationship with state public health
departments is important in its work because states are the main
vehicles for carrying public health programs to the American people. 
Most public health experts we interviewed support CDC's activities to
prevent and control chronic diseases and violence-related injury as
part of the agency's mission to protect the health of the American
public.  (See sec.  2.)


   AGENCY COMMENTS
------------------------------------------------------------ Letter :4

In commenting on a draft of this report, PHS agreed with our findings
and offered several technical comments.  We made the technical
changes as appropriate. 


---------------------------------------------------------- Letter :4.1

We are sending copies of this briefing report to the Secretary of
Health and Human Services; the Assistant Secretary for Health; the
Director, CDC; the Director, NIH; the Administrator, HRSA; the
Administrator, SAMHSA; and other interested parties.  We will make
copies available to others on request. 

Please contact me at (202) 512-7119 if you or your staff have any
questions.  Other major contributors are listed in appendix I. 

Mark V.  Nadel
Associate Director, National and
 Public Health Issues

List of Congressional Committees

The Honorable Thomas Harkin
Chairman, Subcommittee on Labor,
 Health and Human Services,
 Education, and Related Agencies
Committee on Appropriations
United States Senate

The Honorable Arlen Specter
Ranking Minority Member
Subcommittee on Labor,
 Health and Human Services,
 Education, and Related Agencies
Committee on Appropriations
United States Senate

The Honorable
Chairman, Subcommittee on Labor,
 Health and Human Services,
 Education, and Related Agencies
Committee on Appropriations
House of Representatives

The Honorable John Edward Porter
Ranking Minority Member
Subcommittee on Labor,
 Health and Human Services,
 Education, and Related Agencies
Committee on Appropriations
House of Representatives


NO DUPLICATION OF EFFORT FOUND
AMONG PHS AGENCIES SUPPORTING
PUBLIC HEALTH ACTIVITIES IN SIX
PROGRAM AREAS
============================================================ Chapter 1

We found no duplicative efforts in the program activities of the PHS
agencies that we reviewed.  In addressing the same disease or
condition, some PHS agencies conduct or support similar activities,
such as providing health education or financial assistance.  However,
in six program areas, none of the agencies conducted the same
activity directed to the same target population for the same purpose. 

We analyzed the activities of four agencies--CDC, NIH, HRSA, and
SAMHSA--that support public health activities in at least one of
these program areas:  diabetes, breast and cervical cancer,
immunization, intentional injury, tobacco control, and environmental
and occupational health.  Each agency has primary functions--such as
conducting basic research or addressing substance abuse in specific
populations--that distinguish them from the other agencies.  These
different functions, for the most part, guide the focus of their
work. 

Because some agencies have responsibilities for the same health
program areas and conduct similar activities,\1 many formal
coordinating channels exist.  Agency officials said that both formal
and informal coordination and collaboration generally help deter
duplication. 

This section reports on the major activities that the agencies we
reviewed support or conduct in six program areas. 


--------------------
\1 The fact that PHS agencies support programs in the same health
area is not new or unexpected.  The Healthy People 2000 report
establishes 300 objectives developed to help meet broad public health
goals for the 1990s.  PHS coordinated the development of a set of
national public health objectives on health promotion and disease
prevention.  The report outlines activities in each PHS program area,
such as diabetes, cancer, tobacco control, and intentional injury,
that one or more PHS agency conducts or supports.  The report also
identifies the PHS agency that has lead responsibility for
coordination in each program area. 


   DIABETES PREVENTION AND CONTROL
---------------------------------------------------------- Chapter 1:1

Except for health education, all the diabetes prevention and control
program activities are different at CDC, NIH, and HRSA--the three
agencies we reviewed that address diabetes.  Even though all of these
agencies conduct or support health education on diabetes, this
activity is not duplicative because the agencies each have different
target populations and purposes in their health education efforts. 


      DISTINCT ACTIVITIES
-------------------------------------------------------- Chapter 1:1.1

  CDC is the lead federal agency for translating diabetes research
     into public health practice.  CDC is developing and refining
     surveillance data at the national and state levels as well as
     conducting epidemiologic studies to determine the extent of
     diabetes in the United States.  The agency provides financial
     and technical assistance to state public health departments for
     Diabetes Control Programs.  The goal of these programs is to
     prevent and control the complications of diabetes, for example,
     by encouraging diabetes patients to obtain eye examinations to
     prevent diabetic blindness and by ensuring that the
     reimbursement system covers health education for diabetic
     patients.  CDC also supports demonstration projects in states
     and communities.  Project DIRECT,\2 for example, is a multiyear
     project testing research findings in practice.  Its goal is to
     demonstrate the effectiveness of community-based public health
     approaches in reducing the burden, risk factors, and
     complications of diabetes, with particular emphasis on minority
     populations. 

  NIH primarily conducts or supports basic and clinical research on
     diabetes to establish the causes and consequences of diabetes. 
     Much of NIH's diabetes research is extramural and is conducted
     at universities, medical schools, and diabetes centers at major
     research institutions.  Research examples include NIH's 10-year
     Diabetes Control and Complications Trial and studies on genetic,
     immunological, and environmental factors in diabetes. 

  HRSA funds primary and supplemental health care services for
     disadvantaged and underserved populations who have limited
     access to health care, such as migrant workers.  These services
     are delivered under the Maternal and Child Health Service Block
     Grants and through about 550 Community and Migrant Health
     Centers nationwide.  Many individuals with diabetes,
     particularly in medically underserved and rural areas, are
     provided services through these centers.  Services can include
     diabetes screening, rehabilitation, treatment, and follow-up,
     among other health care interventions, as appropriate for the
     individual.\3


--------------------
\2 Project DIRECT stands for Diabetes Intervention:  Reaching and
Educating Communities Together. 

\3 HRSA health centers do not focus on a single health problem or
disease because the centers provide comprehensive primary health care
to individuals.  Because such care addresses the diseases and
conditions covered in this report, we will not repeat descriptions of
HRSA's comprehensive care programs in every program area that we
discuss. 


      SIMILAR ACTIVITIES
-------------------------------------------------------- Chapter 1:1.2

Although these three agencies conduct or support health education,
the health education activities are not duplicative, according to our
criteria, because they have different purposes, emphases, and initial
target populations.  These agencies also have specific legislative
authority\4 to support or conduct health education in diabetes. 

  CDC develops educational materials that translate research into
     public health practice for community leaders, including health
     practitioners.  These materials include consensus documents on
     the prevention, treatment, and management of diabetes
     complications and a training course on controlling and reducing
     diabetes in communities. 

  NIH supports the education of patients about managing diabetes and
     its complications through NIH-funded diabetes research and
     training centers at universities.  These centers include a
     training and information transfer component on the use of new or
     improved methods and innovative approaches to managing diabetes. 
     NIH also disseminates information on diabetes to health care
     professionals, patients, and the public through the National
     Diabetes Information Clearinghouse. 

  HRSA's Bureau of Health Professions funds the education and
     training of the nation's health personnel in its efforts to
     monitor and guide the development of health resources.  Several
     bureau-supported programs that train health care professionals
     include diabetes-related components. 

Agency officials said that diabetes programs are highly coordinated. 
Coordinating groups include the following: 

  Diabetes Mellitus Interagency Coordinating Committee.  The
     Department of Health and Human Services (HHS) established this
     committee at Congress's direction in 1974 to coordinate the
     diabetes mellitus activities of NIH and other federal programs
     with activities related to the disease and to contribute to the
     adequacy and technical soundness of these activities. 

  National Diabetes Advisory Board.  HHS established the advisory
     board at Congress's direction in 1976 to (1) review and evaluate
     a long-range plan to combat diabetes, (2) advise and make
     recommendations to the Congress and the appropriate federal
     agencies on implementing and revising the plan, and (3) maintain
     liaison with other advisory bodies involved with the control of
     diabetes. 

  National Diabetes Data Group.  An advisory group to NIH's National
     Institute of Diabetes and Digestive and Kidney Diseases, the
     group consists of federal, academic, and lay representatives
     with interests and expertise in diabetes.  It has led efforts to
     coordinate and develop the statistical, epidemiologic, and
     public health aspects of disease, particularly in the diabetes
     research arena.\5

  CDC's Technical Advisory Committee for Diabetes Translation and
     Community Control Programs. 


--------------------
\4 For example, CDC is authorized under Public Law 94-317 (1976) to
provide information, including health education, on diseases that
include diabetes.  NIH is authorized under the Public Health Service
Act, Sec.  427, to disseminate information on diabetes through a
national information clearinghouse.  And HRSA has the legislative
authority, under 42 U.S.C.  254c and 254b, to provide education on
diabetes as a supplemental service to patients in its Community and
Migrant Health Centers. 

\5 The Diabetes Data Group has no data collection capabilities and
therefore does not duplicate CDC's surveillance efforts. 


   BREAST AND CERVICAL CANCER
---------------------------------------------------------- Chapter 1:2

Programs in breast and cervical cancer at CDC, NIH, and HRSA have
different activities, targets, or purposes.  CDC and HRSA both
support cancer screening programs.  States providing screening under
CDC's program, however, are required to target women who are not
covered by other programs and to provide the screening services
through HRSA-funded community centers. 


      DISTINCT ACTIVITIES
-------------------------------------------------------- Chapter 1:2.1

  CDC provides financial assistance to state public health
     departments for programs to detect and control breast and
     cervical cancer, authorized under the Breast and Cervical Cancer
     Mortality Prevention Act of 1990 (P.L.  101-354).  States
     participating in CDC's program must establish surveillance
     systems to monitor the quality of screening programs and improve
     quality assurance measures for monitoring screening procedures. 
     In making screening and follow-up services available, states
     must target low-income women who are not covered by other
     programs.  The program also provides for states to deliver
     public and professional education programs for women on cancer
     detection.  In 1993, CDC provided 12 states with funds to carry
     out breast and cervical cancer early-detection programs.  CDC
     also provided financial assistance to an additional 18 state
     public health departments to build the capacity, through
     planning and development activities, to carry out the programs. 
     CDC works with HRSA-funded community centers to reach low-income
     women. 

  Most NIH work in breast and cervical cancer includes conducting and
     supporting basic research, such as studies of the genes involved
     in breast cancer, as well as research on cancer etiology and
     prevention (for example, a trial of tamoxifen, a hormonal agent,
     to prevent breast cancer in women at high risk).  NIH conducts
     public and professional health education on breast and cervical
     cancer, such as developing materials and publications.  Such
     health education activities are specifically authorized under
     the NIH Revitalization Act of 1993 (P.L.  103-43).  Since 1973,
     NIH has also conducted cancer surveillance through the
     Surveillance, Epidemiology, and End Results Program, known as
     SEER, which is the primary source of data for rates on the
     incidence, survival, and prevalence of cancers in the United
     States. 

  HRSA provides financial assistance to Community and Migrant Health
     Centers to perform clinical breast examinations and cervical
     cancer screening as part of their routine screening and physical
     examination services. 

HRSA officials said that they actively coordinate with CDC's breast
and cervical cancer programs.  CDC and HRSA officials said that they
tend to use NIH materials, such as publications, in their public
education efforts on breast and cervical cancer prevention.  An HHS
National Strategic Plan for Early Detection and Control of Breast and
Cervical Cancers was developed by CDC, FDA, and the National Cancer
Institute (NCI), with participation from HRSA and other agencies. 


   IMMUNIZATION
---------------------------------------------------------- Chapter 1:3

Immunization activities at CDC, NIH, and HRSA are different except
for one activity, financial and technical assistance.  CDC and HRSA
both provide funding and staff to state public health departments or
community centers; however, although these activities are similar,
they are not duplicative because the purposes and recipients of the
support are different. 


      DISTINCT ACTIVITIES
-------------------------------------------------------- Chapter 1:3.1

  CDC supports the surveillance of adverse reactions to vaccines
     through a national reporting system.  It also supports
     demonstration projects to evaluate different approaches to
     raising immunization coverage or to develop new approaches to
     measuring immunization coverage. 

  NIH conducts and supports basic research on vaccines, such as
     studies on the immune system, microbiology, and virology.  It
     also supports vaccine development. 

  HRSA administers the National Vaccine Injury Compensation Program,
     which provides no-fault compensation for injuries and adverse
     reactions caused by vaccines covered under the program. 


      SIMILAR ACTIVITIES
-------------------------------------------------------- Chapter 1:3.2

CDC and HRSA both provide financial and technical assistance, but
these activities are not duplicative, according to our criteria,
because they are conducted for different purposes and are provided to
different organizations. 

  CDC purchases vaccines at discount for states and provides
     financial assistance to state and local health departments so
     that they can purchase vaccines at discount.  CDC also provides
     grants to states and cities to support the development of
     Immunization Action Plans (IAP) to strengthen local
     infrastructures for immunization.  Areas of concern under these
     IAPs are service delivery systems, education, evaluation,
     assessment, and outcome measures. 

  HRSA provides financial assistance to Community and Migrant Health
     Centers to support immunization.  HRSA has an agreement with CDC
     to determine the vaccine needs of these centers, which also
     receive vaccines purchased by states under CDC's purchase
     contract. 

  The National Vaccine Program Office (NVPO), in PHS's Office of the
     Assistant Secretary for Health, was established in 1986 as an
     amendment to the Public Health Service Act\6 to provide
     leadership for the nation's vaccine and immunization programs. 
     Its charter is to coordinate and provide direction for each
     element of the immunization process, from vaccine development to
     delivery and evaluation.  NVPO's current activities include

coordinating the President's Immunization Initiative;

completing a new comprehensive National Vaccine Plan, which is
legislatively mandated;

leading the Interagency Committee on Immunization, which is composed
of representatives from government departments and agencies; and

providing the executive secretariat and administrative support to the
National Vaccine Advisory Committee, whose voting members are
appointed, from outside the federal government, by the Assistant
Secretary for Health in consultation with the National Academy of
Sciences. 


--------------------
\6 See 42 U.S.C.  300aa-1, Public Law 99-660. 


   INTENTIONAL INJURY
---------------------------------------------------------- Chapter 1:4

Except for community demonstration programs, agency programs on
preventing and controlling violence-related injuries have different
activities and emphases.  CDC, NIH, and HRSA support demonstration
projects on violence-related injury, but these projects are not
duplicative because they have different purposes or targets, despite
some common elements, such as using similar interventions. 


      DISTINCT ACTIVITIES AND
      PROGRAM EMPHASES
-------------------------------------------------------- Chapter 1:4.1

  CDC conducts surveillance, epidemiology, prevention research, and
     program evaluation on violence-related injuries.  It provides
     financial and technical assistance to state health departments,
     for capacity building in injury prevention, and to university
     Injury Prevention Research Centers, for training and
     cross-cutting research. 

The research that CDC conducts and supports in injury tends to be
multidisciplinary, drawing upon disciplines such as biomechanics,
statistics, engineering, and behavioral psychology.  Although much of
CDC's research is on unintentional injuries, such as car accidents
and falls, CDC also conducted the first case-control study of youth
suicide clusters and has evaluated the impact of the Detroit Gun Law,
at the city's request, among other projects. 

CDC is concerned about the outcomes of violence, meaning injury and
mortality, and the agency takes an epidemiologic or population-based
approach to injury. 

The Secretary of HHS has designated CDC as the lead agency within HHS
to coordinate plans and activities on the prevention of violence. 

  NIH\7 emphasizes behavioral and clinical research on violence and
     traumatic stress and targets both perpetrators and victims of
     violence, minority youth, and substance abusers.  NIH research
     takes a psychological/mental health, environmental, and
     biomedical approach to intentional injury. 

  HRSA supports violence-related health care services targeting
     children and their families.  It also supports health education,
     through publications and conferences on violence, and resource
     planning, through its trauma system development grants to
     states. 

  SAMHSA emphasizes services to prevent and treat violent and
     intentional injuries related to substance abuse and mental
     health problems.  It targets all age groups--youthful victims,
     the homeless, and the elderly. 


--------------------
\7 Most of NIH's work on violence is supported by three institutes
that are quite new to NIH--the National Institute of Mental Health
(NIMH), the National Institute on Drug Abuse (NIDA), and the National
Institute on Alcohol Abuse and Alcoholism (NIAAA).  Until 1992, these
institutes were research components of the Alcohol, Drug Abuse, and
Mental Health Administration (ADAMHA).  In 1992, ADAMHA was
reorganized; NIMH, NIDA, and NIAAA were reassigned to NIH; and ADAMHA
was renamed the Substance Abuse and Mental Health Services
Administration. 


      SIMILAR ACTIVITIES
-------------------------------------------------------- Chapter 1:4.2

CDC, NIH, and SAMHSA all conduct or support community demonstration
projects on violence-related injury, but these activities are not
duplicative, according to our criteria, despite some similarities,
because they have different purposes or target populations. 

  CDC supports demonstration projects to

help communities design, implement, and evaluate multifaceted
programs to prevent violence, injuries, and deaths among youth and
adults in high-risk communities;

establish or strengthen intentional injury programs in states and
localities; and

test violence prevention guidelines. 

  NIH's NIMH has evaluation research and demonstration projects to
     develop, implement, and evaluate programs that address mental
     health problems, such as conduct disorders, and to reduce
     disruptive behavior disorders in high-risk adolescents.  NIMH's
     primary objective in violence prevention is to improve the
     understanding of the mental health antecedents and consequences
     of violent behaviors, for both perpetrators and victims. 

  SAMHSA supports or conducts demonstration projects in communities
     and through states to prevent alcohol and other drug problems by
     high-risk youths, including school drop-outs and gang members: 
     projects include strategies to prevent and reduce violent and
     suicidal behavior.  SAMHSA also supports demonstration drug
     treatment programs to intervene with adults and adolescents
     involved in the criminal justice system who are at risk for
     violent behavior. 

In November 1991, an HHS Office of the Inspector General report found
no duplication among PHS agencies in injury control.  The report's
goal was to determine the nature and extent of possible overlap
between CDC's injury control programs and other such programs in
different federal agencies.  The Inspector General's report found no
duplication among the specific projects reviewed.\8


--------------------
\8 Injury Control, U.S.  Department of Health and Human Services,
Office of the Inspector General (Washington, DC:  Nov.  1991). 


   TOBACCO USE PREVENTION AND
   CONTROL
---------------------------------------------------------- Chapter 1:5

In tobacco control programs, all PHS agencies share a common HHS
health goal:  to help people stop smoking and to prevent people from
starting to smoke.  With tobacco use, the same populations are at
risk--adolescents, blue collar workers, and minorities.  Overall,
despite these and other similarities, agencies' programs in tobacco
control have different activities, purposes, or targets. 


      DISTINCT ACTIVITIES
-------------------------------------------------------- Chapter 1:5.1

CDC and NIH both work with state public health departments as focal
points for organizing coalitions and developing state-level
activities, such as planning and health education on tobacco control. 
However, there are essential differences between their programs, in
activity and purpose. 

  NIH's American Stop Smoking Intervention Study (ASSIST) is a
     large-scale 7-year demonstration project that is the culmination
     of NCI's tobacco control research program in the 1980s.\9 ASSIST
     is a collaborative effort between NCI and the American Cancer
     Society, along with 17 state public health departments. 

NCI's purpose is to demonstrate that the wide-scale application of
proven strategies can achieve specific, measurable goals in reducing
the prevalence and initiation of smoking.  These proven strategies
are based on NCI studies from the 1980s and other smoking and
behavioral research. 

ASSIST's specific goals are to reduce smoking prevalence among adults
to 17 percent by 1998 and adolescents' smoking initiation by 50
percent by the year 2000. 

NIH contracts with state public health departments that have a
tobacco control infrastructure sufficient to achieve ASSIST's stated
goals by the end of the project. 

As a demonstration project, ASSIST has a specific beginning and end,
with implementation starting in 1993 and the project ending in 1998. 

  In contrast, CDC supports resource development by providing
     financial and technical assistance to states and regional
     coalitions for tobacco control. 

CDC's purpose is to help states and regions build their
infrastructure or capacity--that is, to establish and strengthen
programs for long-term tobacco control and prevention.  CDC's
assistance is intended to support state and regional efforts toward
reducing smoking prevalence and initiation, not to achieve specific
levels.  CDC's efforts for building state capacity in tobacco control
and prevention are ongoing, not finite. 

CDC, by contrast with NIH, works with states that lack, or have weak,
tobacco control infrastructures.  CDC's capacity-building cooperative
agreements give priority to states in which the state health agency
expended $1 million or less in fiscal year 1989 for tobacco control
activities.  Because NCI's ASSIST states have well-developed or
well-funded tobacco control programs, they do not qualify for CDC's
capacity-building program.  California is also excluded for the same
reason. 

One regional tobacco control program CDC supports is the Rocky
Mountain Tobacco-Free Challenge, which since 1988 has supported
annual competitions among coalitions in eight states for tobacco
control and prevention approaches in communities. 

  There is much coordination and information-sharing between NIH and
     CDC about their tobacco control programs. 


--------------------
\9 Demonstration is one of the five phases of cancer control and
prevention research that precede national prevention and health
services programs.  As outlined in an NCI journal, Phase I is
hypothesis development; phase II, methods development; phase III,
controlled intervention trials; phase IV, defined population studies;
and phase V, demonstration and implementation.  ASSIST is considered
a Phase V project in NCI's tobacco control research program.  (See
Peter Greenwald and Joseph Cullen, "The New Emphasis in Cancer
Control," Journal of the National Cancer Institute, Vol.  74, No.  3
(March 1985), pp.  545-46.)


      SIMILAR ACTIVITIES
-------------------------------------------------------- Chapter 1:5.2

HRSA and SAMHSA both support some tobacco prevention and cessation
services through community-based programs.  Despite similarities,
they address different target populations and are therefore not
duplicative. 

  HRSA and SAMHSA fund programs that provide different populations
     with health services that sometimes include smoking prevention
     and cessation.  HRSA focuses on pregnant women, children, and
     child care providers, while SAMHSA targets substance abusers. 
     The degree to which smoking cessation and prevention can be a
     part of the health services offered to patients is generally
     determined locally, by the state or community health program. 
     Both agencies also support focused demonstration projects. 
     SAMHSA is responsible for monitoring state compliance with the
     1992 federal legislation (Synar Amendment).\10


--------------------
\10 42 U.S.C.  300x-26(A)(B) (Synar Amendment, Section 1926, of the
Public Health Service Act).  Under this amendment, the Secretary of
HHS has the authority to deny full fiscal year 1994 Substance Abuse
Prevention and Treatment Block Grant awards to states that have not
implemented a law, by October 1, 1993, prohibiting the sale and
distribution of tobacco to anyone under age 18. 


   ENVIRONMENTAL AND OCCUPATIONAL
   HEALTH
---------------------------------------------------------- Chapter 1:6

We examined two programs at CDC and NIH within the environmental and
occupational health area:  agricultural health and safety and
electromagnetic field (EMF) radiation.  These programs were not
duplicative because the agencies have different purposes, activities,
or targets. 


      AGRICULTURAL HEALTH AND
      SAFETY
-------------------------------------------------------- Chapter 1:6.1

Although CDC and NIH are both collecting health data on farm
families, the agencies are conducting different activities with
different purposes. 

  CDC's National Institute for Occupational Safety and Health (NIOSH)
     is conducting surveillance, health education, and research on
     agricultural safety and health.\11

Through its Farm Family Health and Hazard Survey, NIOSH is conducting
surveillance of farm families in six states.  The purpose of the
survey is to collect population-based data on the incidence and
prevalence of disease, injuries, and exposures to farm occupational
health and safety hazards.  The survey data will allow NIOSH to
develop hypotheses about the causes of disease or injuries and to
target interventions or further research from these data. 

NIOSH is using nurses located in rural communities to conduct
surveillance and public education for families.  The goal of the
surveillance is to develop more information on the types of injuries
and diseases that occur among farm families. 

NIOSH also supports research to develop model prevention programs on
agricultural safety and health, evaluate prevention programs
implemented by other organizations, and to evaluate engineering and
ergonomic control technology. 

  NIH is conducting epidemiologic research on farm families in two
     states:  The Agricultural Health Study is a prospective
     epidemiologic study, carried out by NCI, the Environmental
     Protection Agency, and the National Institute of Environmental
     Health Sciences (NIEHS).  The study's purpose is to evaluate the
     health risks associated with agricultural chemical exposures
     during a 10-year period.  In its initial phase, the study uses
     questionnaire survey data to identify the main cohort of people
     and to develop exposure information for the study.  In
     prospective studies like this Agricultural Health Study, a
     cohort of people is carefully selected and classified by their
     exposures to risk factors (such as pesticides).  The cohort is
     followed over time to determine differences in the rate at which
     the disease develops in relation to the exposure to the risk
     factor.  Unlike surveys such as CDC's, this kind of study allows
     NIH to analyze the causes of disease:  NIH's study uses an
     analytic design that allows it to test hypotheses and to show
     relationships among variables. 

  CDC and NIH program officials who are conducting NIOSH's farm
     family survey and NCI's Agricultural Health Study reviewed
     detailed documentation on the projects, and they agreed with our
     finding that there is no duplication of activities. 


--------------------
\11 The Senate Committee on Appropriations mandated that NIOSH
conduct a farm family health and hazard survey.  (See Senate Report
101-127 (Sept.  13, 1989), pp.  93-95.) NIOSH was established by the
Occupational Safety and Health Act of 1970; in 1973, NIOSH became a
part of CDC.  NIOSH is responsible for conducting research and
analyzing the results to prevent illness and control hazards in the
workplace.  NIOSH's mandate includes responding to requests for
investigations of workplace hazards and conducting research on ways
to control or prevent work-related health and safety problems. 


      ELECTROMAGNETIC FIELD
      RADIATION
-------------------------------------------------------- Chapter 1:6.2

Because of reports linking EMF with cancer during the past decade,
EMF has become a public health concern.  Electromagnetic fields are
created by the use of electric power lines and home appliances--such
as clocks, televisions, and electric blankets.  The possibility of
adverse health effects from exposure to EMF has generated controversy
and debate in the media in the past few years.  CDC and NIH have EMF
radiation programs, but no duplication exists because the programs
have different targets and purposes. 

  CDC, through NIOSH, studies the impact of EMF on workers only. 
     NIOSH conducts surveillance of workers' exposure to EMF as well
     as worksite inspections on request.  In January 1991, NIOSH
     convened a scientific workshop on EMF's health effects on
     workers to begin developing a national research strategy on EMF. 

  NIH studies EMF's effects on the general public, especially
     children.  NIH's purposes are to study the development of cancer
     at the molecular and cellular levels and to determine human
     health effects, using animal studies.\12

  CDC's NIOSH and NIH's NIEHS and NCI are collaborating on EMF
     research. 


--------------------
\12 The Energy Policy Act of 1992 (P.L.  102-486) specifically
charged the Secretary of HHS and the Director of NIEHS, NIH, with
responsibilities for programs of research and public information
dissemination on EMF. 


CDC'S PROGRAM ACTIVITIES ARE
SUPPORTED BY LEGISLATION, HISTORY,
AND PUBLIC HEALTH EXPERTS'
OPINIONS
============================================================ Chapter 2

From fiscal years 1987 to 1992, CDC's annual appropriations rose
about $1 billion.  During the same period, the Congress authorized a
40.3-percent increase in CDC's full-time equivalent staff.  Out of
concern about expansions in CDC's funding and staff along with a
broadened scope of CDC's programs and activities, the House Committee
on Appropriations directed that we evaluate the appropriateness of
CDC's programs in three areas--chronic diseases, intentional injury,
and the funding of health services. 

We determined that CDC's activities are appropriate in light of its
mission.  CDC's activities in preventing and controlling chronic
diseases and intentional injury and funding health services are
supported by legislation, history, diversity of staff, and the
judgments of public health experts.  CDC's mission is to prevent and
control disease, injury, and disability.  This mission is consistent
with the agency's legislative authority to conduct or support
prevention and control programs in diabetes, breast and cervical
cancer, and injury.  CDC furthermore has a history of program
activities in chronic disease and intentional injury as well as
long-term relationships with state health departments, which are
responsible for implementing public health programs for the American
people.  Most public health experts we interviewed recognize CDC as
the federal government's leading agency in the prevention and control
of disease and injury and support CDC's activities in these program
areas as part of its mission. 

In August 1993, we reported on CDC's legislative authorities, its
historical roles, and its staff and relationships with state public
health departments.  We also provided the views of public health
experts about CDC's involvement in chronic disease, intentional
injury, and funding of services, such as breast and cervical cancer
screening.\1 A summary of our findings follows. 


--------------------
\1 Correspondence on CDC's Mission and Duplication in PHS
(GAO/HRD-93-32R, Aug.  30, 1993). 


   LEGISLATIVE AUTHORITY
---------------------------------------------------------- Chapter 2:1

  Legislative authority establishes the basis for CDC's programs in
     chronic diseases and intentional injury. 

CDC has broad legislative authority to protect the health of
Americans. 

Initially, CDC was authorized to control communicable diseases. 

In the 1970s, legislation expanded CDC's programs beyond communicable
diseases to include disease control programs for a broad range of
health conditions, including programs to encourage behavior that
would prevent diseases. 

  CDC's programs in diabetes and breast and cervical cancer are
     specifically authorized by law. 

In 1976, CDC was charged with developing diabetes control programs
under the Disease Control Amendments of 1976 (P.L.  94-317). 

The Breast and Cervical Cancer Mortality Prevention Act of 1990
authorizes CDC to provide funding to states for the early detection
and control of these cancers. 

  Programs on injury control and prevention are also legislatively
     authorized under the Injury Prevention Act of 1986.  In 1992,
     congressional committee reports specifically requested that CDC
     emphasize violence-related injuries in its program. 


   CDC'S PROGRAM HISTORY
---------------------------------------------------------- Chapter 2:2

  CDC's programs in chronic disease, health services, and
     violence-related injury reflect CDC's evolving public health
     role. 

Threats to public health have evolved over time, and CDC's programs
and activities have changed accordingly.  Epidemiology shows the
way--morbidity and mortality data define the threats. 

  CDC began to include chronic diseases in its programs in the early
     1970s. 

CDC began a nutrition program as well as birth defects surveillance
in 1970. 

Tobacco control was moved to CDC in 1972, with the assignment of the
Office on Smoking and Health to the agency. 

Cancer was included in CDC's programs in 1975. 

CDC reorganized in 1980 to better carry out work in chronic diseases,
environmental health, and life-style issues. 

  CDC supported health services for the public in the 1960s when it
     awarded grants to states for vaccination programs against polio. 
     In the 1980s, CDC supported demonstration programs on breast and
     cervical cancer to identify barriers to screening. 

  CDC began work on violence-related injury in the early 1980s. 

In 1981, CDC improved its surveillance program to include child
abuse, homicide, and other forms of violence, and in 1983 CDC
established a violence epidemiology branch to study various forms of
violence. 

In 1985, the National Academy of Sciences cited intentional injury as
a public health problem in its report, Injury in America:  A
Continuing Public Health Problem.  The Academy also recommended that
a Center for Injury Control be established at CDC. 


   CDC'S ORGANIZATIONAL CAPACITY
---------------------------------------------------------- Chapter 2:3

  CDC's diversified staff and relationships with states are suited to
     preventing and controlling diseases and injuries. 

CDC has a multidisciplinary technical staff that includes medical
officers, epidemiologists, and behavioral health scientists.  It also
has staff in regional field offices and state public health
departments. 

CDC has long-time, established working relationships with state and
local public health departments, which is where many public health
programs are implemented. 

About 75 percent of CDC's funds go to state and local health
departments to support public health programs.  States also can
request technical assistance in lieu of grant funds. 


   PUBLIC HEALTH EXPERTS' OPINIONS
---------------------------------------------------------- Chapter 2:4

  Public health experts support CDC's activities in preventing and
     controlling chronic diseases and violence-related injury as part
     of the agency's mission to protect the health of all Americans. 
     Many of the public health experts we interviewed agreed on the
     following: 

CDC is the leading prevention agency in the PHS. 

CDC's work in chronic disease and violence-related injury is
appropriate because its activities in these areas are a logical
extension of population-based surveillance and epidemiology.  CDC's
programs respond to pressing public health problems, which are
defined through surveillance and epidemiology. 

CDC's relationships with state and local health departments are
important in translating research into public health practice. 


MAJOR CONTRIBUTORS TO THIS
BRIEFING REPORT
=========================================================== Appendix I

James O.  McClyde, Assistant Director (202) 512-7152
Deborah A.  Signer, Evaluator-in-Charge
Damaris Delgado-Vega, Attorney
