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HRC
HC CORR 94-H
PERSONAL
&
CONFIDENTIAL
DETERMINED TO BE AN
ADMINISTRATIVE MARKING
INITIALS: ADB DATE: 12 12-4-13
PHOTOCOPY
PRESERVATION
File
Carnegie Corporation of New York
437 Madison Avenue, New York, N.Y. 10022
(212) 371-3200
Fax: (212) 754-4073
David A. Hamburg, M.D.
President
September 30, 1994
MEMORANDUM
TO:
Melanne Verveer
FROM: David A. Hamburg DalA
Thank you very much for your call. I enjoyed our
conversation as I always do. The notion of a meeting on child
health in the United States is an attractive one. Perhaps we can
recapture the spirit of our January 1993 discussion in Blair
House. Since then, the First Lady and her colleagues have no
doubt acquired much insight into child health through their
prodigious efforts in behalf of health care reform.
The Carnegie approach during the past decade has taken a
broad view of child health, putting it in the context of all
factors that influence healthy development during childhood and
adolescence. This inevitably relates health to education and to
the social environment that powerfully shapes the long-term
results of development. Within this framework, we have put our
main emphasis on prevention of casualties and promotion of health
because of the lifelong consequences that flow from experiences
in the early years.
The United States government has very strong capabilities in
this field, especially in the Department of Health and Human
Services. Foundations can contribute through the scope and
flexibility of their action. In the first instance, we do this
by adding to dependable knowledge about the problem being
addressed. In addition to stimulating and supporting new
research, we try from time to time to pull together research from
many different sources to make a coherent account--providing an
intelligible, credible synthesis of major facets of healthy child
development. We try very hard to connect this information with
people who could make use of it for constructive social purposes.
Although this often means the relevant professions, we deeply
believe that it is crucial for the public at large to have
Melanne Verveer
September 30, 1994
Page Two
considerable understanding of ways in which healthy child
development can be fostered. This is one of the important
contributions the First Lady has already made; she could do even
more in the next couple of years.
Foundations also tend to use existing and emerging knowledge
for the creation of models or demonstrations that show how the
knowledge could be used to solve a problem in the real world. In
doing so, we build in feasible measures to evaluate the results,
to sort out what is good for whom under what conditions. We try
to spot interesting innovations across the country--of course
there are a great many--and undertake careful assessment of the
best practices available. All that gives foundations the sense
of what is possible, the most important frontiers and ways in
which we can achieve better results than we are now getting.
Thus, foundations can have a stimulating effect upon the nation,
but they are simply too small to bring about a truly national
transformation of the sort that is needed in view of the serious
problems and heavy casualties we are experiencing in childhood
and adolescence today. This is where the First Lady's continuing
commitment can make an immense contribution.
In light of these considerations, it makes sense to invite
to the forthcoming meeting on child health some key people from
the United States government and from foundations. I attach a
list of reasonable people to invite from the foundation
community. I would be glad to discuss these at your convenience.
In constructing such a meeting, you will of course have to
balance two competing considerations: inviting enough people to
get around the contours of these complex problems, and yet not
inviting so many that meaningful exchange is impaired.
Various approaches might well be useful over the next couple
of years. I will not comment on a legislative strategy since we
have no special competence in that field and it appears
problematic at best under present circumstances. A strategy
focusing on the Executive Branch would permit more options. In
the spirit of reinventing government, better ways of using
existing funds and human resources can be delineated. This
effort is well under way, but it necessarily takes time and would
surely benefit from a specific, well-informed focus on child and
adolescent development.
Best of all from my perspective would be an educational
strategy, using the bully pulpit function of high office. This
approach is singularly important in child health because public
understanding has a direct and strong bearing on the shaping of
healthy lifestyles, as well as judicious use of the health care
system and the fundamental uses of education for health.
Melanne Verveer
September 30, 1994
Page Three
Carnegie, like several other foundations, has been
particularly interested in building a professional consensus on
the base of the best available scientific work, linking
independent experts with the policy community, and informing the
public as widely as possible. From these efforts, we have sorted
out key issues and constructive approaches. What follows is a
substantive summary of the issues in child health that could
profitably be addressed in the fall meeting and over the next
couple of years.
Enclosures
SUGGESTED FOUNDATION INVITEES TO FALL MEETING
ON CHILD HEALTH
Barbara Blum
President
Foundation for Child Development
345 East 46th Street, Suite 700
New York, New York 10017
Tel: 212/697-3150
Karen Davis
President
The Commonwealth Foundation
One East 75th Street
New York, New York 10021-2692
Tel: 212/535-0400
Beatrix A. Hamburg
President
The William T. Grant Foundation
515 Fifth Avenue
New York, New York 10022-5403
Tel: 212/752-0071
David A. Hamburg
President
Carnegie Corporation of New York
437 Madison Avenue
New York, New York 10022
Tel: 212/371-3200
Douglas W. Nelson
Executive Director
Annie E. Casey Foundation
701 St. Paul Street
Baltimore, Maryland 21202
Tel: 410/547-6600
Rebecca W. Rimel
President and Chief Executive Officer
The Pew Charitable Trusts
One Commerce Square
2005 Market Street, Suite 1700
Philadelphia, Pennsylvania 19103
Tel: 215/575-4700
Adele Simmons
President
The John D. and Catherine T. MacArthur
Foundation
140 South Dearborn Street
Chicago, Illinois 60603
Tel: 312/726-8000
Vivien Stewart
Chair, Program on Education and Healthy
Development of Children and Youth
Carnegie Corporation of New York
437 Madison Avenue
New York, New York 10022
Tel: 212/371-3200
Valora Washington
Vice President for Children and Youth
W. K. Kellogg Foundation
400 North Avenue
Battle Creek, Michigan 491-7-3398
Tel: 616/968-1611
If you go beyond a small meeting, you might want to invite
the following people:
Bruce J. Anderson
President
The Danforth Foundation
231 South Bemiston Avenue, Suite 1080
St. Louis, Missouri 63105-1996
Tel: 314/862-6200
Robert B. Rogers
President
Ewing Marion Kauffman Foundation
4900 Oak
Kansas City, Missouri 64112-2776
Tel: 816/932-1000
If the meeting is to deal substantially with financing of
child health care, then it would be worthwhile to invite the
following people as well:
Drew E. Altman
President
The Henry J. Kaiser Family foundation
2400 Sand Hill Road
Menlo Park, California 94025
Tel: 415/854-9400
Richard E. Behrman
Managing Director
David and Lucille Packard Foundation
Center for the Future of Children
300 2nd Street, Suite 102
Los Altos, California 94022
Steven A. Schroeder
President
The Robert Wood Johnson Foundation
College Road
P.O. Box 2316
Princeton, New Jersey 08543-2316
Tel: 609/243-5902
TOWARD HEALTHY CHILD DEVELOPMENT
A WAY OF VIEWING HEALTHY CHILD DEVELOPMENT
The human child is an ancient creature, shaped by many millennia of biological
evolution in ways that pose critical requirements for adequate development. These essential
requirements simply have to be met if the child is to grow and develop, to thrive and learn
and pursue a vigorous, constructive, adaptable life. These requirements have always been
difficult to meet; but if met, they provide profound advantages to our species--ways of
learning and adapting and creating that are unparalleled in the annals of life on earth.
During their years of growth and development, children need dependable attachments,
protection, guidance, stimulation, nurturance, and ways of coping with adversity. Infants, in
particular, need caregivers who can promote attachment and thereby form the fundamental
basis for decent human relationships throughout the child's life. Similarly, early adolescents
need to connect with people who can facilitate their momentous transition to adulthood with
sensitivity and understanding. Usually, despite the radical transformations of recent times,
such people are within the child's immediate family; if not, they exist to some extent in the
extended family. But if these caregivers cannot provide the necessary conditions for healthy
development, then others must make an explicit effort to connect children with persons
outside the family who have the right attributes and also the durability to do so.
The role of the family as the fundamental unit responsible for the health, education,
and general well-being of children is crucial. Whatever has happened to it, it is still the
central organizing principle of society. Yet there have been dramatic changes in the
structure and function of American families in just a few decades. Some of these changes
represent new opportunities and tangible benefits. Others represent serious jeopardy to the
well-being of children--on a large enough scale to pose a major problem for the entire
society.
So we must find different ways to meet the essential requirements for healthy child
and adolescent development--not only through the family, but also through a set of pivotal
institutions that have a strong bearing on the outcomes.
To meet the requirements for healthy child and adolescent development, intervention
should start early with family-equivalent functions. The pivotal institutions are schools,
churches, community organizations, child care agencies, and the health care system--all
augmented by educational functions of the media. A developmental sequence of
interventions starts with prenatal care and goes on to preventive pediatric care, parent
education, social supports for young families, high-quality child care, and preschool
education. The next step is upgrading of the elementary and middle grade school experience
as these schools develop partnerships with strong sectors of American society.
PREVENTING THE CASUALTIES OF EARLY LIFE
Many indices show that the United States is suffering heavy casualties during the
years of growth and development--in educational failure, poor health, and very high-risk
behavior. Generally, these casualty rates are considerably higher than those of other
technically advanced democracies.
Within the scientific and professional communities, a remarkable consensus is
emerging on the conditions that influence child and adolescent development--and how parents
and others can cope with the changes in a competent way. Much has become known about
2
ways to prevent the damage being done to children. It is crucial now to have well-informed,
wide-ranging, multi-faceted public discussions so that constructive decisions can be made by
individual families and by policymakers.
What are the essential requirements for healthy child development and the principal
opportunities for meeting these requirements? Can we illuminate a developmental sequence
of experiences fostering healthy child development and ways of accomplishing this sequence
under contemporary American conditions? In what ways can families be strengthened (if
necessary) to meet the developmental requirements? What extra-familial influences can
strongly help to meet them? For fulfilling the requirements of healthy child development,
what motivation, information, skills, and professional services are highly beneficial? For
each phase of development, is there a strong scientific-professional consensus on these
questions? These questions need to be addressed in informed public discussion guided by
responsible leaders. They need to begin at the beginning: our youngest children.
What could be more important than a decent start in life? All the rest depends on this
foundation. The first few years provide the opportunity for a decent start. Such a beginning
greatly increases the odds of good health, lifelong learning, the acquisition of constructive
skills, and the development of valued human attributes including prosocial behavior. In
short, the time from conception through the third year has a great bearing on physical,
cognitive, emotional, and social development--for better or worse.
If there is not a decent start, opportunities are diminished for constructive
development throughout childhood and adolescence. Some of this is reversible later at high
cost. Some is not reversible at any cost. If a poor start leaves an enduring legacy of
3
impairment, then high costs follow. They may show up in various systems: health,
education, justice. We call them by many names: disease, disability, ignorance,
incompetence, hatred, violence. By whatever name, these outcomes involve severe economic
and social penalties for the entire society. So this is a high stakes game we are playing with
our children and hence with the future of our nation.
Progress in child health during this century has been great, yet very uneven.
Progress has come from improved social and economic conditions as well as great advances
in biomedical science, public health, and pediatric practice.
Preventive Interventions in the First Few Years of Life
As a consequence of efforts to improve the health of children, programs have grown
up in a categorical and fragmented manner which often fails to provide comprehensive and
integrated services for children. During the past decade, we have mainly been treading
water. We need now to formulate a vision of what it would take to fulfill the promise of
present knowledge for the health of all our children. To do so, we need to build a consensus
on crucial elements:
1)
Preparation for parenthood through accurate, meaningful education for children
and adolescents in schools, in families, and communities.
2)
Availability of family planning services for all sexually active men and
women, including adolescents; this means not only contraception but true planning of
families based on knowledge and judgement.
4
3)
Prenatal care during all pregnancies, beginning in the first trimester of
pregnancy. This should include educational and social support components.
4)
Obstetrical and prenatal care environments which enhance opportunities for
early attachment between parents and infant.
5)
Optimal nutrition during pregnancy and beyond.
6)
A stimulating, growth-promoting, health-protective environment in the early
years.
7)
Arrangements for day care for children of working parents as needed--care of
high quality to foster development, not custodial in nature.
8)
Completion of immunizations against all of the preventable diseases for all
children.
9)
Conjunction of child health and social services to minimize the occurrence of
disorders such as failure to thrive, developmental attrition, and child abuse.
10)
Early detection of developmental disabilities and the provision of appropriate
services to provide effective care.
11)
School health services, including early detection and treatment of learning
disorders.
12)
Strengthening of research, not only on the disorders of childhood and
adolescence but on developmental biology as well as the development of long-term healthy
lifestyles.
Preventive services have been found to be effective and indeed cost-effective. One of
the reasons the United States compares so unfavorably with the other established democracies
5
on measures of health status (infant mortality being a powerful example) is our failure to
emphasize primary and preventive care. One of the main contributors to the cost escalation
in the health care sector has been the nation's fascination with expensive tertiary care while
neglecting investment in prevention. Yet, the knowledge base on preventive interventions
has grown.
Many of the causes of damage to children are interrelated and potentially preventable
at reasonable cost. One vivid example is prenatal care--now weak or absent for at least a
quarter of pregnant women in the United States. Yet prenatal care has a powerful capacity
to prevent lifelong damage and is highly cost effective. At its best, prenatal care is a two-
generation intervention that helps both children and parents.
High-quality, early prenatal care for all pregnant women is the essential building
block for children's healthy development. It should include vigorous outreach efforts to
bring poor young women into prenatal care early.
The essential components of prenatal care are medical care, education, and social
support services. Education begins with prenatal care because early, effective care protects
the vulnerable brain of the growing fetus, thus allowing the child later to develop its full
learning capacities; and it makes use of the distinctive motivation of the pregnant mother as
well as the young father to strengthen their knowledge and skill in caring for themselves and
their prospective baby. Moreover, the educational component of prenatal care can be
expanded to include a constructive examination of options for the life course--links to job
training, formal schooling, or other education likely to improve prospects for the future of
6
the young family. In poor communities, young parents need a dependable person who can
provide social support for health and education through the months of pregnancy and beyond.
If the United States implements this enlarged vision of prenatal care, every year many
thousands of babies could be saved. But save them for what? Further opportunities are
needed to foster healthy child and adolescent development. Evidence is accumulating that
interventions in the first few years and then in early adolescence can shape a person's
lifelong course in healthy, learning, constructive ways:
Well-baby care with emphasis on disease prevention and health promotion;
Parent education to strengthen competence and build close parent-child
relationships;
Social support networks in which parents give mutual aid to foster health and
education for their children and themselves;
Child care of high quality outside the home, especially in day care centers;
Preschool education in the Head Start mode; enhanced education in elementary and
middle grade schools; and
Constructive activities beyond school hours in community- based organizations.
Such interventions have strong potential to prevent damage as reflected in indices of
health and education.
Well-baby care oriented to preventing lifelong damage is vital not only for child
health but for building parental competence. This care gives well-informed guidance and
emotional support to help families attain healthy lifestyles. It provides vital services--for
7
example, early treatment of ear infections and correction of vision deficits so that hearing
and visual impairments do not interfere with education.
Five crucial aspects of high-quality child health care need to be considered. It should
be comprehensive, continuous, coordinated, accessible, accountable. These desiderata for
poor communities constitute something more than a hypothetical ideal. A concrete example
has been of national importance over several decades: community health centers, originally
known as neighborhood health centers. They still flourish in various parts of the country
despite inadequate funding. They offer a range of medical and support services in the
community and have proved their accessibility to low-income populations. Some of these
centers have been carefully evaluated, and the evidence of their value is clear.
The most effective preventive medicine for infants is immunization against the
common infections of childhood. Clearly the best course to pursue is comprehensive
immunization at appropriate times in the earliest years. The administration's bold initiative
in this field needs to be widely understood and pursued with long-term commitment.
A substantial amount of research in child development makes clear that intervention
programs can help parents become teachers of their own children--at least to make clear to
their children the strong value they put on intellectual achievement and constructive human
relations. Research has shown that quality day care plus parent education can yield strong
results in cognitive and social development during infancy and early childhood in high-risk
urban poverty populations. Often the adolescent mothers involved in these intervention
efforts benefit as manifested by their going on to higher levels of education; and there is
some evidence of beneficial effects on younger siblings. Like prenatal care, this can be a
8
two-generation intervention--benefiting young parents and their children, even for the entire
life span.
The lessons of Head Start have wide applicability. This kind of early stimulation,
encouragement, instruction and health care--all with substantial parental involvement--can
also be incorporated into a variety of child care settings, and thereby help to reduce
casualties. The linkage of health and education is fundamental in these interventions. The
basic concepts can be usefully adapted to earlier ages. But Head Start is not best seen as a
one-time event--akin to immunization. Rather, it is a valuable part of a development-
promotion sequence throughout childhood and adolescence.
Home visiting by human services professionals can be a relatively efficient and
effective way of addressing the many needs of poor families with young children. Home
visitors can engage family members in solving problems of housing, food, health, child
rearing, child development, and family relationships.
Research evaluations of home visiting programs show that they can have beneficial
effects on health and well-being, especially for poor adolescent mothers and their families.
Families that have had the benefit of home visiting have lower rates of small-for-gestational-
age and low-birthweight babies, the babies are healthier at birth, have fewer accidents in the
first year of life, are immunized more often, experience less child abuse and neglect, and
show improved cognitive performance. These benefits can be long lasting, as demonstrated
by the best- studied early intervention programs aimed at preventing damage to disadvantaged
children.
9
Barriers to Health Care for Young Children
Research has clarified five barriers that stand between children and preventive
primary health care: 1) Absence of insurance or other source of financing. 2) Capacity
problems in the health care system. 3) Services that are not "user friendly". 4) Lack of
motivation to seek health care. 5) Serious social disorganization in the community.
Research and field experience suggest that the first barrier--having no source of
payment for care--is the most potent one. When children and their families have insurance,
they are able to increase their participation in preventive services and health care generally.
However, access to health insurance does not level the playing field, particularly for high-
risk and/or low-income children and pregnant women. Access to insurance is not equivalent
to access to health care, and reducing the financial barrier does not necessarily eliminate the
other four.
A wealth of experience gives clues about what to do to improve the health care
system, in addition to providing all citizens with a financing source for health care.
Increasing service capacity. There are several clear remedies for increasing the
service capacity of distressed communities. They include increasing grant-supported services
such as community health centers; supporting the training and deployment of health
professionals and mid-level professionals (nurse-midwives, physicians assistants) committed
to working in medically underserved areas; and delivering care in unconventional ways and
in unconventional settings (e.g. services provided via home visiting, through school-based
clinics, or in conjunction with Head Start centers).
10
Making services more "user friendly". Achieving this goal through broad scale
changes in national policy is not easy because the tone and details of services usually are set
by leaders at the local rather than at the national level. But standards of performance,
training funds, and incentives that emanate from central sources, such as the federal
government, can signal attention to these intangibles, and highlight success stories.
Increasing motivation. Raising the level of motivation and information that
individuals need to act in their own best interests requires education, social support, and
outreach to those who, despite a functioning health care system, still fail to use its most basic
offerings, such as immunizations.
Repairing social disintegration. The last barrier, the disintegration of our poorest
communities is, of course, one of the most pressing national problems. It has little to do
with health or preventive services, and much to do with poverty, discrimination, economic
development, revitalization of schools, and the strengthening of families and communities.
EARLY ADOLESCENCE: A CRITICAL AND NEGLECTED OPPORTUNITY
Early adolescence (ages 10-15) is a crucially formative and badly neglected period. It
is a time of biological upheaval and social transition. There is much exploratory behavior,
including very risky behavior that has lifelong significance. Many dangerous patterns
emerge during these years: becoming alienated from school and dropping out; starting to
smoke cigarettes, drink alcohol, and use other drugs; starting to drive automobiles and
motorcycles in high-risk ways; not eating an adequate diet or exercising enough; risking
11
early pregnancy and sexually transmitted diseases; and in some ways worst of all,
undertaking the use of weapons, even highly destructive ones.
Initially, adolescents explore these new possibilities tentatively. Experimentation is
typical of adolescence. Before damaging patterns are firmly established, there is a vital
opportunity to prevent lifelong casualties. This opportunity is frequently missed in most
communities now-all too often with tragic results.
Preventive Interventions for Early Adolescents
The public policy response to adolescence has been problem specific, often
overlooking the underlying needs of adolescents under contemporary conditions. To meet the
essential requirements for healthy adolescent development, we must help adolescents to
acquire constructive knowledge and skills, inquiring habits of mind, dependable human
relationships, a reliable basis for earning respect, a sense of belonging in a valued group, and
a way of being useful to others. These basic needs can be met by a conjunction of pivotal
institutions: family; school; churches; community-based organizations; the health-care
system; and the media.
Interventions in early adolescence include:
1)
Reforming middle grade schools to create small communities for learning,
where stable, close relationships with adults and peers allow for intellectual and personal
growth.
2)
Creating school environments which promote healthy lifestyles, with particular
emphasis on a life sciences curriculum.
12
3)
Training in life skills including decisionmaking, conflict resolution, and
resistence to peer pressure.
4)
Strengthening social support mechanisms for adolescents by reengaging
families with their children's schools, and, where necessary, providing mentors to
supplement the family.
5)
Creating safe havens in community-based organizations after school, when
many adolescents are left alone, and where healthy lifestyles could be learned.
6)
Providing a perception of opportunity and of value to the community for
adolescents by engaging them in community service, and work-study programs.
7)
Making health care services and counseling available in "adolescent friendly"
and accessible locations, including school-based or school-linked.
As children experience puberty and emerge into an era in which they feel they should
quickly become adults, they in effect ask, "How shall I use my body?" Any responsible
education system must answer that basic question with a substantial life sciences curriculum
that gives them accurate information about their bodies, including the effects of various high-
risk behavior patterns. But information is not enough.
Life skills training can become a vital part of education in schools and community
organizations, so that adolescents can learn how to make informed, deliberate and
constructive decisions--rather than ignorant, impulsive, and destructive ones. Such training
can also enhance their interpersonal skills, their ways of relating decently to others, learning
from their experiences, even unpleasant ones, such as how conflicts can be resolved without
13
violence. Skills can be developed for establishing dependable friendships and participating in
supportive problem-solving groups. But even this is not enough.
People need people, especially to weather the inevitable difficulties of growing up, the
stresses of education, and the turbulent search for ways to protect our own health and the
health of those we care about. To the extent that contemporary families are unable to meet
these needs, specially designed social support interventions can be exceedingly helpful.
Thus, the life sciences curriculum linked with life skills training and social support
interventions can provide the vital information, skills and motivation necessary to meet the
requirements for healthy adolescent development. Moreover, this conjunction of information,
skills and motivation for development, indeed for survival, can be provided through the
foresight and cooperation of several pivotal institutions that powerfully shape the transition
from childhood to adulthood: family, schools, health care system, media, and community
organizations that reach out to youth.
But there is still a serious unmet need for accessible health care. It may be at or near
the school. In any event, it must be arranged in such a way that adolescents can clearly
recognize that the care is available, within reach, and adapted to their distinctive needs.
Education can contribute to the development of healthy lifestyles. Through education
in various channels, motivation may be strengthened and sustained, accurate information
assimilated, and relevant skills developed. Such education involves not only the schools and
health professionals but also the media. Family, churches, and community organizations can
contribute as well. In poor communities, a key element in motivation is the perception of
opportunity. Without such perception and concomitant hope, there is little incentive to avoid
14
the immediate pleasures associated with psychoactive drugs and other health-damaging
behavior.
Recent school-based and community-wide preventive interventions have been carried
out in careful research designs. These focus on cigarette smoking but have made some
extension to alcohol and other drugs as well--"gateway" substances. The results are clear: It
is feasible to diminish substantially the use of gateway substances in early adolescence.
Moreover, this can be done in a way that enhances personal and social competence pertinent
to other aspects of adolescent development. In school and out, it is possible to build
competence, to earn respect, to construct a friendship group capable of resisting pressure to
use drugs, and to delineate a vision of an attractive future and prospects for a decent life.
An important part of this in poorer communities has to do with making early opportunities
visible to young people before the drug pathway becomes firmly established. Work-study
activities are helpful in this regard, along with training in essential, generic employability
skills and practical employment counseling.
Nearly one million adolescents between the ages of twelve and nineteen are victims of
violent crimes each year, and this has been true at least since 1985. Over all the concerns
about adolescent violence hangs the threat of firearms. Yet, there is overwhelming evidence
that we can intervene effectively in the lives of young people to reduce or prevent their
involvement in violence. For example, research indicates that conflict resolution and
mediation programs show positive effects in reducing violence. Assertiveness, taught as a
social skill, helps young help learn how to resist unwanted pressures and intimidation,
resolve conflicts nonviolently, and make sound decisions about the use of weapons.
15
Programs which promote healthy and enduring relationships with adults as well as peers,
such as mentoring and community-based youth activities, have the potential to provide
constructive alternatives to joining violent groups.
Barriers to Health Care for Adolescents
Many adolescents are in need of preventive primary health care and treatment for
health problems, yet they are likely to face barriers to these services. There is a growing
consensus about these barriers: 1) Lack of health insurance and limitations in coverage. 2)
Inadequate information about the availability of services. 3) Health services that may not be
appropriate to the adolescent developmental and experiential levels. 4) Scarcity of
experienced and well-trained health providers who treat the health problems of adolescents,
especially when the adolescents are poor and uninsured. 5) Lack of independent legal access
to services. 6) Concerns about parental consent and notification and fear that confidentiality
will be breached. 7) Gaps among service systems for adolescents with multiple health
problems.
There are numerous examples of promising adolescent health promotion, primary
prevention, and treatment interventions, but they have been implemented only sporadically.
These promising interventions can provide considerable guidance for program implementation
and the continuing design of more effective approaches for adolescents.
16
OVERCOMING DISADVANTAGE
The problems of children in poverty intensify--indeed dramatically highlight--the
problems of modern societies altogether. The poignant dilemma is that great technical
advances are associated with massive dislocations--and children are often caught in the
crunch, especially in the inner city. Degraded conditions became a breeding ground for
disease and violence. So it is clearly in the self-interest of the entire nation to consider the
well-being of all our children.
For the child growing up in an area of concentrated poverty, two crucial prerequisites
to healthy, constructive development appear to be seriously lacking: secure attachments to
dependable and successful adults, and the perception that opportunities exist in the
mainstream economy. To the extent that families and communities are eroded, disintegrated,
or otherwise weakened under circumstances of persistent poverty and social depreciation, it is
necessary to focus on other social support networks--by strengthening the family or by
providing substitute experiences that meet these essential needs.
With younger children, social supports have to become a deliberate feature of
effective interventions throughout development: in prenatal care, child care, preschool
education, after-school and Saturday experiences during elementary years, and in the reform
of the middle grade schools. At every level, in some developmentally appropriate way, it is
possible to construct parent groups, parent education, outreach to families through indigenous
paraprofessionals, and links with professionals as needed for more serious problems. In
short, social support networks that sustain effort and hope are crucial for health and
education in poor communities.
17
A variety of organizations and institutions can provide supplements or even surrogates
for parents, older siblings, and an extended family. Across the country there are
encouraging examples of such interventions. Some are based in churches (such as the
initiative of the Congress of National Black Churches), some are based in community
organizations (e.g. Boys and Girls Clubs), others involve youth service (Campus Compact,
based in colleges and universities), and others are based in minority organizations. The
central point here is that churches, schools, community organizations, and businesses can
build constructive social support networks that attract disadvantaged youngsters in ways that
foster their health, their education, and their capacity to be accepted rather than rejected by
the mainstream society.
CONCLUDING COMMENT
In this unique society--probably the most technically advanced, affluent, and
democratic the world has ever known--the crucially formative years of childhood and
adolescence have become battlefields, literally as well as figuratively. Our schools as well as
our hospitals and our streets are littered with avoidable casualties. The time has come to
make a nationwide, research-based effort to reduce greatly the killing, maiming, and
enormous waste of talent.
We can make many constructive responses to the casualties of early life. Some
interventions are well documented. Others are promising, but the research is too limited for
definitive answers. We can make substantial progress by deepening our understanding of
human development, by fostering public understanding of our children's urgent needs and
18
opportunities, and by strengthening our scientific and professional commitment to tackle
these problems over a wide spectrum of constructive approaches.
There is reason to believe that powerful sectors have begun to converge on the
problems of children: business, government, clergy, media, science and several
professionals including the military. If a broad public consensus emerges on the facts, multi-
sectoral leadership continues to grow, and constructive policy options are fully considered,
we could see a real transformation in the health and well-being of all our children. The First
Lady could provide extraordinary leadership for this great effort. Some possibilities include
highlighting promising approaches, mobilizing multiple sectors of society, and examining
needed linkages between existing services. The First Lady could do a great deal to educate
the public and policymakers. One option would be through a high-level mechanism such as a
Council on Children and Families. No doubt she would utilize a variety of opportunities for
this vital mission, always conveying to the American people an accurate and inspiring picture
of what is needed and what is possible. In this way, she would make a contribution of
enduring value.
David A. Hamburg, M.D.
President
Carnegie Corporation of New York
19
THE WHITE HOUSE
October 31, 1994
Allen Harris, R.N.,C.
Kaiser Foundation Medical Center
2590 Geary Boulevard
San Francisco, California 94115
Dear Mr. Harris:
Thank you for writing about the Terry
Beirn Community Program for Clinical
Research on AIDS (CPCRA). As you know,
the CPCRA plans and conducts community-
based clinical trials of experimental
treatments for AIDS.
In your note, you raised concern
about reductions in the CPCRA budget. The
budget for the CPCRA for fiscal year 1995
is approximately $20 million, as it was in
fiscal year 1994. The CPCRA recently
awarded contracts to 12 existing and four
new community-based research sites. Five
existing sites will be phased out over the
next few years based on the evaluations of
an independent peer review.
Thank you again for writing. Please
feel free to contact Jennifer Klein at
(202) 456-2599 with any additional
questions or concerns.
Sincerely yours,
Rochem Clinin
Hillary Rodham Clinton
Handled by phone
call.
J. Klein
[
Sp
provided
Results
Generating Political Will to End Hunger
BOARD OF DIRECTORS
Bill Clapp
July 16, 1994
President and CEO
Matthew G. Norton Co.
Susan George
Associate Director
Transnational Institute
Author
Hillary Rodham Clinton
Vicky Guzman, MD
The White House
President, ASAPROSAR
1600 Pennsylvania Avenue
Valerie Harper
Washington DC 20500
Actress
Sam Harris
Executive Director
Dear Ms. Clinton,
RESULTS
RESULTS Educational Fund
Over the last decade, the House and Senate Foreign Operations
Raul Julia
Subcommittees have played a leadership role in assuring increased funding
Actor
for child survival, basic education and micronutrients such as vitamin A
Carol Kane
which have helped saved the lives of four million children each year. In
Actress
1994, Congress removed binding funding levels and child survival funding
Sara Keeney
was cut for the first time in a decade.
Grassroots Board Member
Scott A. Leckman, MD
"The Clinton administration," says The Arizona Daily Star, "has been
Grassroots Board Member
inexcusably slow to grasp the importance of reserving money for child
survival, and last year the Agency for International Development cut child
Ernest Loevinsohn
Dir. General, Policy Branch
survival funding by $40 million below 1993 levels and basic education by
Canadian International
$30 million. There is no justification for this. It represents the first cut
Development Agency
in child survival money since the fund was created 10 years ago."
T. Brient Mayfield
2
0
President
Resource Optimization, Inc.
The Senate foreign aid appropriation bill provides the following binding
funding levels: $185 million for child survival; $135 million for basic
Hon. Claudine Schneider
education and $25 million for micronutrients. We urge House and Senate
Former Member of Congress
conferees to agree to the Senate's binding levels.
Hon. Maxine Waters
U.S. House of Representatives
Sincerely,
Shirley Williams
Grassroots Board Member
Sam Harris
Chuck Woolery
Sam Harris
Grassroots Board Member
Executive Director
Prof. Muhammad Yunus
Managing Director
Grameen Bank
Organizations listed for
informational purposes
only.
236 Massachusetts Avenue, N.E., Suite 300, Washington, D.C. 20002, U.S.A. Tel: (202) 543-9340 Fax: (202) 546-3228
Australia Canada Germany Japan Mexico Russia Ukraine United Kingdom United States
Affiliates: El Salvador Lesotho
Editorial Comment on the FY 95 Foreign Aid Appropriations Bill
Congress should specify that the U.S. Agency for International Development provide
funding for child survival, basic education and micronutrient programs at or above the
1993 level.
"The Progress of Nations," Albuquerque Journal,
June 27, 1994.
New Jersey's House members should urge the House conferees to accept the Senate's
funding levels and the binding language requiring USAID to devote these resources to
children and families.
"Save the children," The Times: Trenton, NJ,
June 23, 1994.
What the Senate bill does is to earmark a certain amount of foreign aid money for
child survival so that it can't be shifted to some other use Now the full Senate has to
approve it, and then a joint House-Senate conference committee.
"New foreign aid priorities," The Arizona Daily Star: Tucson, AZ,
June 23, 1994.
The $285 million that the U.S. would set aside for such "child survival"
programs under a foreign aid amendment sponsored by Sen. Mitch McConnell
looks like an enlightened investment, one that can contribute to social and
economic progress at reasonable cost Sen. McConnell and his allies are
pushing in the right direction. They deserve to carry the day on the floor and
in negotiations with the House.
"Foreign aid for children," The Courier-Journal: Louisville, KY,
June 26, 1994.
In the United States, one way people can help is to support earmarking foreign
aid funds to be used for child survival, basic education and nutritional
supplements The earmarking, which is not included in the House version of
the bill, is necessary since the Clinton Administration last year cut funding for
Third World children's programs.
"Progress of Nations' report shows goals are achievable", The Ann
Arbor News: Ann Arbor, MI,
June 27, 1994.
Tucson, Thursday, June 23, 1994
Comment
The Arizona Dailn Star
Founded 1877
Stephen E. Auslander, Editor
Michael E. Pulitzer, Publisher
James M. Kiser, Editorial Page Editor
EDITORIALS
New foreign aid priorities
When the Senate takes up a foreign
In a new report for UNICEF entitled
aid bill, probably this week, it will consid-
"The Progress of Nations," author Peter
er a change in how the aid is spent. As
Adamson points out that people tend to
unimportant as the action may seem, it
see the Third World as a theater for trage-
could save the lives of millions of children
dy where nothing relieves the miseries and
in developing countries.
disasters. In fact, remarkable success sto-
What the Senate bill does is to ear-
ries happen all the time in the poor na-
mark a certain amount of foreign aid mon-
tions when they are given the simplest
ey for child survival so that it can't be
tools. Oral rehydration with a salt solution
shifted to some other use. Immunizing,
something like Gatorade prevents the diar-
feeding and teaching children in develop-
rhea deaths of a million children a year.
ing nations is not as politically rewarding
Yet millions without access to it continue
as filling special requests of foreign lead-
to die.
ers, but it is a sounder, more long-lasting
Since the mid-1980s there have been
use of foreign aid money.
3 million fewer child deaths because of in-
The Clinton administration has been
expensive vaccine series sent by countries
inexcusably slow to grasp the importance
like the United States, yet 2 million chil-
of reserving money for child survival, and
dren a year continue to die from vaccine-
last year the Agency for International De-
preventable diseases.
velopment cut child survival funding by
$40 million below 1993 levels and basic
World Bank studies show that for
education by $30 million. There is no jus-
each additional year of educating girls -
tification for this. It represents the first
long neglected in developing countries -
cut in child survival money since the fund
there is a 10 percent decrease in both
was created 10 years ago.
birth rates and child death rates, as well
as a 10 percent to 20 percent increase in
Arizona's Sen. Dennis DeConcini
wages. That is a small remedy of a tradi-
managed to earmark child survival money
tional neglect that yields rich rewards in
as the bill emerged from the Senate ap-
return.
propriations subcommittee on foreign op-
erations. Now the full Senate has to ap-
Not a dollar more in foreign aid is
prove it, and then a joint House-Senate
asked for this year - simply a shift in pri-
conference committee.
orities. It seems eminently wiser for the
The way the bill stands now, it would
U.S. government to invest in the right pro-
restore the cut money, spending $285 mil-
jects than to let it siphon off money to-
lion for child survival, $135 million for ba-
ward less urgent, less prolonged benefits.
sic education and $25 million for micronu-
You build a nation through its people,
trients such as Vitamin A. Deficiency of
and the earlier you affect its tiniest citi-
Vitamin A causes 250,000 children a year
zens, the deeper the impact for stabilizing
to go blind.
and democratizing its future.
THE ANN ARBOR NEWS
MONDAY, JUNE 27, 1994
UNICEF
One goal that UNICEF seeks to accomplish through the
annual report is to overcome malnutrition. About 55 per-
'Progress of Nations' report
cent of 13 million children under 5 die from malnutrition
each year. Simple. inexpensive steps can be taken to de-
shows goals are achievable
crease deaths from malnutrition. beginning with promot-
ing breastfeeding over bottle feeding and educating par-
Each year the United Nations Children's Fund puts out
ents on how to feed children a balanced diet.
a report that evaluates and ranks nations according to how
Providing adults with know-how. the report says. is one
well they treat their citizens. particularly their children. It
of the best ways to achieve results in all areas - educa-
provides an instrument for holding governments account-
tion. health care. nutrition. family planning, equality for
able on a level that is more difficult to judge than the
women.
strength of the economy or military.
Governments also need to be active participants. For ex-
The 1994 "Progress of Nations" is a 54-page report that
ample. by doing something as simple as adding iodine to
paints a picture of a world in which many countries. poor
salt, governments can reduce iodine deficiency. The lack
and rich alike. are beginning to achieve some of the inter-
of iodine in diets causes mental deterioration. which is es-
national goals set at the 1990 World Summit for Children.
pecially severe for children, dry skin and a subnormal met-
That's truly good news. even though there is still much
abolic rate.
work to be done.
Peter Adamson. the editor of "Progress of Nations" says
Progress continues to
that the conditions that support improvement in the meet-
be made. for example. in
ing human needs are these: A functioning democracy
immunizing children. The
tends to be good for children. Equally important is the
The report
summit goals call for 90
commitment of the government's leaders. in democracies
percent immunization for
or not. to improving living conditions. Another key is the
provides an
infants by the year 2000.
willingness of governments and people to use technologies
The report shows that in
and techniques in which we have the ability to achieve a lot
instrument for
1978. only 15 percent of
for a small investment. such as providing Vitamin A sup-
holding
developing world's chil-
plements.
dren were being immu-
In the United States. one way people can help is to sup-
governments
nized for simple childhood
port earmarking foreign aid funds to be used for child sur-
accountable on
diseases. That figure now
vival. basic education and nutritional supplements. The
has climbed to 80 percent.
Senate is debating the 1995 foreign aid funding bill this
a level that is
Also. more Third World
week and next. and in its version. has set aside $692 million
governments are begin-
out of a $10.9 billion for those purposes. The money is
more difficult to
ning to use oral rehydra-
channeled through the U.S. Agency for International De-
tion therapy to prevent
velopment. The earmarking, which is not included in the
judge than the
deaths caused by diar-
House version of the bill. is necessary since the Clinton ad-
strength of the
rhea. The result is that
ministration last year cut funding for Third World children
about 1 million more lives
programs by $40 million. The Senate bill would return
economy or
are being saved today.
funding to 1993 levels. It's a minimal step in support of pro-
compared to a decade ago
grams that actually work.
military.
when the simple. inexpen-
The measures provided in UNICEF's Progess of Na-
sive therapy moved out of
tions" are tools that people can use to advocate for better
laboratories and into real
living conditions at home and abroad. By pointing out
lives. Still. 3 million chil-
where needs are being met. the report provides role mod-
dren each year die be-
els: by showing where needs are not met. the report shows
cause of the effects of diarrhea. Yet. when countries like
where the world community can work to bring about
Zambia. Cameroon. Bhutan. Cuba, Uruguay and Venezue-
change. It points the way. but progress still depends on the
la can successfully treat more than 80 percent of those suf-
willingness of people to use the report and other tools to
fering from diarrnea. there is reason for hope.
improve our world.
The Courier-Journal
SUNDAY, JUNE 26. 1994
Foreign aid for children
HE appalling events in
cripple children in poor countries,
T
some poor countries -
including blindness that results
war, famine, political tur-
from lack of Vitamin A and diseases
moil - would seem to be
like polio and measles that can be
grounds for unrelieved pessimism
slowed by immunization. A simple
about the prospects for many mil-
therapy combats dehydration
lions of people.
caused by widespread diarrhea. The
In fact, according to the annual
McConnell amendment would ad-
report of the United Nations Chil-
vance such efforts.
drens Fund, these horrors obscure
Addressing basic health, nutri-
steady, sometimes dramatic pro-
tional and educational deficiencies
gress that developing nations have
is very much in line with the boom-
made in improving nutrition, health
ing interest in backing "microen-
and education. What's no less strik-
terprises" - tiny ventures, almost
ing is that big improvements can be
always run by women, that have
made for relatively modest sums.
begun to stir economic activity in
The $285 million that the U.S.
places where there is very little.
would set aside for such "child sur-
As The Wall Street Journal re-
vival" programs under a foreign aid
ports, even big multilateral agencies
amendment sponsored by Sen.
like the World Bank, under fero-
Mitch McConnell looks like an en-
cious attack again for financing
lightened investment, one that can
huge development projects that of-
contribute to social and economic
ten leave people worse off, are buy-
progress at reasonable cost. Con-
ing into the idea that it's productive
trary to Clinton administration
to build from the bottom up.
wishes, the measure would restrict
Sen. McConnell and his allies are
use of the money to these purposes.
pushing in the right direction. They
The means exist, UNICEF argues,
deserve to carry the day on the floor
to control the scourges that kill or
and in negotiations with the House.
The Times
JUNE 23. 1994
Save the children
We Americans read and hear of massacres in Rwanda, of
seemingly endless fighting in Bosnia, of food shortages in
Haiti, of man-made suffering all across the planet, and our
natural reaction is to throw up our hands in despair. How can
we possibly mitigate these complex tragedies?
One thing to keep in mind is this: that far greater numbers of
children die every year of chronic poverty than of war. They
die not of massacres but of measles and dehydration. Nearly 13
million children perish annually of preventable malnutrition
and disease. And we know how to prevent this.
Global investment in child survival is saving millions of chil-
dren's lives each year. Yet the effort is falling far short of the
ability. UNICEF's Progress of Nations report, released this
week, noted that, thanks to increased global immunization
rates, there are three million fewer child deaths annually. Yet
two million continue to die from vaccine-preventable diseases.
With oral rehydration therapy - a simple Gatorade-like solu-
tion now used by nearly 40 percent of the world's families -
one million child deaths are prevented each year. But three
million continue to die from dehydration. Basic education to
all, especially girls, decreases birthrates and child death rates;
yet 60 percent of girls in sub Sabaran Africa and 47 percent in
South Asia don't reach fifth grade.
Sadly, cuts in U.S. foreign aid for life-saving child survival
and basic education programs indicate that the Clinton admin-
istration fails to fully recognize those basic, doable strategies
that can protect children around the world. This year, for the
first time in a decade, the U.S. Agency for International Devel-
opment (USAID) cut funding to child survival, vitamin A and
basic education programs. That happened after Congress elimi-
nated earmarks (binding funding levels) for 1994 foreign aid
spending, giving USAID freedom to allocate funds as it chose.
Last month the House approved a foreign aid funding bill
that held child survival and basic education funds at their 1993
levels and again failed to earmark them. However, on June 16,
the Senate Appropriations Committee reported out a bill con-
taining binding funding levels of $285 million for child survival
($10 million above the 1993 level), $135 million for basic educa-
tion and $25 million for micronutrients. The bill calls for NO
increase in the overall foreign aid budget. Sen. Frank Lauten-
berg, D-N.J., as a member of the committee's Foreign Opera-
tions Subcommittee, was a key player in getting this done.
Assuming Senate passage of the bill, the focus will then be on
the House-Senate conference to reconcile the two versions.
New Jersey's House members should urge the House conferees
to accept the Senate's funding levels and the binding language
requiring USAID to devote these resources to children and
families. If America cares about the world's future, and avert-
ing human anguish, it will seize this golden opportunity.
Trenton, New Jersey
ALBUQUERQUE JOURNAL
Monday, June 27, 1994
The Progress of Nations
Take a look at the salt shaker on the kitchen table.
Other problems such as severe Vitamin A deficiency will
Those ordinary-looking crystals have helped prevent ter-
take longer to overcome. More progress can be made only
rible health problems in America for decades, ever since
if nations continue their commitment to improving chil-
manufacturers started fortifying salt with iodine.
dren's lives. That commitment includes money.
People who don't have sufficient iodine in their diets can
The United States, which provides funding for some of
suffer from goiter and reduced mental and physical per-
the health improvement projects, should make sure funds
formance. For newborns, insufficient iodine can lead to
for these critical programs aren't reduced. Congress
mental retardation.
should specify that the U.S. Agency for International
But a health problem that is mostly a distant memory in
Development provide funding for child survival, basic
America continues to exact a terrible toll in many devel-
education and micronutrient programs at or above the
oping nations, especially among children. It is one of many
1993 level. Funding for some of the programs was reduced
health problems that can be prevented easily and cheaply
for this year.
- if people have basic knowledge and funding to combat
Our own nation falls short in its treatment of some chil-
the problems.
dren, although many problems here are different than
The United Nations Children's Fund last week drew
those in developing nations, the report said. According to
much-needed attention to the progress nations have made
the World Health Organization, the United States is first
in improving the health and well-being of children. In a 50-
among the industrialized nations in the rate of teen-agers
page report, UNICEF also showed that millions of children
who are murdered.
continue to suffer unnecessarily.
Despite the continuing problems here and around the
Peter Adamson, the report's editor, said the public -
world, Adamson and others who worked on the UNICEF
after seeing the carnage in Rwanda and scenes of starva-
report are right to emphasize what has been accomplished.
tion and deprivation in other countries - may view devel-
In many cases, small steps taken by people at the grass-
oping countries as places of tragedy and hopelessness.
roots level have to big changes in the lives of individ-
But, in fact, some of the poorest nations in the world are
ual children.
making huge progress in bettering the lives of children.
Local workers such as teachers and nurses, who have
And they are doing that with a tiny fraction of the funds
learned how important the contents of a salt shaker can be,
that nations spend on bombs, guns and tanks.
are transforming young lives for the better. But they need
Take the example of iodine. According to UNICEF and
the support of the United States and the rest of the world
the World Health Organization, efforts to educate the pub-
if they are to extend these small, health-saving - and life-
lic and increase iodization of salt are paying off. More than
saving - measures to every child.
half a billion people in the 12 most seriously affected coun-
tries have started using iodized salt in the past five years
- and an estimated 120 million children were spared from
iodine deficiency. Adamson is convinced most salt sup-
plies in the world will be iodized by 1995.
Press-Telegram
604 Pine Avenue, Long Beach, Calif. 90844
WEDNESDAY, JUNE 22, 1994
Children who will survive
I
t's sometimes overwhelming to think
Thousands of volunteers from the devel-
about the millions of children around
oping countries are spreading the word
the world who needlessly die because of
about family planning, oral rehydration
malnutrition, preventable diseases and
therapies for children with diarrhea and
lack of access to adequate health care. And
the benefits of immunization. Some of
for those who are maimed or orphaned by
them get involved in prenatal health,
wars raging in places like Rwanda, Bosnia
nutrition planning and literacy programs.
and Yemen, remedies often seem hopeless-
These are not the famous individuals
ly elusive.
whose good works will be featured in
But, according to the editor of a United
books, magazines or on television. They
Nations Children's Fund (UNICEF) re-
are the foot soldiers who are trying to
port, millions of children are alive today
make a difference in their own communi-
because an increasing number of govern-
ties. Sometimes that difference is star-
ments are implementing child-centered
tling: Sri Lanka has an 88 percent literacy
programs designed to save lives, while
rate, although the per capita income is
improving the quality of life. Peter Adam-
only $540 per year. When compared to
son, an adviser to the executive director of
Saudi Arabia, which has a per capita
UNICEF and editor of The Progress of
income of $7,940, but a literacy rate of
Nations annual report, shared this good
only 62 percent, it becomes obvious that
news Tuesday with a group of editorial
money isn't the only barometer by which
writers across the country and Canada. In
to measure a country's progress.
an one-hour telephone conference call,
The nongovernmental organizations, the
Adamson told how some poor countries
have taken meaningful strides to increase
World Health Organization and UNICEF
should also be credited for many of the
immunization rates, decrease malnutrition
and expand primary educational opportu-
advances that have been made in the past
nities.
20 years. These organizations lobby gov-
ernment leaders around the world to adopt
It is a mistake to picture developing
and fund programs that protect and pro-
countries as a theater in which only
mote children. UNICEF alone has met
tragedies are played. This view belies the
with 100 of the world's presidents and
fact that more than 90 percent of the
prime ministers, attempting to show the
children in poor countries like Zimbabwe,
Sri Lanka, Jamaica, Cuba and Botswana
long-term cost effectiveness of eradicating
are now guaranteed primary school educa-
preventable diseases.
tion. It would overlook the momentum
The organizations' current test is to
that has been building around the world
convince the Clinton administration to
for all governments to provide iodized salt
maintain foreign assistance funding for
or other food with iodine to all its citizen-
child survival and basic education pro-
ry. In the last five years alone, supplemen-
grams. For the first time in a decade, the
tary iodine programs have saved millions
U.S. Agency for International Develop-
of children from being born severely men-
ment last year cut funding to such pro-
tally retarded.
grams. In May, the House recommended
There are about 3.5 million children
that funding be restored to 1993 funding
walking around and playing today who
levels, but did not make the recommenda-
would have been disabled by polio had
tion binding. It's now up to the Senate. If
there not been government-sponsored vac-
lawmakers are interested in continuing
cination programs. Another 2 million chil-
the admittedly slow, but steady progress of
dren a year escape a fatal encounter with
improving conditions for the world's chil-
measles, while an additional 1 million will
dren, they will reject attempts to cut the
survive the dreadful dehydration of diar-
relatively modest amounts of foreign aid
rheal diseases.
that helps them.
The Oregonian
MONDAY. JUNE 27, 1994
Good news about kids
Worldwide child-survival programs
claim a growing number of living, breathing success stories
ake a break from bad-news
ing of child welfare.
T
headlines. It's time to hear
Adamson talked to The Oregonian
some good news about the
recently to shine a spotlight on the
state of the world's children.
success of child-survival programs.
The attention the developing and in-
dustrialized worlds have paid to child
"People think the Third World is a
survival in the last several years has
stage on which no light ever falls," he
yielded significant results:
said. "That simply isn't true. There
Two million children through-
are stories happening on that stage
out the world won't die of measles in
that aren't tragedies. Millions of peo-
1994, because immunizations are pro-
ple are working, unrecognized. there
tecting them.
and throughout the world every day
to make things better."
One million children won't die
from dehydration caused by diarrheal
There is, of course, plenty more the
disease because their families have
United States and other countries can
been taught inexpensive, life-saving
do to promote child welfare here and
oral-rehydration techniques.
abroad. Increasing the amount of U.S.
Hundreds of thousands of new-
foreign aid earmarked to child surviv-
borns and children won't suffer men-
al and fully funding nutrition pro-
tal retardation this year because io-
grams for American mothers and in-
dine has been added to their salt
fant children are two places to start.
supply.
But those statistics are for another
"In sheer scale and human impact,
day.
these successes are just as important
Today, think about all those run-
as any of the famines and wars," said
ning, playing, singing, living children
Peter Adamson, author of "Progress
who have been saved. And go ahead
of Nations," Unicef's annual account-
and smile.
The Dakland Tribune.
The patient's prognosis:
better than you think
ARNAGE in Rwanda. Starvation
whose children increasingly are being felled
C
in Ethiopia. Death and mayhem
by suicide, murder, child abuse, neglect. It
in Bosnia. The world is going to
points out that too many children still die
hell in a handbasket, right?
from diarrhea, polio, measles, that 60 per-
Well
yes. And no.
cent of girls in sub-Saharan Africa and 47
percent in South Asia drop out of school be-
We hear all about the yes. But we hear
fore they reach the fifth grade.
precious little about the no, according to
RESULTS. a citizens' lobby formed to create
But the report does accentuate the posi-
the political will to end poverty and to work
tive, in part because those who worked on it
with the United Nations Children's Fund
feel that the steady litany of bad news IS
(UNICEF).
turning people away
Wonderful. uncredible strides have been
made toward making the world a safer and
Theater of tragedy
better place in the past decade. especially
In a conference call with this newspaper.
for children. But the gloom and doom we
Sam Harris of RESULTS and Peter Adamson
read about day after day have given the im-
of UNICEF spoke repeatedly of political
pression that if things are changing at all
will," to end poverty and their fear that It is
they changing for the worse And that,
eroding. They took pains to avoid criticizing
according to RESULTS, has instilled a resig-
the news media for disseminating bad news,
nation bordering on despair that IS keeping
and acknowledged that relief organizations
the citizens of the industrialized world from
often emphasize the downside to get people
getting involved in further change.
to contribute.
UNICEF last
But both said
week released its
they've found a
second annual Pro-
A lot of wonderful and
"disillusionment
gress of Nations re-
that sets in. People
port, a country by
encouraging things have
think it's not worth
country comparison
helping because
of progress made
been happening with the
the problems are
toward meeting the
unsolvable." as Ad-
basic needs of fami-
world's children. We need
amson put it.
hes and children It
to keep up the drumbeat.
Harris found the
is a staggering col-
United States a na-
lection of statistics
tion "in deep de-
that shows literally
spair. and in
millions of children surviving and leading
Europe, Adamson said, "there is a colossal
better lives because of progress in health
distortion of public perception. It's much
and education made in the past decade.
worse than the reality.' Citizens of the in-
dustrialized nations, Adamson said, think of
Millions of children saved
the developing world as "a theater of tra-
Some examples among many:
gedy.'
In the early 1980s 4 million children
Vaccines and other solutions that could
were dying every year from dehydration due
save millions of lives are tantalizingly close,
to diarrhea. Because of oral rehydration the-
Adamson said; they need only money and
rapy, a simple Gatorade-like solution now
the political will that will make the money
utilized by 40 percent of the world's fami-
available.
lies, 1 million child deaths are prevented a
The only specific expenditure the pair
year.
mentioned was the decision this spring by
The number of deaths from measles
the U.S. Agency for International Devel-
has dropped from 2.5 million to 1 million.
opment to cut $40 million from its child sur-
Millions of kids who might have been
vival budget this year and $30 million from
crippled from polio are healthy, because of
its basic education budget. It is the first cut
vaccines (an effort in which Rotary Interna-
in these funds in 10 years and they want
tional played a major part).
Congress to restore the money to at least
Literacy rates are going up around the
last year's levels, in binding language that
globe. Zimbabwe. for example, tripled the
would force AID from cutting it again.
number of students in primary school in 18
Those seem like reasonable and necessary
months, and now 94 percent of that nation's
requests. But the larger thrust of UNICEF's
children reach grade 5.
argument also is important. We get so weary
Because SO many girls are now going
from hearing about all the bad things that
to school, birth rates and child death rates
are happening that we forget about the very
are going down.
real progress that IS being made.
The Progress of Nations report does not
UNICEF's message: We've come a long
sugarcoat the way things are. It illuminates
way, further than you could possibly
changes that still need to be made every-
imagine; we have a way to go. Don't give up.
where, including the industrialized nations,
Those are words to live by.
The Oregonian
MONDAY, JUNE 27, 1994
Good news about kids
Worldwide child-survival programs
claim a growing number of living, breathing success stories
ake a break from bad-news
ing of child welfare.
T
headlines. It's time to hear
Adamson talked to The Oregonian
some good news about the
recently to shine a spotlight on the
state of the world's children.
success of child-survival programs.
The attention the developing and in-
dustrialized worlds have paid to child
"People think the Third World is a
survival in the last several years has
stage on which no light ever falls," he
yielded significant results:
said. "That simply isn't true. There
Two million children through-
are stories happening on that stage
out the world won't die of measles in
that aren't tragedies. Millions of peo-
1994, because immunizations are pro-
ple are working, unrecognized, there
tecting them.
and throughout the world every day
One million children won't die
to make things better."
from dehydration caused by diarrheal
There is, of course, plenty more the
disease because their families have
United States and other countries can
been taught inexpensive, life-saving
do to promote child welfare here and
oral-rehydration techniques.
abroad. Increasing the amount of U.S.
Hundreds of thousands of new-
foreign aid earmarked to child surviv-
borns and children won't suffer men-
al and fully funding nutrition pro-
tal retardation this year because io-
grams for American mothers and in-
dine has been added to their salt
fant children are two places to start.
supply.
But those statistics are for another
"In sheer scale and human impact,
day.
these successes are just as important
Today, think about all those run-
as any of the famines and wars," said
ning, playing, singing, living children
Peter Adamson, author of "Progress
who have been saved. And go ahead
of Nations," Unicef's annual account-
and smile.
Thursday, June 23, 1994
The Capital Times
15A
JOHN NICHOLS
Breaking down walls of cynicism that allow children to die
If there is one real-
a decade ago.
ity that frustrates
Translation: The poorest chil-
Peter Adamson, It is
dren of the world got a better
that life-and-death
break under George Bush's ten-
issues affecting the
ure than they getting from Bill
children of the
Clinton
world will never get
Is Bill Clinton a child hating
the same attention
monster? No. More likely than
Nichols
as the exploits of an
not, he and his feeble staff have
O.J. Simpson.
simply bought into the notion
For all our talk
that U.S. aid really doesn't make
about valuing children, as a SOCI-
that much difference - that in a
ety we pay them very little mind.
world of Rwandas and Somalias,
Adamson, the editor of the
progress is simply impossible.
United Nations Children's Fund's
annual "Progress of Nations" re-
In this regard. of course, they
ports, has just released a monu-
are tragically misguided
mental study regarding the pros-
The simple reality is that,
pects of the world's youngsters
while we cannot eliminate dis-
It is a sweeping document,
ease, we certainly can stop mil
packed with vital Information
lions of unnecessary deaths as a
about infant mortality, nutrition,
result of preventable illnesses.
education and all the issues that
And there IS no question that we
we dutifully say are our chief
have the ability - at remark-
concerns.
ably little cost - to climinate
But Adamson knows that the
malnutrition
cause to which he has devoted
A few US senators recog
his life will never get the same
nize that reality. Last werk the
attention as an ex-football player
Senate Appropriations Commit-
with a gun, a desperate look in
tee approved a bill restoring
his eyes and a few miles of free-
full funding of basic education
way ahead of him.
programs at $135 million, and
"It's the No. 1 problem in my
actually increasing child sur-
work. I'm not saying Journalist
vival funding to $285 million.
X should not write about O.J.
In coming days the full Sen-
Simpson and should write about
ate will address this issue, and it
oral rehydration,'' Adamson
will then go to a Senate
told me the other day from his
conference committee Only with
office is Brussels. "All I'm saying
pressure from a determined citi-
is that there are real human-im-
zenry will these legislators buck
pact stories that get lost in the
the Clinton administration
media today, and I just wish that
A woman holds her mainourished children in Kongor, southern Sudan, where civil war has destroyed the agricultural base. Only International
It is true that most Amer-
once 8 year they could get some
icans will end this week know-
attention."
aid will keep children such as these alive.
Ing more about O.J. Simpson's
As a journalist who is often
mental state than we do about
critical of the celebrity obsession
splendor of capital cities and
developing world is that of a
the suffering of our world's
that has overwhelmed modern
public buildings, but by the well-
media, 1 still feel guilty talking
being of their peoples.'
'What I fear is happening is that the
theater of darkness - a stage
children. That IS the failing of
that only plays tragedy," Adam-
the media themselves and of a
with someone like Adamson. He
If we operate from that per-
spective, there is cause for cele-
whole image of the developing world is
son says 'That creates a feeling
citizenry that does not demand
reminds me of the stories that re-
of disillusionment. of powerless-
more of television, radio and
main essentially untold. And of
bration, Adamson says. From a
that of a theater of darkness - a stage
ness What we are trying to say
newspapers than to package
the suffering that results.
dismal state of affairs 10 years
19 that that 19 not the case, that
In the scheme of things, the
that only plays tragedy. That creates a
celebrity gossip as "news."
ago, we have moved to a place of
you can have progress.'
Progress of Nations report that
cautious optimism
feeling of disillusionment, of
The danger in this should be
But that does not excuse
Adamson released in Brussels
For instance:
obvious. If those of us who con-
anyone. Those of us who are
this week was an encouraging
The number of children who
trol the vast majority of the
aware have a responsibility to
document.
die each year because they have
powerlessness. What we are trying to say
planet's resources think our pre-
break down the walls of супі-
"Our main theme with the re-
not received basic immunizations
is that that is not the case, that you can
cious wealth will be squandered
cism and demand that our Con-
has droppeed by 3 million.
in an effort to save the dispos-
gress make the United States a
port is that in a year that has
seen a stream of almost constant
As a result of instruction re.
have progress.
sessed of the world, then too
prime combatant in the war ont
malnutrition and disease.
bad news from the poorest na.
garding oral rehydration therapy
many of us feel justified in refus-
PETER ADAMSON
tions of the world - Rwanda.
which has reached 40 percent
ing to act.
We know the answers. We
Somalia, Haiti and 80 on - there
of the world's families 1 mil-
That's what has happened in
know the combination of fac-
has also been genuine progress,"
lion child deaths are prevented
13 million children will die this
SO much about." says Adamson
Washington since the Clinton ad-
tors that are needed for real
he explains. "We don't underesti-
each year.
The number of new polio
year as a result of preventable
"But there is so much stress on
ministration came to power. De-
progress toward cluninating
mate the horror of what has hap-
malnutrition and disease.
the failures, on the disasters.'
spite all their lofty talk about
malnutrition and disease,
pened in a Rwanda or a Somalia,
cases reported annually has been
"feeling the pain" of others, the
Adamson says. "We know that
but there are times to focus on
dramatically reduced - to such
But Adamson makes a critical
Just as the Western media are
Clintonites this year cut U.S.
lives are being transformed,
the achievements as well."
an extent that, during the past
point: If it is possible to reduce
obsessed with the freeway ad.
spending on child survival pro-
and that more lives can be
UNICEF's Progress of Nations
decade, more than 3.5 million
the death rate in a time when al-
ventures of its O.J. Simpsons, it
grams by $40 million below 1993
transformed. This is the story
reports, which offer a country-
children have been spared a
most no attention is paid to
is virtually incapable of seeing
levels, and cut basic education
that needs to be told."
by-country comparison of pro-
dread disease they would almost
issues of Third World poverty,
the Third World as anything but
funding by $30 million. These re-
gress made toward meeting the
certainly have developed
think what could be accom-
a disaster zone, explains the vet-
ductions represent the first
basic needs of children and fami-
Don't go thinking that all the
plished if people actually knew
eran UNICEF activist.
slashing of child survival spend-
John Nichols is assistant edi-
lies, seek to create a new stand-
world's problems have been
how easy It is to save lives.
"What I fear is happening is
ing by the United States since
torial page editor for The Capi-
ard. That standard is expressed
solved. Even If 1 million children
"These accomplishments in
that the whole image of the
funding of such programs began
tal Times.
In the statement: "The day will
a year are being saved by oral
terms of sheer impact are as im-
come when the progress of na-
rehydration therapy, another 3
portant as the famines and the
tions will be judged not by the
million still die. Indeed, roughly
floods and the wars that we bear
Anchorage Daily News
June 22, 1994
Helping kids
A little foreign aid would go a long way
Ever wonder what you personally could do to help
end overpopulation and starvation in the world?
You can't box up and send your leftovers to needy
people in the developing world, but you can take pen
in hand to urge Congress to spend a bit more of our
foreign aid budget on proven ways of saving lives and
cutting population growth.
Last year, Congress gave the country's main
foreign aid agency, USAID, more flexibility in
spending its budget. As a result, U.S. spending on
vaccines and other low-cost, life-saving treatments for
children fell $40 million - the first time in the
program's 10 years it has been cut. U.S. foreign aid
for basic education - a key strategy to help reduce
overpopulation - dropped by $30 million.
Foreign aid advocates don't want Congress to let
the same mistake happen again, They want Congress
to guarantee aid levels of $390 million on health aid to
young children, $260 million for basic education and
$42 million on programs distributing Vitamin A,
which will fight the blindness that afflicts 250,000
children a year.
The U.S. House wants funding restored to last
year's levels, but its action is only advisory, not
binding. The U.S. Senate still has a chance to get it
right, though. The appropriations committee, which
includes Alaska Sen. Ted Stevens, has yet to set final
aid figures.
The proposal at issue requires no increase in
spending on foreign aid. It simply shifts around 2
percent of the foreign aid budget.
Restoring past spending levels to help save
children in other countries is the least we can do.
According to United Nations' figures, the United
States spends 0.18 percent of its gross national
product on humanitarian foreign aid. The average for
industrialized countries is 0.34. Only the
Scandinavian countries and the Netherlands exceed
the 0.7 percent target agreed to during the 1960s.
True, money is tight in the federal budget. But it's
not so tight that the United States can't do its part to
help save the lives of children in countries less
fortunate than ours.
The Oakland Tribune.
The patient's prognosis:
better than you think
ARNAGE in Rwanda. Starvation
whose children increasingly are being felled
C
in Ethiopia. Death and mayhem
by suicide, murder, child abuse, neglect. It
in Bosnia. The world is going to
points out that too many children still die
hell in a handbasket, right?
from diarrhea, polio, measles, that 60 per-
Well
yes. And no.
cent of girls in sub-Saharan Africa and 47
percent in South Asia drop out of school be-
We hear all about the yes. But we hear
fore they reach the fifth grade.
precious little about the no, according to
RESULTS. a citizens' lobby formed to create
But the report does accentuate the posi-
the political will to end poverty and to work
tive, in part because those who worked on it
with the United Nations Children's Fund
feel that the steady litany of bad news is
(UNICEF).
turning people away.
Wonderful. incredible strides have been
made toward making the world a safer and
Theater of tragedy
better place in the past decade. especially
In a conference call with this newspaper.
for children. But the gloom and doom we
Sam Harris of RESULTS and Peter Adamson
read about day after day have given the um-
of UNICEF spoke repeatedly of "political
pression that if things are changing at all
will," to end poverty and their fear that It is
they re changing for the worse And that,
eroding. They took pains to avoid criticizing
according to RESULTS, has instilled a resig-
the news media for disseminating bad news,
nation bordering on despair that IS keeping
and acknowledged that relief organizations
the citizens of the industrialized world from
often emphasize the downside to get people
getting involved in further change.
to contribute.
UNICEF last
But both said
week released its
they've found a
second annual Pro-
A lot of wonderful and
'disillusionment
gress of Nations re-
that sets in. People
port. a country by
encouraging things have
think it's not worth
country comparison
helping because
of progress made
been happening with the
the problems are
toward meeting the
unsolvable." as Ad-
basic needs of fami-
world's children. We need
amson put it.
lies and children. It
to keep up the drumbeat.
Harris found the
is a staggering col-
United States a na-
lection of statistics
tion "in deep de-
that shows literally
spair, and in
millions of children surviving and leading
Europe, Adamson said, "there is a colossal
better lives because of progress in health
distortion of public perception. It's much
and education made in the past decade.
worse than the reality." Citizens of the in-
dustrialized nations, Adamson said, think of
Millions of children saved
the developing world as "a theater of tra-
Some examples among many:
gedy.
In the early 1980s 4 million children
Vaccines and other solutions that could
were dying every year from dehydration due
save millions of lives are tantalizingly close,
to diarrhea. Because of oral rehydration the-
Adamson said; they need only money and
rapy, a simple Gatorade-like solution now
the political will that will make the money
utilized by 40 percent of the world's fami-
available.
lies. 1 million child deaths are prevented a
The only specific expenditure the pair
year.
mentioned was the decision this spring by
The number of deaths from measles
the U.S. Agency for International Devel-
has dropped from 2.5 million to 1 million.
opment to cut $40 million from its child sur-
Millions of kids who might have been
vival budget this year and $30 million from
crippled from polio are healthy, because of
its basic education budget. It is the first cut
vaccines (an effort in which Rotary Interna-
in these funds in 10 years and they want
tional played a major part).
Congress to restore the money to at least
Literacy rates are going up around the
last year's levels, in binding language that
globe. Zimbabwe. for example, tripled the
would force AID from cutting it again.
number of students in primary school in 18
Those seem like reasonable and necessary
months, and now 94 percent of that nation's
requests. But the larger thrust of UNICEF's
children reach grade 5.
argument also is important. We get so weary
Because so many girls are now going
from hearing about all the bad things that
to school. birth rates and child death rates
are happening that we forget about the very
are going down.
real progress that is being made.
The Progress of Nations report does not
UNICEF's message: We've come a long
sugarcoat the way things are. It illuminates
way, further than you could possibly
changes that still need to be made every-
imagine; we have a way to go. Don give up.
where, including the industrialized nations,
Those are words to live by.
Results
REGISTRATION
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WHITE HOUSE MAIL
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PUBLIC LAW 103-306-AUG. 23, 1994
108 STAT. 1611
Republic of China: Provided further, That not more than
$50,000,000 of the funds appropriated under this heading may
be made available to the UNFPA: Provided further, That not more
Reports.
than one-half of this amount may be provided to UNFPA before
March 1, 1990, and that no later than February 15, 1995, the
Secretary of State shall submit a report to the Committees on
Appropriations indicating the amount UNFPA is budgeting for the
People's Republic of China in 1995: Provided further, That any
amount UNFPA plans to spend in the People's Republic of China
in 1995 above $7,000,000, shall be deducted from the amount of
funds provided to UNFPA after March 1, 1995 pursuant to the
previous provisos: Provided further, That with respect to any funds
appropriated under this heading that are made available to UNFPA,
UNFPA shall be required to maintain such funds in a separate
account and not commingle them with any other funds.
TITLE II-BILATERAL ECONOMIC ASSISTANCE
FUNDS APPROPRIATED TO THE PRESIDENT
For expenses necessary to enable the President to carry out
the provisions of the Foreign Assistance Act of 1961, and for other
purposes, to remain available until September 30, 1995, unless
otherwise specified herein, as follows:
AGENCY FOR INTERNATIONAL DEVELOPMENT
DEVELOPMENT ASSISTANCE FUND
For necessary expenses to carry out the provisions of sections
103 through 106 of the Foreign Assistance Act of 1961,
$853,000,000, to remain available until September 30, 1996: Pro-
vided, That of the funds appropriated under this title under the
heading "Agency for International Development", (1) not less than
$280,000,000 should be made available for activities which have
as their objective the reduction of childhood mortality, including
such activities as immunization programs, oral rehydration pro-
grams, and education programs which address improved nutrition,
and water and sanitation programs, (2) not less than $185,000,000
should be made available for basic education programs, and (3)
not less than $25,000,000 should be made available for
micronutrient programs.
POPULATION, DEVELOPMENT ASSISTANCE
Abortion.
For necessary expenses to carry out the provisions of section
104(b), $450,000,000, to remain available until September 30, 1996:
Provided, That none of the funds made available in this Act nor
Sterilization.
any unobligated balances from prior appropriations may be made
available to any organization or program which, as determined
by the President of the United States, supports or participates
in the management of a program of coercive abortion or involuntary
sterilization: Provided further. That none of the funds made avail-
able under this heading may be used to pay for the performance
of abortion as a method of family planning or to motivate or coerce
any person to practice abortions; and that fn order to reduce reliance
on abortion in developing nations, funds shall be available only
to voluntary family planning projects which offer, either directly
or through referral to, or information about access to, a broad
Note from Bob Hernreich, enclosing draft of letter supporting
President's health care reform which DNC requested of him. He sent it
but has not heard back yet.
See
Pan-caryan find ant status n this
Direct to
for review/followup
PHOTOCOPY
HRC HANDWRITING
I
5/13 message
at home
Robin E. Hernreich
2684 Larkspur Court
Vail, Colorado 81657
303-476-1433
5/16 spoke to
Hunreich satis
Hellary -
fied with provess
P was asked by the DNC
to Cropt a letter supporting
the Overdents health Call
reform.
This is what R not them
t proof for policy, to.
l have ept to here both
from them. But l wanted
you $ m a copy.
But,
B
I
MM
4/3/2/2021
Bob Hernreich
Vail, Colorado
303-476-1433
rough very
-
deopt
I
CLINTON.TXT
Before the partisan brouhaha of Whitewater there had been considerable and
lively discussion of America's foremost crisis -- health care. Evident in
these discussions is a good deal of misperception, miscalculation -- and
good, old misrepresentation on the part of the President's opponents. The
truth will be slow to emerge, particularly because of the Whitewater
smokescreen. This is unfortunate, because health care needs to be
discussed broadly and boldly. It doesn't need to be buried beneath a
false, however controversial, side issue.
The fundamental platform of the President's health care proposals is
"universality" -- health care access for everyone. WHY UNIVERSALITY?
Simply - It's about time! The perceived role of government has changed
over the years. Now, citizens expect government, at the very least, to
provide adequate access to nourishment, safety, and health services. This
is the same as life, liberty, and the pursuit of happiness, merely phrased
in 21st century nomenclature. And here lies the crux of the matter -- It
will soon be the 21st century! Since we as a nation have the ability,
shouldn't we strive to provide these basic necessities. Don't we as
members of the human race have the obligation to seek and provide the
basics of safety, nutrition, and health services for all our citizenry in
the 21st century.
Besides philosophical there are practical reasons to support UNIVERSALITY.
Universality would infuse efficiency into our present health care system
and re-establish a free Labor market. These are very important.
EFFICIENCY: We spend 15% of GDP on health care. This is far more than our
industrialized competitors. If we could reduce the health care/GDP ratio,
our economy would become more efficient and, thereby, more competitive
with other countries. This ratio would be substantially reduced, if only
Medicaid were controlled. Medicaid is a runaway, uncapped entitlement. If
not controlled, it will be disastrous. The President's plan contemplates
controlling Medicaid.
A FREE LABOR MARKET: When Labor as a real market emerged at the end of the
Mercantile era, many ill-considered, though well-intentioned, ideas, such
as the Speenhamland Act in England, had the unintended consequence of
destroying the free market for Labor by destroying the mobility of labor.
This interconnection between labor mobility and the existence of a REAL
Labor market has continued throughout history. UNIVERSALITY conveys
portability of health services, which, in turn, allows the mobility of
labor. Conversely, without universality the free market for labor is
grossly impeded. Without this free Labor market REAL wages decline, and
living standards diminish. This is unacceptable.
In closing, let's discuss two items that must be and are addressed in the
President's health care package: bureaucracy and medical malpwactice
reform. Presently, 22% of all health care expenditures are spent on
administration, i.e. bureaucracy. It seems to me, we already have a
bloated health bureaucracy. Granted, the proposed Regional Alliances are
new. But, they are intended to replace, not suppplement, a large part of
Page 1
CLINTON.TXT
the present bureaucracy. After all, who needs layer upon layer of
compliance police, insurance claims processors, cost-containment cops,
utilization reviewers, etc. in a rational universal system where
everybody is covered -- where money can ACTUALLY be spent on ACTUAL care!
Will this happen? It will if legislation is intelligently crafted and not
castrated by lobbyists.
Medical malpractice reform would limit unnecessary litigation, thereby
reducing outrageous malpractice premiums which drive medical costs skyward.
Trial lawyers will bellow, insisting that tort reform means only the rich
will have the "privilege" (sic) of affording adequate legal representation.
The poor won't be able to afford it. This is egregiously false. But,
pursuing this line of reasoning leads me to believe that, ironically,
without reform it's possible nobody will be able to afford adequate legal
representation, because everybody will be too poor -- except the trial
lawyers, who will by then own all the resort homes in Vail and Aspen.
Page 2
HC CORR
THE WHITE HOUSE
October 5, 1994
Ms. Lorance Hockert
Hockert Pressman & Flohr
880 Third Avenue
New York, N.Y. 10022
Dear Ms. Hockert:
I enjoyed meeting you during my visit
to New York. Thank you for writing about
the importance of public health and pre-
vention. As you point out, today too many
Americans are unable to get the preventive
care they need. And too many physicians
and hospitals are forced to absorb the
costs of providing emergency care to un-
insured or underinsured individuals -- who
are unable to get preventive services and
instead must wait until their illnesses are
serious and costly before seeking help.
As you may know, Senator Mitchell
announced last week that the Senate will
not be able to pass health care legislation
in this session of Congress. The President
and I, however, are proud that we have come
further than ever before in the effort to
reform our health care system. We remain
committed to returning next year to fight
for health security for all Americans.
Sincerely yours,
Hillary Rodham Clinton
HOCKERT PRESSMAN & FLOHR
ATTORNEYS AT LAW
880 THIRD AVENUE
NEW YORK, NY 10022
LORANCE HOCKERT
TELEPHONE
July 20, 1994
ALAN PRESSMAN*
(212) 935-6250
ARLENE FLOHR*
TELEFAX
(212) 688-0066
*ALSO ADMITTED IN NEW JERSEY
Ms. Hillary Rodham Clinton
The White House
Pennsylvania Avenue
Washington, D.C. 20500
Dear Ms. Rodham Clinton:
It was indeed a pleasure to meet with you last Tuesday
at the reception at the Waldorf Astoria.
I am writing today just to follow up on our very brief
conversation regarding the Health Care proposals that are pending
before Congress. I may not have indicated to you that I am
formerly the Secretary of The Board of Health and have been
involved in public mental health issues on a broad based scale.
Of particular concern to me with the Health Care proposals is
that there does not appear to be sufficient emphasis on the
provision of public health services which by definition are
universal. Public health, as I am sure you have learned over
time, proves the adage "that an ounce of prevention is worth a
pound of cure". The focus of our Health Care industry,
unfortunately, over the past 15 years, has been too focused on
the provision of curative medicine, rather than funding for
public health programs, such as heart care, promotion of well
baby clinics, TB preventatives, mass immunization, and the like.
These services are provided to all by the New York City Board of
Health which just thirty years ago was considered a model for the
entire world and has been decimated by funding cuts
As I also indicated, in the same vein with Public
Health, is the provision of Mental Health Care Facilities on a
clinic basis through community based organizations. These type
of organizations provide Mental Health Care and family therapy to
the indigent. These are the most in need of mental health
services as the indigent, more than any other group, are the
victims of the vagaries of modern society. The failure to
provide Mental Health Care for this population is one important
cause for serious and chronic mental and health programs (AIDS,
TB and Drug Abuse, for example), which of course are a tremendous
drain on our financial and medical resources.
HOCKERT PRESSMAN & FLOHR
Ms. Hillary Rodham Clinton
Page 2
Again, it was a pleasure to meet with you and to be
able to express my views.
Very truly yours,
Lorance Hockert
LH/jdp
CC: Fernando Ferrer
Borough President, Bronx, NY
Congressman, Elliott Engel
PERSONAL
&
CONFIDENTIAL
DETERMINED TO BE AN ADMINSTRATIVE
MARKING Per E.O. 12958 as amended, Sec. 3.3 (c)
Initials: ADB Date 12-4-13
THE WHITE HOUSE
May 12, 1994
Ms. Sue Holmes, President
League of Women Voters
of Kansas
919½ South Kansas Avenue
Topeka, Kansas 66612
Dear Ms. Holmes:
Thank you for your letter and for
coming to the White House to learn more
about the President's health care reform
initiative. We deeply appreciate the
League's support and look forward to
working with you to bring equitable,
affordable, quality health care to all
Americans.
With kind regards, I am
Sincerely yours,
Hillary Rodham Clinton
LEAGUE WAY KANSAS
League of Women Voters of Kansas
9191/2 South Kansas Avenue
Topeka, Kansas 66612
May 1, 1994
Hillary Rodham Clinton
White House
Washington, D.C.
Members of the League of Women Voters of Kansas (LWVK),
meeting in Council at Great Bend on April 30-May 1, commend
you for your initiative in inviting 50 Kansans, including
three LWVK members, to Washington, D.C. on May 2 to a
briefing on health care reform.
The League believes that this kind of citizen participation
should be an integral part of developing public policy.
The League supports health care reform that provides
affordable access to a basic level of quality care for all
US residents, and controls health care costs.
Sue Holmes
Sue Holmes, President
League of Women Voters of Kansas
League of Women Voters of the United States
HEALTH CARE POSITION STATEMENT
Announced by the national board, April 1993
GOALS:
The League of Women Voters of the United States believes that a basic level of quality
health care at an affordable cost should be available to all U.S. residents. Other U.S. health care policy
goals should include the equitable distribution of services, efficient and economical delivery of care, ad-
vancement of medical research and technology and a reasonable total national expenditure level for
health care.
BASIC LEVEL OF QUALITY CARE
the reduction of administrative costs,
Every U.S. resident should have access to a basic level of
regional planning for the allocation of personnel, facilities
and equipment,
quality care that includes the prevention of disease, health
the establishment of maximum levels of public reimburse-
promotion and education, primary care (including prenatal
ment to providers,
and reproductive health), acute care, long-term care and
malpractice reform,
mental health care. Dental, vision and hearing care also are
the use of managed care,
important but lower in priority. The League believes that
utilization review of treatment,
under any system of health care reform, consumers/patients
mandatory second opinions before surgery or extensive
should be permitted to purchase services or insurance
treatment,
coverage beyond the basic level.
consumer accountability through deductibles and copay-
ments.
FINANCING AND ADMINISTRATION
EQUITY ISSUES
The League favors a national health insurance plan financed
The League believes that health care services could be more
through general taxes in place of individual insurance
equitably distributed by:
premiums. As the United States moves toward a national
allocating medical resources to underserved areas,
health insurance plan, an employer-based system of health
providing for training health care professionals in needed
care reform that provides universal access is acceptable to
fields of care,
the League. The League supports administration of the U.S.
standardizing basic levels of service for publicly funded
health care system either by a combination of the private and
health care programs,
public sectors or by a combination of federal, state and/or
requiring insurance programs to use community rating in-
regional government agencies.
stead of experience rating,
The League is opposed to a strictly private market-based
establishing insurance pools for small businesses and or-
ganizations.
model of financing the health care system. The League also is
opposed to the administration of the health care system sole-
ALLOCATION OF RESOURCES TO
ly by the private sector or the states.
INDIVIDUALS
TAXES
The League believes that the ability of a patient to pay for
services should not be a consideration in the allocation of
The League supports increased taxes to finance a basic level
health care resources. Limited resources should be allocated
of health care for all U.S. residents, provided health care
based on the following criteria considered together: the ur-
reforms contain effective cost control strategies.
gency of the medical condition, the life expectancy of the
COST CONTROL
patient, the expected outcome of the treatment, the cost of
the procedure, the duration of care, the quality of life of the
The League believes that efficient and economical delivery of
patient after treatment, and the wishes of the patient and the
care can be enhanced by such cost control methods as:
family.
LWVL
League of Women Voters
1730 M Street, NW
Washington, DC 20036
202/429-1965
FAX: 202/429-0854
HC CORR
THE WHITE HOUSE
WASHINGTON
August 11, 1994
Sister Helen Huewe, OSF
President
Mercy Health Center
250 Mercy Drive
Dubuque, Iowa 52001
Dear Sister Huewe:
Thank you for your letter about the proposed partnership
between Mercy Health Center and The Finley Hospital. I am
advised that this matter is currently the subject of litigation,
and I am therefore unable to comment on it.
I do share your concern that spiraling health care costs
have made it difficult for small health care institutions to
deliver affordable health care. The Antitrust Division of the
Department of Justice has been working to ensure that the
antitrust laws do not have the perverse effect of raising, rather
than lowering, the cost of health care. In September 1993, the
Department of Justice and the Federal Trade Commission issued
joint Statements of Antitrust Enforcement Policy in the Health
Care Area to provide guidance to institutions on mergers,
acquisitions and joint ventures. Just last month, the Department
reached an innovative agreement with hospitals in Florida that
allows cost savings to be realized while preserving competition
and consumer choice.
I regret that I am unable to discuss the specifics of your
case. I appreciate your efforts to provide affordable, high
quality health care in Dubuque. This nation now has an historic
opportunity to change our health care system to make it work for
all of us. The President and I look forward to continuing to
work with Congress to make health security a reality for all
American families.
Sincerely yours,
Hillary Hillary Rodham Clinton Clenta
Pebbie Get to appropriate
MERCY
Person in policy dept mike
HEALTH CENTER
250 Mercy Drive
Dubuque, lowa 52001
319/589-8000
April 20, 1994
Hillary Rodham Clinton, Esq.
Conversations on Health
The Robert Wood Johnson Foundation
George Washington University
2121 I Street, N.W., Suite 502
Washington, DC 20052
Dear Ms. Clinton:
In March of 1993, I had the privilege of being on a panel with you in
Ankeny, Iowa, regarding cost containment in health care. It is
interesting that the one issue I pointed out to you as needing to be
addressed was antitrust enforcement. That is why I am writing to you
today.
Our community, Dubuque, Iowa, needs your help. Dubuque is located in
rural Iowa on the Mississippi River. We have two hospitals in Dubuque,
Mercy Health Center and The Finley Hospital, serving the tri-state area
of Wisconsin, Illinois, and Iowa. Both are not for profit, charitable
institutions.
To become more cost effective and to position our community for health
care reform, the two hospitals have developed a partnership, Dubuque
Regional Health System ("DRHS"). The purpose of DRHS is to reduce the
cost of health care to the community by eliminating unnecessary
duplication. The parties estimate that the partnership will result in
savings of $24 million over four years. The parties are forming a
partnership (as opposed to merging) so that they can preserve the
identity and culture of Mercy and Finley while still achieving these
savings.
We expect a broad range of savings from DRHS. Our initial studies
indicate that cost savings will be realized in six specific areas of
administrative operations, including billing; purchasing; biomedical
engineering; planning and marketing; administration; and human resources.
Cost savings will also be realized in eight patient care areas, including
ER, surgery, cardiovascular, oncology, occupational medicine, orthopedics
and neurosurgery, physical therapy and obstetrics. The study estimates
that the transaction will also produce opportunities to realize savings
(through future cost avoidance) with respect to ten major areas of
substantial capital expenditures, ranging from CT scanners, to magnetic
resonance imagers ("MRIs"), to invasive cardiac equipment, to ER
expansion.
These savings reflect the fact that Mercy and Finley today operate with
small censuses and therefore high excess capacity in many of their
patient care units. Substantial costs can be eliminated by combining
units and reducing this excess capacity. The same efforts will result
in the elimination of a need for substantial expensive duplicative
equipment at both hospitals. These two small hospitals, only six blocks
A member of Mercy Health Services
Hillary Rodham Clinton, Esq.
April 20, 1994
Page Two
apart, certainly do not need two MRIs, two sets of complex invasive
cardiology diagnostic equipment, two fully equipped 24-hour emergency
rooms/trauma centers, two OB units, and two 24-hour surgery suites, all
of which they have today despite very substantial excess capacity.
Competition has driven them to duplicate all these services and increase
costs.
This plan to enter into a partnership to save costs has been created at
the direction of the business community, the purchasers of health care.
At least 71 different business and community leaders, representing
virtually all of the significant ultimate purchasers of health care from
the hospitals, have strongly endorsed DRHS in specific written statements
received by the hospitals. This group includes business and labor,
community leaders and political leaders, ranging from the city and county
of Dubuque to local state representatives to the Governor of Iowa and
both Iowa United States Senators.
This reflects a long tradition of involvement by the Dubuque community
in controlling health care costs. Many of the Dubuque business leaders
have demonstrated their willingness as Mercy and Finley board members to
keep prices down. For example, in 1993 Finley management requested a
4.5% rate increase, but the Finance Committee of its board approved only
a 3.5% rate increase. The Finley Board also instituted a 1% price roll-
back, effective for the period October, 1993 through July, 1994.
DRHS has been structured to maximize community input. A majority of the
board members of DRHS are representatives of purchasers of health care.
The first action of DRHS will be to form a community-based planning
process which will obtain input from all segments of the community in
deciding on the configuration and cost of future hospital care in
Dubuque. DRHS also intends to regularly inform the public of its
progress in achieving cost savings and controlling prices, so that
employers, unions and other purchasers of health care will be in a
position to judge our performance and take steps if we do not perform.
In fact, the administration of Mercy and Finley have visited a large
number of community leaders, and indicated that we expect to achieve the
efficiencies mentioned in this letter. We realize that by making these
statements, we are setting a public standard by which we will be held
accountable. We recognize this, and intend this, because we know that
DRHS must succeed and must help the community.
Mercy and Finley also know that DRHS will need to keep prices down in
order to survive in this increasingly competitive environment. Though
Mercy and Finley are the only hospitals in Dubuque, they are unusually
susceptible to competitive pressures from the broad tri-state region from
which they draw patients. Mercy and Finley must deal with substantial
actual and potential competition from more than fifteen hospitals in
their region. In particular, because of their small size (Finley has an
inpatient acute care census of only 55 and Mercy 108), the hospitals
badly need incremental business to cover their fixed costs. They can
therefore ill afford to lose any business to the competition. In fact,
if the large number of hospitals providing actual or significant
potential competition for Mercy and Finley each took less than one
patient per day from DRHS, that would be sufficient to make a price
increase unprofitable.
Hillary Rodham Clinton, Esq.
April 20, 1994
Page Three
The importance of this competition is confirmed by statements from at
least 35 Dubuque employers and labor leaders. These statements all
indicate that if, contrary to their expectations, DRHS attempted to raise
prices above competitive levels, that would provide incentives for their
employees to seek hospitalization at one of the many other hospitals in
the area.
Despite all these facts, we have become embroiled in a very serious
antitrust investigation by the Department of Justice. We have already
spent several hundred thousand dollars in responding to this
investigation, and believe that we have shown how this transaction will
benefit the community and create more effective competition.
Nevertheless, the staff of the Department of Justice has apparently
concluded that this transaction will create a "monopoly" that could
result in higher prices. We are now attempting to convince the senior
officials in the Antitrust Division that this conclusion is wrong. If
we do not succeed, we will need to fight out this matter in court, at
even greater expense. These costs will only add to the burden of health
care costs faced by businesses and consumers.
When I originally met you, and raised the concern that antitrust could
interfere with hospital cost savings, I was pleased to see that you
agreed, and indicated that this was an issue that you were investigating.
Later, the Justice Department and Federal Trade Commission issued their
new guidelines, creating "safe harbors" for some transactions.
Unfortunately, despite the small size of Mercy and Finley, they cannot
benefit from these safe harbors. Under the safe harbors, a merger
involving a hospital with an acute care census of 40 or less would
ordinarily not be subject to antitrust review. Finley's acute care
census is only 55, just over the safe harbor figures. But this has not
prevented our transaction from being subject to this extensive review and
the risk of a challenge, even though our two non-profit hospitals have
never acted to abuse the system or overcharge purchasers.
I am writing to you because I hope that you can help us with this serious
problem. I know that you are concerned with health care reform as part
of a process of seeking new ways of solving our problems to reduce costs
and increase health care coverage. Finley and Mercy have been attempting
to do just that. We would appreciate your help in assuring that the
federal government does not frustrate our efforts. If you would speak
to Assistant Attorney General Bingamin about our transaction, that could
tremendously help the delivery of health care in Dubuque.
Thank you very much for any assistance you can provide us regarding
Dubuque Regional Health System. If you need further information, please
contact either me at 319-589-8061 or our attorney, David Ettinger, at
313-256-7751.
Sincerely,
Sister Helen Huewe, osf
Sister Helen Huewe, OSF
President
SHH/ims
CC: David Ettinger
THE WHITE HOUSE
January 10, 1994
Ms. Elizabeth D. Hutcheon
527 Foothill Road
Bridgewater, New Jersey 08807
Dear Betty:
Thanks for your letter and for all of
your efforts to promote the President's
health care reform plan. I'm glad that
you and Douglas had such a good time at
the White House.
Your work with the Catastrophic
Illness in Children Relief Fund sounds
enormously rewarding. I look forward to
the day when families such as the ones you
described will not have to seek outside
assistance in order to receive the medical
care they rightly deserve.
With best wishes for the New Year, I
remain
Sincerely yours,
Hillary Hillam Rodham Clinton
3
Elizabeth D. Hutcheon
527 Foothill Road
Bridgewater, NJ 08807
Dec. 15, 1993
Hillary Rodham Clinton
The White House
1600 Pennsylvania Ave., NW
Washington, DC 20500-2000
Dear Hillary,
I was so pleased to be invited to the holiday party at the White House last week and
wanted to let you know how much I enjoyed the evening. The White House was
dazzling in its holiday splendor, and the display of crafts was a treat to see. But most
of all, I appreciated the gracious gesture from you and the President in so patiently
posing for photos with all your guests. I know that my son, Douglas, and I will prize
our souvenir of a very special event.
In the new year, I will continue to volunteer with the DNC's National Health Care
-
Campaign in New Jersey to promote the health care reform plan, and now hope to
schedule a forum in February at the University of Medicine and Dentistry of New
Pam
Jersey in Newark to build support for the plan. I have contacted Pam Barnett at your
suggestion for help in arranging a speaker to represent the Administration and
appreciate her assistance in putting me in touch with the appropriate staff members.
2
Every day I am reminded of the absolute necessity of health care reform as I speak
CC on
with people on behalf of one of my clients, the Catastrophic Illness in Children Relief
my
Fund. I have previously written to you about this unique program which helps New
Jersey families of sick children pay for medical expenses that are not covered by
desk
insurance or any state or federal programs. This week, I spoke with several families,
including one whose 11-year-old daughter was hospitalized with a ruptured appendix
during a time when her father, recently employed after a period of unemployment,
did not yet have health insurance. They were struggling to pay $17,000 in medical
bills and were being forced to choose between saving for the college education of
their honors student daughter or making monthly payments to the hospital and
physicians.
Another family was insured when their six-month-old daughter had surgery for a
benign brain mass, but $21,000 in additional medical expenses for treatment of the
child's subsequent seizures were not covered since the insurance company deemed her
illness a pre-existing condition.
PHOTOCOPY
HRC HANDWRITING
MOA DEC 2 1993
- 2 -
In these and other cases, the Fund made grants to the families to cover their expenses.
However, the financial crises felt by these families is symptomatic of the vast
inequities in our current approach to health care and clearly points out the imperative
for change.
As always, I congratulate you and the President for your tenacity and dedication in
promoting solutions to some of the most crucial problems facing our country. I
would be pleased to be called on to help in any way that you might find useful.
Best wishes for a happy, healthy holiday season.
Sincerely,
Betty Demy Hutcheon
THE WHITE HOUSE
May 12, 1994
Mr. Glenn H. Hutchins
2701 - 31st Street, N. W.
Washington, D. C. 20008
Dear Glenn:
Thank you for your letter and
expression of continued support for our
efforts to pass the Health Security Act.
I deeply appreciate all of your hard work
and the many hours you have devoted to
this process and look forward to working
with you again from a different vantage
point.
With gratitude and warm regards, I
remain
Sincerely yours,
Idillary Hillary Rodham Clinton
Stayintouch please -
do letter 1 Ty
2701 31st NW
20008
THE WHITE HOUSE
PHOTOCOPY
WASHINGTON
HRC HANDWRITING
April 29, 1994
Hillary Rodham Clinton
The White House
Old Executive Office Building
Room 100
Washington, DC 20500
Dear Mrs. Clinton:
Today I informed Mack McLarty of my decision to leave the
White House. I hope that this decision, which is motivated by
purely personal reasons, will not prevent me from continuing to
play a role in promoting national health care reform.
As you are probably aware, I have spent the better part of
the last two and a half years working in the campaign, transition
and administration. During that time, I have neglected many
personal matters to which I now intend to turn my attention.
I very much want to continue playing as active a role as
possible in promoting health care reform. To that end, I am in
discussions with the DNC about affiliating with their health care
reform efforts. I am fully prepared to continue to pour a
substantial amount of time and effort into the cause.
I want to thank you for providing me with the extraordinary
opportunity to serve you and the President. I am committed to
this administration's agenda and will continue to be an ardent
advocate of its many initiatives. As I indicated to Mack and
Phil Lader, I also stand ready to return to the service of our
country when it is determined that I can be of assistance.
I am proud of all that we have accomplished in creating and
promoting the Health Security Act. I am especially proud of you
for the scope and intensity of your commitment to do what is
right for the American people. I am certain your efforts will
bear fruit this year and give us all cause for rejoicing in the
fall.
Sincerely,
Glenn H.Hutching
Glenn H. Hutchins
Enclosure: Letter to T.F. McLarty