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Statement by
Walter W. Williams, M.D., M.P.H.
Associate Director for Minority Health, Centers for Disease Control and Prevention
on
CDC Efforts to Eliminate Racial and Ethnic Disparities in Health
before the
Congressional Black Caucus, the Congressional Hispanic Caucus, and the Congressional Asian Pacific American Caucus

April 12, 2002

Good morning. My name is Dr. Walter W. Williams, and I am the Associate Director for Minority Health at the Centers for Disease Control and Prevention (CDC). Thank you for inviting me to participate in today's hearing on the Status and Progress of the Department of Health and Human Services Initiative to Eliminate Racial and Ethnic Disparities in Health. Today, I will focus on our REACH 2010 Demonstration program, and current program status, progress and challenges of selected CDC programs for the six health focus areas of diabetes, cardiovascular disease, breast and cervical cancer screening and management, HIV/AIDS, childhood and adult immunization, and infant mortality. I would also like to address our other programs and activities which address health disparities.

For too many racial and ethnic minorities in our country, good health is elusive, and appropriate health care is often associated with economic status, race or ethnicity, and gender. The demographic changes that are anticipated over the next decade magnify the importance of addressing disparities in health status. Groups currently experiencing poorer health status are expected to grow as a proportion of the total U.S. population; therefore, the future health of America will be influenced substantially by our success in improving their health. A national focus on disparities in health status is particularly important as major changes unfold in the way in which health care is delivered and financed.

One of Secretary Thompson's priorities is the elimination of health disparities. He has charged each organizational component within HHS to work together as "one Department" to maximize effectiveness and impact in closing the health gap among racial and ethnic minority populations.

Eliminating health disparities will require new knowledge about the determinants of disease, causes of health disparities, and effective interventions for prevention and treatment. In addition, we will need to improve access to the benefits of society, including quality preventive and treatment services, as well as innovative ways of working in partnership with health care systems, state and local governments, tribal governments, academia, national and community-based organizations, and communities. For instance, CDC recently established an innovative transpartnership initiative to create an opportunity for minority and majority academic institutions to collaborate in three primary areas. First, the partnership facilitates prevention research through multi-institutional collaboration to eliminate health disparities. Second, the initiative aims to strengthen the academic workforce by fostering a cadre of minority public health researchers. Finally, the partnership works to build research infrastructure at member institutions, which include schools of public health and medical colleges others. The trans-partnership initiative will benefit both CDC and the partnering institutions by producing quantifiable research results with relevance to improving the health of underserved populations while developing inter-institutional relationships that will provide the foundations for continuing collaboration. The new trans-partnership initiative will enhance the existing relationships CDC maintains with academic institutions and partner organizations dedicated to eliminating racial and ethnic health disparities.

Eliminating disparities in health also will require enhanced efforts at preventing disease, promoting health and delivering appropriate care. This will require maximizing collection and use of standardized data to correctly identify high-risk populations and to evaluate the effectiveness of health interventions targeting these groups. CDC's National Center of Health Statistics (NCHS) plays a key role in collecting data to compare the health of racial and ethnic population groups. These efforts include oversampling minority populations in surveys, conducting analyses of differentials, and developing plans for data systems that can provide more detail on smaller population groups. For example, during CDC's Data Users Conference in July of this year, we will convene a forum to discuss data needs for Asian Americans, Native Hawaiians and other Pacific Islanders which would assist in developing activities to enhance health statistics for minority populations through activities such as expanding the capacity of existing surveys, developing new tools, improving analytic approaches and working with states. Meeting the data needs of users who are interested in more detailed data on smaller population subgroups is costly and a major challenge. We continue to explore options for enhancing health statistics for minority populations.

CDC is very concerned about the continued existence of health disparities among racial and ethnic groups and is implementing many programs designed to advance the Eliminating Racial and Ethnic Health Disparities initiative. Our programs encompass an array of activities including research and demonstration programs, program evaluation, training, fellowships and intergovernmental personnel actions, support for public health conferences and the development of capacity and infrastructure for public and private organizations. Today I will discuss our activities in the six focus areas outlined in the Secretary's initiative, as well as several other priority activities. I will begin my discussion with CDC's REACH 2010 program.

REACH 2010

Racial and Ethnic Approaches to Community Health (REACH 2010) is CDC's cornerstone initiative aimed at eliminating disparities in health status experienced by racial and ethnic minority populations. It is designed to eliminate disparities in six priority areas: cardiovascular disease, immunizations, breast and cervical cancer screening and management, diabetes, HIV infections/AIDS, and infant mortality. It is an outstanding example of community-based participatory projects that currently support 37 demonstration communities, two of which are funded in partnership with the California Endowment through the CDC Foundation, and four of which are funded through an interagency agreement with the Administration on Aging. About 90 percent of the projects serve African Americans or Hispanics, and the remainder serve Asian Americans, Pacific Islanders and American Indians. The intent of REACH 2010 is to support community-driven demonstration projects that yield replicable models to eliminate health disparities in all communities of color. A new component of Reach 2010 is funding to American Indian/Alaska Natives. Five projects were funded for a three year period starting in 2001 for capacity building of tribes and tribal organizations.

Systems change is one of the areas targeted through the REACH 2010 evaluation logic model and an area that most of the grantees are pursuing programmatically. Our challenge is to support their strategies and recommendations and to seek broader systems level change to support local activities.

Expanding the scope of REACH 2010 to include additional health priority areas such as the elimination of syphilis, alcohol and substance abuse, and violence is another programmatic challenge. These are areas that are identified by statistics and by communities of color as persistent health challenges impacting their communities.

Diabetes

Diabetes is a disease for which African Americans and Hispanics have some of the highest rates of all population groups. The prevalence of diabetes among African Americans is approximately 70 percent higher than whites and the prevalence in Mexican Americans is nearly double that of whites. To address these disparities, CDC is implementing activities that focus on preventing complications of diabetes in minority populations. Prominent among the programs is Project DIRECT, a multi-year diabetes community demonstration project in Raleigh, North Carolina. During the first year, the project boosted the percentage of patients receiving foot care counseling from 20 percent to 50 percent. Patients are now taking better care of themselves and are more likely to be referred for needed eye and vascular exams. In another initiative supported by CDC, University of North Carolina at Chapel Hill School of Public Health is conducting participatory prevention research in African-American churches in North Carolina to expand and refine an intervention to deliver a community-based diabetes self-management program that builds on physician-directed diabetes care. Similarly, The National Diabetes Education Program (NDEP), a joint program sponsored by CDC and the National Institutes of Health (NIH) has reached 3.6 million Hispanics to date with Public Service Announcements, media broadcasts and print media, including the Hispanic/Latino Campaign called "Mas que Comida es Vida" (It's More than Food, It's Life) that focuses on Hispanics who have diabetes or who are at high-risk to develop the disease. In addition, six national minority organizations are funded by the National Diabetes Education Program to develop and deliver culturally and linguistically appropriate community-based diabetes prevention and control messages to African-American, Hispanic/Latino, American Indian, and Asian-American and Pacific Islander populations. Diabetes prevention and control activities targeting the Hispanic population are also focused on the U.S. Mexico Border where CDC is working with the four southwestern U.S. border states, the six border states in Mexico, the Pan American Health Organization, and Mexico's Secretariat of Health to assess the burden of diabetes care, and barriers to good diabetes self-management.

In the next three to five years, the diabetes program plans to enhance current activities and expand its capacity to respond to emerging public health diabetes issues such as primary prevention, childhood diabetes, diabetes and women's health, and recognition of the pre-diabetes condition (impaired glucose tolerance). In addition to increasing the number of Comprehensive state-based diabetes control programs beyond the current 16, CDC also faces challenges of strengthening surveillance efforts focused on high risk populations, expanding the National Diabetes Education Program's activities and partnerships, and expanding applied prevention research activities to improve early detection, quality of care and preventive care practices. Issues related to culture among ethnic groups (e.g., diet and body image) are additional challenges that need to be addressed.

Cardiovascular Disease

Heart disease remains the number one case of death for all Americans. Heart disease death rates are more than 25 percent higher for African Americans than for whites, and African American men and women who had the highest death rates from diseases of the heart during the past decade have experienced lower declines than the overall U.S. population. In addition, African American women have experienced a much lower decline than either white women or African American men. CDC's is addressing these disparities in cardiovascular health by assisting states in developing, implementing, and evaluating cardiovascular health promotion, disease prevention, and control programs.

Notably, cardiovascular health research activities include a two-year project with Morehouse School of Medicine entitled "Multiple Cardiovascular Disease Risk Reduction in Adult African-Americans: A Pilot Study." The project will employ a randomized controlled intervention trial to determine the effectiveness of cardiovascular disease (CVD) multiple risk reduction strategies in African-Americans, who experience disproportionately high CVD mortality and morbidity. In an effort to increase physical activity, thereby helping to curb CVD, St. Louis University administers a CDC-funded extramural prevention research program designed to promote the use of walking trails in six rural African-American communities in southeast Missouri. New CVD efforts will address Asian/Pacific Islanders, one of the fastest growing racial/ethnic populations in the U.S. CDC has just completed data collection through the Prevention Research Center, University of California, Berkeley on "Cardiovascular Health and Social Context Among Ethnic Subgroups and Ethnic Enclaves," that will result in programmatic opportunities for the Asian Indian population.

Compared to what is known about CVD disparities in African Americans, relatively little is known about disparities in American Indians, Alaska Natives, Hispanics, Asian Americans and Native Hawaiians/Pacific Islanders. Disparities in cardiovascular disease, especially the social and environmental determinants, and the best strategies for their elimination are inadequately studied. Our surveillance data show that gaps for many cardiovascular health disparities are widening. Our challenge is to support research projects designed to assess the social environmental determinants of these widening gaps as well as to provide support for state-based programs designed to address priority populations where the disparities are manifest. In addition, a particular challenge is assuring a culturally competent and diverse public health workforce, and sustaining strategic partnerships with national minority organizations that facilitate effective collaboration with targeted populations.

Breast and Cervical Cancer Screening and Management

During the last decade, the age-adjusted female breast cancer death rate for whites declined by 20 percent, the rate for Hispanics declined by 21 percent, and despite efforts targeting breast cancer rates among black females, the rate for blacks declined only 6 percent. The rate for Asian Pacific Islanders was nearly unchanged. While African American women develop breast cancer less often than do white women, mortality rates from invasive breast cancer are greater notwithstanding higher mammography screening rates. Studies have shown that African American women are more likely to be diagnosed with breast cancer at a late disease stage and to have a shorter survival time than white women. Such disparities may result from multiple factors, such as late stage of disease diagnosis, barriers to health care access, lower socio-economic status, history of other diseases, biologic and genetic differences in tumors, health behaviors, and the presence of risk factors. More research is needed to understand differences in cancer deaths among racial and ethnic populations, as well as on ways to better target prevention efforts to reach the underserved and those at highest risk.

CDC's National Breast and Cervical Cancer Early Detection Program is currently in its twelfth year, and funds all 50 state health agencies, the District of Columbia, 14 tribal organizations, and six territories to conduct breast and cervical cancer early detection programs. More than three million screenings have been performed, with nearly 50 percent of those provided to minority women. The program is dedicated to ensuring that eligible women in the United States receive screening services and prompt follow-up if necessary, as well as assurance that the tests are performed in accordance with current guidelines.

Childhood and Adult Immunization.

Disparities in immunization coverage for preschool aged children have been greatly reduced among all racial and ethnic groups. For example, in 1985, 64 percent of preschool aged white children and 49 percent of nonwhite children were reported by their parent to be appropriately vaccinated with a measles containing vaccine. By the period from July 2000 through June 2001, this gap had closed considerably with provider-verified coverage for whites at 92 percent and for African Americans 89 percent. During the same time period, nationwide coverage levels for many vaccines were also within one percentage point of or above the Healthy People 2010 Goal of 90 percent coverage for three or more doses of DTaP vaccine, one or more doses of MMR vaccine, three or more doses of Hib vaccine, and three or more doses of hepatitis B vaccine. Preliminary data evaluating the impact of routine infant hepatitis B immunization indicate a dramatic reduction in the prevalence of chronic HBV infection in Asian Americans and Pacific Islanders. Childhood coverage for varicella vaccine is higher among African-Americans, Hispanics and Asian and Pacific Islanders than among whites. There remains a gap in coverage for the fourth dose of DTaP between different racial and ethnic groups, but this dose is considered less important to disease risk.

Despite the success in childhood vaccination, significant disparities continue to persist in coverage levels for adults of different racial and ethnic backgrounds. In 2000, 67 percent of whites, 56 percent of Hispanics, and 48 percent of African Americans aged 65 years or older received an influenza immunization. Additionally, 57 percent of whites, 30 percent of Hispanics, and 31 percent of African Americans aged 65 years or older had been vaccinated with pneumococcal polysaccharide vaccine. The risk of hepatitis B virus infection among African Americans and Hispanics is nearly threefold that for whites. Recent data indicate that almost 75 percent of newly acquired cases occur among adults in groups for which hepatitis B vaccination is recommended.

CDC's current activities to address the disparities in adult immunization coverage include strategic partnerships with national minority organizations such as the National Medical Association and the Congress of National Black Churches and targeted interventions working to improve the use of clinical preventive services among African American women on Medicare. Current activities also include partnerships with the National Asian Women's Health Organization and the National Alliance for Hispanic Health to improve nationwide immunization coverage. These efforts establish a foundation upon which programs can be designed to help eliminate coverage disparities among adults.

Infant Mortality

According to 1999 data, the U.S. infant mortality rate is at an all-time low of 7.0 deaths per 1,000 live births. However, racial and ethnic minorities, particularly African American, Puerto Rican American, and American Indian/Alaska Natives, consistently contribute to the higher rates of mortality. CDC addresses the elimination of racial and ethnic disparities of infant mortality by focusing on pre-term Delivery (PTD) and Sudden Infant Death Syndrome (SIDS), the second and third leading causes of infant mortality. Pre-term delivery, defined as delivery before 37 weeks of gestation, is the leading cause of Black infant deaths and therefore, the largest contributor to the racial disparity in infant mortality.

CDC is implementing pre-term delivery activities designed to increase the understanding of specific factors that cause PTD and the associated disparity, and to define testable interventions to prevent pre-term delivery. This is carried out through research, dissemination and translation activities. Research activities are being conducted at the Children's Memorial Hospital in Chicago, Illinois to examine the transgenerational effects of personal and environmental stress or pregnancy outcomes among African American women, while at the University of North Carolina, Chapel Hill researchers are measuring the effect of community level factors on PTD. To translate research into strategies to address PTD disparity, CDC is engaged in a multi-year collaboration with the W.K. Kellogg Foundation and the CDC Foundation to translate research into strategies to address PTD disparity. In addition, technical assistance is provided to the Healthy African American Families project at Drew University in Los Angeles, California and three other sites to develop new intervention strategies. CDC is also working with the Center for Women Policy Studies in the development of a survey designed to better understand state legislators' knowledge of pregnancy outcomes and to better inform the development of state policy.

The primary goal of Sudden Infant Death Syndrome (SIDS) activities is to prevent SIDS death. This is accomplished through research of risk and protective factors, development of guidelines and prevention strategies, and collaborative partnerships. Research studies are currently underway in collaboration with Loyola University and the National Institute of Child Health and Human Development (NICHD), as well as the Aberdeen Area Tribal Health Board, the Indian Health Service and NICHD. Through the REACH Initiative, CDC provides direct technical assistance and consultation to the Genesee County (Flint) Health Department and the San Francisco Department of Public Health to develop interventions to address infant mortality.

HIV/AIDS

Since FY 1999, CDC has received funding through the Minority AIDS Initiative to enhance efforts to prevent HIV infection and transmission in communities of color. CDC has awarded funds to states, nongovernmental organizations, and other partners to address prevention needs. Factors considered in these awards are AIDS prevalence, geographical location, target population, and risk behavior, and organizations' ability to provide services to target population. These funds have supported community-based programs to prevent HIV, capacity-building programs to assist community-based organizations, targeted education efforts to raise awareness of the importance of HIV testing, supplemental surveillance to define the magnitude of the epidemic in minority communities, and research to develop and refine prevention programs.

CDC also has developed a health communications campaign to promote awareness of the benefits of HIV testing, encourage testing for sexually active high-risk individuals, and address barriers to HIV testing and treatment. Entitled Know Now!, the campaign uses a private-sector marketing database and AIDS epidemiology data to target messages to specific audiences, including high risk racial and ethnic minorities. These messages will be delivered at the grassroots level through local media, community-based organizations, and partnership involvement. The campaign will be piloted in five cities this year -- Jackson, Mississippi; New Orleans, Louisiana; Houston, Texas; Miami, Florida; and Detroit, Michigan. Whereas the risk factors for HIV and viral hepatitis infection are similar, cooperative agreements with the National Minority AIDS Coalition, the Immunization Action Coalition, and the American Liver Foundation are also being used to develop messages for minority groups at increased risk for hepatitis virus infections.

To more effectively target HIV prevention, research is needed to determine better estimates of new infections. During the next year, CDC will begin developing ways to measure the number of new infections. CDC will use a national estimate of HIV incidence to measure progress toward the overarching goal of the HIV Prevention Strategic Plan: "to reduce the number of new HIV infections per year in the U.S. from an estimated 40,000 to 20,000 per year by the year 2005, focusing particularly on eliminating racial and ethnic disparities in new HIV infections."

Reducing Sexually Transmitted Diseases (STDs) and HIV incidence among men having sex with men (MSM) is one of the key challenges in the next 3-5 years for HIV/AIDS prevention. Recent studies in six U.S. cities have documented alarmingly high levels of infection among MSM of color, particularly among the young. It is estimated that 60 percent of all men becoming infected with HIV are MSM. AIDS diagnoses among MSM reflect the disproportionate racial/ethnic pattern of the epidemic. In 1999, African American MSM had a rate of nearly 56 cases of AIDS per 100,000; Hispanic MSM nearly 27 cases per 100,000; American Indian MSM nearly 11 per 100,000; and Asian/Pacific Islander MSM had nearly six cases of AIDS per 100,000 population. The rate of white MSM was 11 per 100,000. In fiscal year 2002, 67 percent of the health department HIV prevention project areas listed MSM as their primary target population and 81 percent listed MSM within their top three priorities. CDC is currently developing guidelines to improve HIV/STD programs for MSM for use by CDC grantees and partners providing services to this population.

CDC also funds cooperative agreements with state and local health departments to provide Hepatitis C Coordinators to develop strategies to integrate hepatitis C and viral hepatitis prevention services (counseling, testing, referral, surveillance, and vaccination) into existing public health activities serving adults at high risk for infection, such as HIV/AIDS, STD, drug treatment and correctional health programs.

Continued behavioral surveillance among high-risk groups is also a challenge for HIV/AIDS prevention. These behavioral data can guide secondary prevention efforts by identifying barriers to adherence, which helps prevent the emergence of resistant strains of bacterial and viral STDs and improves health and survival.

Additionally, CDC led the development of the National Plan for the Elimination of Syphilis in the U.S. together with Federal agencies, state and local health departments, and representatives of communities heavily affected by syphilis. The centerpiece strategy of the plan is mobilizing affected communities to develop and implement local syphilis elimination efforts by enhancing surveillance, expanding access to high quality clinical preventive services, improving knowledge about prevention of syphilis and where to receive quality services, strengthening outbreak response preparedness, and enhancing health promotion. Dramatic progress has been made between 1997 and 2000: infectious syphilis rates fell 31 percent; congenital syphilis rates declined almost 52 percent; the number of counties without syphilis rose from 75 percent to 80 percent; and the gap between reported infectious syphilis rates among African American and whites dropped by 52 percent. This is significant because syphilis increases HIV transmission at least two-to-five fold.

Finally, as a way to reach large populations of youth of color, CDC supports school-based HIV/AIDS prevention programs in 15 large urban school districts with more than 70 percent minority student enrollment. This teaching includes HIV/AIDS prevention programs in the classroom. The following is a list of these districts:, Los Angeles, San Bernardino, San Diego, San Francisco, Miami, Chicago, New Orleans, Boston, Baltimore, Detroit, New York City, Philadelphia, Dallas, Houston and Washington, DC. As a result of these and other efforts, these young people are engaging in safer behaviors. From 1991 to 1999, the proportion of the nation's African American high school students who ever engaged in sexual intercourse fell from 81 percent to 71 percent. The proportion of currently sexually active students who used a condom at last intercourse increased from 48 percent in 1991 to 70 percent in 1999. Similarly for Hispanic high school students, the proportion who were currently sexually active and used a condom at last intercourse increased from 37 percent in 1991 to 55 percent in 1999.

Asthma

Although asthma prevalence is only two to three percentage points higher (depending on the age group) among African Americans than white Americans, rates for death, hospitalization, and emergency department visits due to asthma are three times higher for African Americans.

Through the National Asthma Control Program, CDC is working to reduce the burden of asthma, especially on racial and ethnic minorities. The program consists of three components: tracking, which is the collecting and analyzing of data on a continuous basis to define asthma's burden and help to focus interventions on those experiencing the greatest burden; interventions, to assure that sound scientific information is translated into public health practices and programs to reduce the burden of asthma; and partnerships, to ensure that all stakeholders have the opportunity to be involved in developing, implementing, and evaluating local asthma control programs.

The goals of the program are to reduce the number of deaths, hospitalizations, emergency department visits, school or work days missed, and limitations on activity due to asthma. With appropriations of $35 million in fiscal year 2002, CDC is funding 13 asthma tracking projects, 45 asthma interventions, and 30 asthma partnership projects under the National Asthma Control Program. CDC is also funding six urban school districts and six national nongovernmental organizations to support and address asthma control within a coordinated school health program.

These programs and activities are aimed at decreasing the burden of asthma among populations, but especially among the racial and ethnic minorities most affected. Examples of projects aimed specifically at eliminating disparities include CDC funding: of state health departments in California, Illinois, and Michigan to develop, implement, and evaluate a rapid asthma death notification and investigation system which will assist in planning and evaluating efforts to reduce deaths and the disparity in death rates; and, of grantees in 16 states (Alabama, Arizona, California, Florida, Illinois, Massachusetts, Maryland, Minnesota, Missouri, Mississippi, North Carolina, New Jersey, New York, Ohio, Oregon, and Texas) and in Washington, D.C., to provide inner-city families with asthma education and individualized asthma control plans.

Children Lead Poisoning Prevention Program

Lead poisoning is one of the most preventable environment-related health problems of young children, but nearly one million children less than six years of age have elevated blood lead levels (BLLs). BLLs³10 micrograms per liter are considered to be elevated.

Of children aged one to five years, the highest blood lead levels are found among African American, non-Hispanic children followed by Mexican-American children. Geometric mean BLLs: African American children: 4.3; Mexican American: 3.1; and white, non-Hispanic: 2.3. Among low-income children, BLL is: 3.8; middle income: 2.8; and high income: 1.9.

Of the children aged one to five years with elevated blood lead levels living in a home built before 1946, 21.9 percent were African American, non-Hispanic; 13 percent Mexican Americans, and 5.6 percent white, non-Hispanics. Deteriorated leaded paint in older housing is the most important remaining exposure source for these children. Lead poisoning, which can affect virtually everybody system, can result in learning disabilities, behavior problems, and at very high levels, seizures, coma, and even death. CDC has provided Federal leadership in the secondary prevention of childhood lead poisoning through state and local programs. By 1999, 40 state and 16 local health departments received funding through CDC to: ensure screening of high-risk children and follow-up services for children identified as having elevated BLLs; conduct surveillance of blood lead test results; educate healthcare providers and the general public about preventing childhood lead poisoning; and expand primary prevention efforts in high-risk areas.

In fiscal year 2002, approximately $41 million was appropriated for CDC's Childhood Lead Poisoning Prevention Program. Achieving the goal of virtual elimination of childhood lead poisoning is a major challenge that will require a robust collaborative effort of multiple Federal agencies, their partners at the state and local level, and private sector organizations. A Federal interagency strategy to achieve this goal by 2010 has been developed by CDC, the U.S. Department of Housing and Urban Development, the Environmental Protection Agency and others.

The key elements of the interagency strategy include: expanded Federal funding and leveraging private resources to control lead paint hazards before children are exposed to them (primary prevention); early identification and intervention for children with elevated BLLs (secondary prevention), especially for Medicaid-enrolled children; surveillance to monitor progress; and research to further improve prevention methods.

In 2001, the CDC developed the High-Intensity Targeted Screening (HITS) approach for improving the nation's ability to target and screen children for lead poisoning and prevent exposure to lead. HITS consists of the following components. First, Door-to-Door Screening, where teams from local childhood lead poisoning prevention programs and community members, assisted by CDC, visit homes in high-risk communities to screen children for lead. Second, Intervention, when children are found to have elevated BLLs, the families are offered appropriate medical treatment and a home lead evaluation. Third, Capacity Building, where local programs will use HITS data to improve lead screening plans, better direct resources, increase technical capacity, and monitor progress toward lead poisoning elimination. Fourth, Partnership Building, where the HITS approach requires partnerships to be developed between community members and multiple Federal, state, and local agencies, resulting in a more comprehensive approach to eliminating childhood lead poisoning at the local level.

The first HITS project in two inner-city communities in Chicago was completed in November 2001. Blood samples were collected from 580 children 12 to 71 months of age. Though data analysis is ongoing, preliminary analyses indicated that approximately 30 percent of the children had elevated BLLs. The total cost of the project is estimated to be around $62,000.

Smoking and Health

African Americans continue to suffer disproportionately from chronic and preventable disease compared with white Americans. Of the three leading causes of death in African Americans -- heart disease, cancer and stroke -- smoking and other tobacco use are major contributors. CDC funds 13 states and one territory to strengthen their capacity to identify and eliminate disparities related to tobacco use. These states are providing replicable models and critical "lessons learned" on strategic activities that can be undertaken to address tobacco related disparities by other state and local grantees, as well as national partners.

The challenges of developing implementation strategies are immense. Focus is needed on increasing quantitative and qualitative data that inform work on tobacco related disparities. We must also address the need to build capacity and infrastructure among states, territories, tribal support centers, national networks, and specific populations to carry out tobacco control interventions and address tobacco related disparities. CDC will then integrate "lessons learned" into training activities for other national tobacco control program grantees.

Prostate Cancer

Prostate cancer is the most commonly diagnosed form of cancer (other than skin cancer) among men in the U.S. and is second only to lung cancer as a cause of cancer-related death among men. African American men develop prostate cancer at a higher rate than men in any other racial or ethnic group, but the reasons for the increased rate remain unknown. They are also far more likely to die of this disease: 68.1 of every 100,000 non-Hispanic African American men die of prostate cancer compared with 28.8 of every 100,000 non-Hispanic white men, and 19.0 of every 100,000 Hispanic men. CDC-sponsored research with Loma Linda University on prostate cancer screening behaviors among African-American men examines the relationship between what primary care physicians report telling their patients about prostate cancer and how the men perceive the messages. The project will also describe factors that may inhibit or promote preventive screening behaviors among African American men. In addition, CDC is working with the Prevention Research Centers at the University of California at Berkeley to examine clinical and demographic factors that may explain increased risk for prostate cancer among African American men. Findings from this research will be used to tailor prostate cancer prevention efforts.

Youth Media Campaign

CDC's Youth Media Campaign targets young people aged 9 to 13 years ("tweens"), their parents or other primary caregivers, and other key adults (e.g., coaches, school personnel, community group personnel, community leaders, etc.) who have an influence on young people. The campaign is designed to attack head-on the growing epidemic of obesity among America's young people (e.g. 120 percent increase among African American youth in the past decade), through the use of state-of-the art communications strategies currently used by commercial marketers. The media campaign, with development oversight from Frankel of Chicago and Saatchi and Saatchi of New York, will use mass media, in-school media, and a national events tour to 15 cities per year to build campaign awareness and offer youth opportunities to try positive activities-especially physical activity. As a component of the overall campaign, CDC has also awarded two additional contracts to top agencies with expertise in marketing communications to ethnic and minority kids. The "tween" populations targeted by this component of the campaign are African American, Asian American, Hispanic/Latino and American Indian children. The campaign will launch in spring 2002.

In September 2001, the CDC awarded contracts for the national and ethnic-audience components of the campaign. The campaign is working with four minority-owned advertising agencies to reach ethnic youth, their families and communities. Ethnic marketing efforts will complement the general market campaign with specific messages to address ethnic population needs and issues. This will include in-culture and in-language communication as well as efforts focused on segments of ethnic populations that are not effectively reached by general market media: urban inner-core, language dependent, less acculturated, and new immigrants. The ethnic agency efforts will invite participation in the general market campaign as well as provide education about the importance of positive activities on short- and long-term health.

Thank you again for the opportunity to testify before you today. I would be happy to answer any questions at this time.