Executive Summary

The United States has made great progress over the last decade in improving the overall quality of life of the population, particularly with regard to improving health and reducing poverty. Nearly all indicators of health and development have improved, and the United States has increased its worldwide commitment to assisting developing countries. Despite these successes, challenges still exist, and disparities remain among certain racial and socio-economic groups. The government of the United States is committed to addressing these challenges and disparities, and to continuing its international assistance. The high level of prosperity and development in the United States is the result of the U.S. system of economic and political liberty, in which the rule of law protects human rights, core labor standards, property and contract rights, and democratic governance. Individuals are free to pursue the training they desire, work at jobs of their choice, start a business and employ others, and enjoy their income and property under the equal protection of the laws. In personal terms, couples are free to have as many or as few children as they desire. In economic terms, general good health means that people invest in education and training with the expectation of surviving to benefit from this effort. Privately owned businesses operating within the U.S. free market system make health care, higher education, and amenities available to most of the population. In addition, U.S. state and local governments, which are funded by taxes, provide most primary and secondary education free of charge, while the national government provides health care to the elderly and the very poor. The key to any nation’s future is how well it educates its children. An increased emphasis on access to quality education for all can break the cycle of poverty and eliminate disparities in academic achievement. With that in mind, President Bush in January signed into law the No Child Left Behind Act of 2001, an innovative program that reforms public education in the United States. This law requires that children be tested to ensure they are progressing, and that schools are held accountable for their results. Furthermore, it expands funding to public schools while localizing important decisions, and it provides parents with greater choice in their children’s education. In addition to this, the President has also outlined sweeping reforms for the welfare system in an effort

1 to eliminate the cycle of dependence and enable welfare recipients to achieve financial independence by preparing for and obtaining gainful employment. To improve overall health of the United States, the Bush Administration has outlined a health care agenda that expands access to affordable, quality care. The general health of the United States is presently at an all-time high. Life expectancy rates have never been higher, and the incidence rates of many diseases are in sharp decline. In addition, incidence of many other diseases and conditions that continue to plague Americans can be prevented or mitigated. To battle these threats, President Bush in June 2002 released HealthierUS: The President’s Health and Fitness Initiative. This program assists Americans in improving their health and reducing disabling chronic conditions by improving their diets, increasing physical activity, utilizing preventive screenings, and avoiding risky behaviors that lead to health problems. In addition, President Bush has committed to providing care for the uninsured through health tax credits and medical savings accounts, maximizing efficient utilization of the Children’s Health Insurance Program, and increased funding to community health centers. To ensure that all Americans can look forward to healthy aging, the United States has developed a plan that increases the overall health and security of the elderly population. As the “baby boom” generation begins to reach age 65, tremendous stress will be put upon the federal government to provide increased services. Therefore, Congress and the President have committed to improving the quality of the Medicare system while reforming it to ensure the program’s long-term solvency. Furthermore, funding for research into aging issues has been increased, as has support for family caregivers. The federal government has also taken new steps that encourage elderly people to remain socially active in their communities. Infant and maternal mortality rates in the United States are low, and the U.S. Department of Health and Human Services (HHS) and other government agencies are working to further reduce this problem. To accomplish this, HHS has resolved to increase both access to prenatal care and funding towards research, and its Centers for Disease Control (CDC) has launched the Safe Mother Initiative. Furthermore, in recognizing that children who grow up in homes with two married parents have a better

2 chance to succeed, President Bush has proposed to increase funding of healthy marriage programs to $300 million next year. Also of concern to the Bush Administration is the prevalence of unintended teenage pregnancies. President Bush has earmarked unprecedented funding for teen abstinence programs, and he has increased funding to family planning programs, including those that promote abstinence. In addition, the United States is committed to funding research into innovative methods of family planning in an effort to better meet couples’ needs through a broader range of choices. Although the incidence rate of HIV/AIDS has fallen sharply in the United States over the last seven years, the Bush Administration has allocated unprecedented funding to support research, prevention programs, and improved care. In fact, the President's budget for fiscal year 2003 increases total U.S. government spending on HIV/AIDS to over $16 billion. This funding will go toward researching a vaccine and better treatment methods, expanding prevention programs, and ensuring access to Ryan White treatment programs. On the international front, the United States is the largest bilateral donor to the developing world. To encourage economic development and poverty reduction, President Bush in March 2002 announced the creation of a new Millennium Challenge Account, a program that will link U.S. aid to sound policies in developing countries. Because the United States views the HIV/AIDS epidemic as a global tragedy, it has led the efforts in creating the Global Fund to Fight AIDS, Tuberculosis and Malaria while providing unmatched funds to combat HIV/AIDS around the world. In addition, the Bush Administration announced the creation of the Mother and Child HIV Prevention Initiative, a program funded at $500 million with the goal of reducing mother to child transmission of HIV by 40 percent within five years in 12 African countries and the Caribbean. Finally, the United States continues to provide international funding to highly effective abstinence-based prevention programs, such as the Abstinence, Be faithful, Use a Condom if A and B fail (ABC) program in Uganda.

3 Section 1. Overview of Population and Development Situation and Prospects, with Special Attention to Poverty

In the United States, individuals have the power to lift themselves out of poverty through sustained participation in the economy. Government-provided primary and secondary education, and personal investment in further education and training, allows individuals to attain more remunerative employment as their careers progress. Most jobs provide health insurance as a benefit. For a safety net, the federal government provides health care to the elderly and the poor. The governmental welfare system provides support for those who are jobless and poor, but this support is intended to be temporary. As a result of these measures, U.S. per capita output is high.

Trends and Priority Issues Population and demographics The United States takes an official census every ten years. U.S. Census data from the year 2000 place the population at 281,421,906, with approximately 77.2 percent of the population living in urban areas. Whites comprise the largest racial/ethnic group within the United States at 75.1 percent of the population, followed by Hispanics of any race at 12.5 percent. African-Americans represent 12.3 percent of the population, followed by Asians, American Indians and Alaskan Natives, and Native Hawaiians and other Pacific Islanders at 3.6, 0.9, and 0.1 percent, respectively.1

Education In the United States, slightly more than 99.5 percent of the population is literate. The overall high school graduation rate is 82.8 percent, which is a solid increase from the rate of 77.6 percent recorded in 1990. However, disparities in education remain. While whites have an 83.7 percent graduation rate, African-Americans and Hispanics trail with rates of 76.0 and 55.5 percent, respectively. It is encouraging, however, that all racial groups have recorded some progress since 1990, with African-Americans experiencing the largest increase of 9.8 percent.2 However, narrowing this education gap remains a

4 high priority for the United States, particularly in light of the important part that education plays in reducing poverty.

Poverty The poverty rate in 2000 dropped to 11.3 percent, down half a percentage point from 1999. This rate was not statistically different from the record low of 11.1 percent set in 1973. About 31.1 million people were poor in 2000, which represents a decrease of 1.1 million people over the previous year.3 This decrease was not concentrated in any one region of the United States, although the poverty rate did fall significantly for those living in metropolitan areas but outside of central cities.4

Several groups set record-low poverty rates in 2000, including blacks, at 22.1 percent, and female-householder families, at 24.7 percent. People 65 years old and over (10.2 percent), Asians and Pacific Islanders (10.8 percent), Hispanics (21.2 percent), white non-Hispanics (7.5 percent), married-couple families (4.7 percent), and people living in the South (12.5 percent) had poverty rates that were not statistically different from their record lows. In addition, the poverty rate for 18- to 24-year-olds declined more than for any other group.5

While racial and ethnic disparities remain, the data from 2000 show an encouraging trend. Black Americans remained disproportionately poor, but the difference in poverty rates between blacks and white non-Hispanics has narrowed since the most recent poverty rate peak. In 1993, the black poverty rate was 23.2 percentage points higher than that for white non-Hispanics; by 2000 this difference had fallen to 14.6 percentage points.6

Future Direction

No Child Left Behind The key to eliminating the cycle of poverty for the poor is to address the deficiencies in education and ensure that all children have access to a quality education.

5 President Bush has made educating every child his highest domestic priority. He pledged to reform the public education system that—despite nearly $200 billion in federal funding since 1965—has failed the neediest in the nation's classrooms. On January 8, 2002, President Bush signed into law the No Child Left Behind Act of 2001. This program utilizes innovative yet proven techniques to improve overall student performance and close the achievement gap between rich and poor students, including the gap in graduation rates.7 For example, No Child Left Behind (NCLB) demands stronger accountability for results in public schools by requiring all states to set high standards of achievement and create a system to measure results. Furthermore, it requires states to set high standards for achievement in reading and math, which are the building blocks of all learning, and to test every child in grades 3 through 8 to ensure that students are making progress. NCLB also provides greater flexibility and local control over schools by reducing the amount of federal bureaucratic management and placing decision-making at the local level where it belongs.8 In addition, NCLB also expands options and choice for parents by providing unprecedented federal support for children from disadvantaged backgrounds and requiring states to provide annual report cards for school performance and statewide progress. Finally, it increases federal funding under the Elementary and Secondary Education Act to more than $22.1 billion—a 27 percent increase over last year, and a 49 percent increase over the 2000 levels. Also included in the budget is an estimated $10.4 billion to help disadvantaged students succeed, and nearly one billion dollars for programs to ensure every child in America learns to read.9

Welfare reform With a goal of reducing the devastating cycle of welfare dependence, the United States Congress in 1996 thoroughly reformed the welfare system in the United States. On June 3, 2002, HHS Secretary Tommy G. Thompson released a study that showed the effects of this reform. The study found the sharp reduction in poverty rate coincided closely with the historic drop in the number of people dependent on welfare in the years immediately following the landmark 1996 welfare reform law. In all, 4.7 million fewer

6 Americans were dependent on welfare within three years after the welfare reform law first passed, and 5.4 million fewer Americans were living in poverty. The percentage of the population dependent on welfare fell from 5.2 percent to 3.3 percent during this time, and the poverty rate fell from 13.7 percent to 11.3 percent—the lowest rate since 1979.10 With this success in mind, President Bush has proposed a new welfare reform bill with a stronger work requirement to help even more Americans achieve the goal of independence for themselves and their families. This bill promises to build upon the success of the 1996 reforms by making welfare even more focused on the well-being of children and supportive of families. It requires welfare recipients to work 40 hours per week, either at a job or in programs designed to help them achieve independence, including job training. Furthermore, this proposal will continue historically high levels of support for childcare by providing $4.8 billion per year, and it will encourage states and local governments to adopt innovative solutions to help welfare recipients achieve independence.11

Section 2. Fertility Levels and Trends, and their Implications for Reproductive Health, Including Family Planning

Trends in Fertility The overall fertility rate for women between 15 and 44 years of age has remained between 65 and 67 births per 1000 women since 1995. The rate in 2000 was 67.5 births, a slight increase of 1.6 over the previous year. Of all racial and ethnic groups, the fertility rate for white, non-Hispanic women in 1999 was the lowest at 58.5 births per 1000. Hispanic women, whose rate of 105.9 births represented a rise for the second year after four consecutive years in decline, recorded the highest fertility rate. Black, non- Hispanic and American Indian or Alaska Native women both recorded rates with little fluctuation from the previous year, at 73.7 and 71.4 births, respectively. The largest change in fertility rate was recorded by Asian or Pacific Islander women, whose rate of 70.7 births represented an increase of 4.9 over the previous year.12

Priority Issues

7 Preventing unintended teen pregnancies and abortion The prevalence of unintended teenage pregnancy remains a problem. These pregnancies can carry many negative consequences. Socially, the costs for mothers can often be measured in reduced educational attainment and employment opportunity and greater welfare dependency. Economically, health care costs are increased. Medically, unintended pregnancies are serious in terms of the lost opportunity to prepare for a healthy pregnancy, the increased likelihood of infant and maternal illness, and the likelihood of abortion.13 Approximately one abortion occurs for every three live births annually in the United States, a ratio two- to four-times higher than in many other industrialized democracies.14 President Bush has made solving this problem a high priority. This past January, he stated that Americans must “affirm a culture of life,” and that “our society has a responsibility to defend the vulnerable and weak, the imperfect and even the unwanted; and that our nation should set a great goal that unborn children should be welcomed in life and protected in law.”15 Indeed, better family planning programs offer an outstanding opportunity to reduce the recourse to abortion. As the ICPD ’94 Programme of Action states, “All attempts should be made to eliminate the need for abortion.”16

Future Direction Family planning Since unplanned pregnancies often carry so many negative consequences, the United States considers family planning programs, especially those that promote abstinence for unmarried persons, to be vital to the welfare of the country. With that in mind, President Bush last year requested $265 million in funding for the Office of Family Planning, an office established by Title X of the Public Health Service Act (1970). The program is designed to provide access to contraceptive supplies, counseling, and information to all who want and need them, with priority given to people with low- incomes. In addition, Title X-supported clinics provide a number of preventive health services such as patient education and counseling; breast and pelvic exams; cervical cancer, Sexually Transmitted Infection (STI) and HIV screenings; and pregnancy

8 diagnosis and counseling. For many clients, Title X-supported clinics provide the only continuing source of health care and education.17 In addition, the United States is committed to funding research into innovative methods of family planning in an effort to better meet couples’ needs through a broader range of choices. For example, the United States Agency for International Development (USAID) supports organizations such as the Institute for Reproductive Health (IRH) at Georgetown University. IRH has developed simplified approaches to highly effective methods of natural family planning, designed specifically for use by illiterate populations, whose ease and affordability will greatly assist the U.S. development aim of helping individuals worldwide achieve the family size they desire.

Section 3. Mortality and Morbidity Trends and Poverty

Mortality and most morbidity rates continue to decline—with the exception of obesity and related diseases. Life expectancy continues to increase, and general health continues to improve. Future efforts will focus upon prevention, research, and the elimination of disparities in health and in health insurance coverage.

Trends in Mortality Life expectancy Life expectancy is one of the single most important indicators of national health. In 2000, the life expectancy at birth for the entire population in the United States increased to an all-time high of 76.9 years, which is a 1.5-year increase since 1990. This most recent rise in life expectancy is consistent across all ethnic and racial categories. However, the life expectancy for African-Americans, despite a modest increase to 71.8 years, remains 5.6 years shorter than that of whites.18 The trends also clearly show that, as expected, life expectancies for individuals vary across socio-economic lines. This remains a great challenge and opportunity that policymakers are addressing.

Causes of death

9 Mortality from heart disease, the leading cause of death in the United States, continued to decline in 1999, to 267.8 deaths per 100,000 people. Since 1970, heart disease mortality has declined at an average rate of about 2 percent per year. Mortality from cancer, the second leading cause of natural death in the U.S., also continued to decline in 1999 to 202.7 deaths per 100,000. This follows a decrease of 6 percent between 1990 and 1998.19 Deaths from cerebrovascular disease also dropped, to a rate of 61.8 deaths per 100,000. However, deaths from chronic lower respiratory disease have risen slightly in the last couple years, to a rate of 45.8 deaths 100,000. Though HIV/AIDS remains a significant cause of illness, disability, and death in the United States, great strides have been made in improving both the length and quality of life of those infected. Indeed, the death rate from HIV/AIDS in the United States has been cut nearly in half over the last decade, from 10.2 deaths per 100,000 in 1990 to 5.4 in 1999.20 However, HIV/AIDS is now the leading cause of death for African-Americans aged 25- 44, according to the CDC within HHS.21

Trends in Morbidity General health According to the National Center for Health Statistics (NCHS) within HHS, the percent of people who assessed their health as excellent or very good slightly increased to 68.6 percent in 2001. The percentage of respondents who assessed their health as fair or poor remained statistically steady at 9.0 percent.22 It is clear that there is also a direct correlation between poverty status and general health. In 2000, 36.2 percent of people living near or below the poverty line reported poor or fair health. However, only 6.3 percent classified as “nonpoor” reported the same.23 Eliminating health disparities such as this remains a key challenge that must be met in order to improve the quality and length of life for all Americans.

Disease Because of advances in prevention efforts and medical technology, the occurrences of many life-threatening diseases are in decline in the United States. The total number of new HIV/AIDS cases has dropped, and so have the incidence rates of

10 cancer. However, the incidence rates among blacks for HIV/AIDS increased slightly, and the occurrence of cancer in women has remained steady.24 Immunization efforts have all but eliminated the occurrences of many other diseases that once plagued the United States, such as mumps, rubella, and pertussis (whooping cough).25 However, the occurrence of obesity, a leading cause of other disease, has risen a dramatic 60 percent in the last 20 years.26 Diabetes, a disease often caused by obesity, now affects more than 17 million people in the United States. Its prevalence has increased steadily since 1980, and it is the leading cause of adult blindness, kidney failure, and non-traumatic amputations, and a major cause of heart disease and stroke. Diabetes is the sixth-leading cause of death in the United States, and every year the disease costs the nation an estimated $100 billion in direct medical costs as well as indirect costs, such as disability and premature death.27

Priority Issues Preventable disease Sadly, many people are suffering and dying from diseases they could have prevented. Two of the largest contributors to disease, smoking and obesity, account for hundreds of thousands of deaths per year. Last year alone, more than 440,000 people died of smoking-related illness.28 Five chronic diseases associated with obesity—heart disease, cancer, stroke, chronic obstructive pulmonary disease, and diabetes—account for more that two-thirds of all deaths in the United States.29 Alcohol and drug abuse are also responsible for devastating but preventable health consequences.

Racial and socio-economic disparities in health coverage An ongoing goal for the United States is to eliminate the health disparities between people of different races, ethnicities, income levels and gender. Despite a slight improvement over the last five years, the percentage of people under 65 years without health coverage has changed very little over the past decade. As it stands, approximately 16.0 percent of the population in 2001 reported having no health care coverage.30 Not surprisingly, the racial and income groups with traditionally poorer health also had the lowest rates of coverage. People slightly above, at, or below the poverty level were

11 nearly five times more likely to be without health coverage. Additionally, blacks had a seven percent lower coverage rate than whites, a disparity that had remained virtually unchanged during the previous five years.31 Of course, disparities in overall health are also the result of complex interaction among genetic variations, environmental factors, and specific health behaviors. Therefore, any attempt to remedy observed health disparities must include efforts that empower individuals to make informed health decisions, promote community-wide safety, education, and access to health care.32

Future Direction Although the general rates of mortality and morbidity in the United States are in decline, the U.S. remains committed to further increasing the length and quality of life and to eliminating disparities in health among racial, ethnic, and socio-economic lines. To accomplish this, the government has developed a comprehensive health policy that focuses on research, improved access, and prevention.

Greater access to health care coverage Since many health problems and disparities can be traced to a lack of access to quality health care, the President has outlined an agenda that aims to ensure all Americans will have affordable, quality health care coverage. He has committed $117 billion in initiatives to make good health care coverage more available and affordable to people of all races and income levels.33 The President’s plan lifts the excessive restrictions on Medical Savings Accounts (MSAs) by lowering the deductible requirements to levels that are increasingly common in private health insurance plans to allow preventive health coverage. These changes will allow many more Americans to set up tax-free accounts to protect themselves from high out-of-pocket costs. The President supports legislation that would make it easier for small employers to pool together to offer their employees better health coverage options, like many large corporations are able to offer. The President’s budget proposes $89 billion in new health credits to make private health insurance more affordable for low- and middle-income American families that do

12 not have employer-subsidized insurance. The credits would be worth up to $1000 for individuals and $3000 for families, would be available when people need them to pay their insurance premiums, and do not depend on taxes owed. The Administration will work with states to give many Americans the option of using the health credits through state-sponsored purchasing pools, to help ensure that they too have access to a broad range of affordable coverage options. The credits will enable six million Americans who would otherwise be uninsured during a year to get coverage, and will help many more who are struggling to pay for their own health insurance with little or no government help.

Better Medicaid and State Children’s Health Insurance Program (S-CHIP) The Bush Administration will continue to work with states and Congress to provide innovative coverage in these important government programs, including health care coverage options. In just the past year, the Administration has already worked with states to expand innovative Medicaid and S-CHIP coverage for almost two million more Americans. The President’s budget strengthens S-CHIP by making available to states an estimated $3.2 billion in unused S-CHIP funds that otherwise would be lost. The S-CHIP law originally required states that did not use their full S-CHIP allotment during the previous three years to return unused funds to the Federal Treasury. These additional matching funds will enable all states to expand coverage to the uninsured. Other efforts to increase coverage in the United States include strengthening the health care safety net. The President’s budget includes $1.5 billion for Community Health Centers (CHCs), a $114 million increase that would continue the Bush Administration’s long-term strategy to add 1,200 new and expanded health center sites over five years and serve an additional 6.1 million patients. The increase for fiscal year 2003 will support 170 new and expanded health centers, and provide services to a million more patients. Also, since 1970, over 20,000 doctors, nurses, dentists, midwives, and mental health clinicians have been placed in medically underserved communities through the National Health Service Corps (NHSC). The President’s budget includes $191.5 million—a $44 million increase—to strengthen the NHSC. With the increased funding,

13 the NHSC will provide scholarships or loan assistance to about 1,800 professional practicing in underserved areas—an increase of about 500 participants. These services provide health care for Americans in rural and inner-city areas, thus strengthening the health care safety net for people without health insurance and others living where health care providers remain scarce. Indeed, nearly half of all patients treated at health centers have no insurance coverage, and many others have inadequate coverage.34

Funding breakthrough medical research Recognizing that a key to the future health of the nation is an intense focus on research, the President’s fiscal year 2003 budget includes a total of $27.3 billion for the National Institutes of Health (NIH) within HHS, which completes the doubling of the NIH budget. This increase will allow the NIH to expand its efforts to support research to improve prevention, detection and treatment of diseases.35 The NIH supports 50,000 scientists working in over 2,000 institutions across the United States. Thanks to NIH funding, these scientists have been making great advances in the prevention, diagnosis, and treatment of diseases and disorders. As we look to the future, medical science stands at the threshold of profound research advances that were unthinkable a decade ago. Researchers are identifying genes that are responsible for abnormalities that cause many diseases, and this can bring us closer to curing Alzheimer’s Disease, Parkinson’s Disease, heart disease, AIDS, diabetes, etc. With an expanded focus on research, we can ensure the plagues of the 20th Century do not continue to haunt us in the 21st.

Prevention In a May 2002 speech to the 54th World Health Assembly in Geneva, U.S. Secretary of Health and Human Services Tommy G. Thompson declared, “It is time to change the priorities in our health care system to invest in prevention earlier in life, allowing people to lead healthier lives.”36 With this in mind, President Bush in June released HealthierUS: The President’s Health and Fitness Initiative. This program intends to improve health and reduce illness and chronic conditions through individual improvements in physical activity, diet, seeking preventive screenings, and avoiding

14 risky behaviors. Among other goals, it encourages children not to start smoking and adults to quit, and it commits the resources of the federal government to alert Americans to the vital health benefits of simple and modest improvements in physical activity, nutrition, and behavior.37 This intensified focus on prevention promises to yield a much healthier America, and similar prevention programs could prove very effective in other countries around the globe.

Section 4. Migration, Urbanization, and Poverty

In the United States, only three percent of the population is engaged in agriculture as its primary source of income.38 Large-scale migration to cities is no longer a primary concern. The U.S. economy benefits from an inflow of immigrants who come in search of jobs. Between 1990 and 2000, the foreign-born population of the United States increased by 44 percent to 28.4 million, comprising about 10 percent of the population. Approximately 26 percent of the U.S. foreign-born population is from Asia. Education levels, labor force participation rates, and the percentage of persons receiving public assistance were very similar for the Asian-born and native-born populations. Median household income for households with an Asian-born householder was $51,400 compared with $41,400 for native-born householders.39

Section 5. Population Ageing

The U.S. elderly population enjoys good health, and it is one of the fastest growing segments of the population. Americans generally enjoy healthy aging, thanks to the widespread availability and affordability of health care, support from children and extended family members, and the generally solid economic circumstances that our elderly enjoy as a group. To better serve the elderly, the Bush Administration has plans to modernize Medicare, focusing upon prevention of disease and investment in health; to encourage the elderly to remain socially active in their communities; to encourage and provide support for families to care for their elderly relatives; and to increase funding for research on aging.

15 Current Status and Trends One of the most important measures of a society is the welfare of its elderly population. In the United States, the life expectancy for people at the age of 65 in 2000 rose to 17.9 years, its highest level ever and an increase of 1.5 years since 1980. Elderly people comprise 12.4 percent of the total population, or approximately 35.0 million people. This represents a 12 percent increase since 1990, when there were 31.3 million elderly people.40 Despite the relatively slow growth of the elderly population in the nineties (compared with a 13.3 percent growth of the entire population), the number of Americans aged 45-64 has increased by 34 percent since 1990. Therefore, in between the years 2010 and 2030, the elderly population is expected to double as the “baby boom” generation reaches age 65. It is estimated that by the year 2030, one out of every five people, or 20 percent of the population, will be 65 years or older.41

Priority Issues Access to services As the elderly population is expected to sharply increase, there are many implications for a tremendous increase in the need for special services. The Social Security system will meet a challenge never before faced, and the health care system will soon face an increase in the number of elderly people requiring treatment. The federal Medicare and Medicaid systems will face new challenges as well, as millions more Americans will soon rely on the government to assist in the costs of health care. Clearly, the coming influx of elderly people must be met with a delicate combination of careful planning and innovative policy.

Future Direction Medicare Because America’s older population is growing rapidly, planning and caring for the needs of the elderly is a priority of the United States government. HHS administers the Medicare and Medicaid programs, which have become the largest health coverage

16 programs for the elderly. In 2002, Medicare spending for the health care of the program’s almost 40 million aged and disabled enrollees totaled $228 billion. President Bush’s budget increases Medicare funding $196 billion over the next 10 years, to $423 billion in 2011.42 To meet the challenges Medicare soon will face, President Bush is committed to modernizing the Medicare system. Among other improvements, the President has devoted $110 billion to begin the modernization process in fiscal year 2005. These reforms include providing better coverage options, ensuring all seniors have affordable access to prescription drug coverage, and providing better options for low- income seniors to protect them against high out-of-pocket expenses. Furthermore, to ensure the solvency of the Medicare program, the President’s plan ensures greater overall financial security by maintaining an accurate measure of the program’s financial status.43

Prevention programs As with the rest of the population, many improvements in the overall health of the elderly can be gained through quality prevention programs. Therefore, Medicare has recently expanded coverage for preventive measures such as mammograms, pap smears, colorectal cancer screenings, bone-mass measurement, and diabetes self-management.44 Furthermore, HHS in 1998 launched the Healthy Aging Project, which was designed to study the best ways to promote health and prevention among the elderly population. The project identifies strategies that have been empirically successful in promoting healthy aging, and it passes this knowledge along to health care providers to improve the delivery of preventive services.45

Volunteerism One way to ensure better health among the elderly is to encourage them to remain socially active by volunteering in their communities. In March 2002, President Bush announced the USA Freedom Corps, a new program that offers service opportunities to Americans of all ages who are looking for ways to serve their community, country, and world. The President’s entire Cabinet is encouraging older Americans to participate in the USA Freedom Corps, or in other volunteer opportunities, such as the Senior Corps or the Medical Reserve Corps.46

17 Family care In response to largely successful long-term care programs in states such as California, New Jersey, and Wisconsin, Congress in 2000 established the National Family Caregiver Support Program (NFCSP). The program was developed by the Administration on Aging within HHS, and it calls for all states to work with local agencies and community-service organizations to provide services to family caregivers. The program is especially geared toward persons with the greatest social and economic need, and it helps to provide them with proper information, assistance, counseling, and other supplemental services to assist them with their caregiving endeavors. NFCSP was funded at $125 million in fiscal year 2001, and last year HHS Secretary Tommy G. Thompson released the initial $113 million to the states for implementation of the program.47

Research Finally, the United States is committed to investigating the causes and effects of the aging process to improve the life of older Americans. This research includes studies to address all aspects of aging, from conditions and diseases that primarily affect older people to physical, behavioral, and cellular characteristics of the aging process. The National Institute on Aging (NIA), which is a division of the broader NIH within HHS, leads the research effort to understand the nature of aging and to extend the healthy, active years of life. The NIA conducts this research in a broad number of areas, including Alzheimer’s Disease, geriatrics, and the biology of aging. Total funding for NIA programs in 2002 was $896.1 million, and the President’s fiscal year 2003 budget increases this spending to $971.7 million.48 Across all of NIH, aging related research is estimated to be $1,878.2 million in 2002 and $2,039.6 million in 2003. This increased commitment to research promises to further improve the lives of the elderly population for years to come.

Section 6. Reproductive Health

18 Current Status, Trends, and Priority Issues Infant mortality The infant mortality rate is an important indicator of maternal health, quality and access to medical care, socio-economic conditions, and public health practices.49 In the United States, the infant mortality rate is very low. Over the past five years, infant mortality has remained essentially unchanged, hovering around 7.0-7.2 deaths per 1000 live births.50 However, this is a decrease of over 19 percent since 1990, much of which can be credited to a variety of factors, including advances in the survival of low-birth weight and pre-term infants and in the prevention of some causes of post-neonatal mortality such as Sudden Infant Death Syndrome.51 Additionally, the proportion of mothers getting early prenatal care is at a record high and the rate of smoking among pregnant women continues to fall.52 However, racial and socio-economic disparities still exist in infant mortality rates, and this is a problem that demands an increased focus.

Prenatal care With adequate prenatal care that includes risk assessment, treatment for medical conditions or risk reduction, and education, it is possible to further cut infant mortality. Each component can contribute to reductions in perinatal illness, disability, and death, by identifying and mitigating potential risks and by helping women to address behavioral factors that contribute to poor outcomes, such as smoking and alcohol abuse.53 Prenatal care is more likely to be effective if women begin receiving care early in pregnancy. Since 1990, the proportion of infants whose mothers entered prenatal care in the first trimester has increased 8.8 percent, from 76 percent to 83 percent. Among African Americans, this proportion grew 19 percent and among Hispanics, 22 percent. Thus, increases in early entry into prenatal care have been concentrated in those populations whose perinatal illness and disability rates and mortality rates are highest and who are most likely to have low incomes. These increases likely stem, in part, from increased access to Medicaid coverage for pregnancy-related services and improved outreach by Medicaid programs.54

19 Maternal mortality Maternal mortality is a basic indicator of overall maternal health and the quality and accessibility of primary health care available to pregnant women.55 Although the infant mortality rate has remained steady for the last five years, the incidence rate of maternal mortality has seen modest fluctuation. However, the rate remains very low. Since 1982, the overall maternal mortality rate has bounced between approximately 6.6 and 8.4 deaths per 100,000 live births. This fluctuation continued in 1999, as the rate again jumped to 8.3 deaths per 100,000 live births, an increase of 2.1 deaths over the previous year.56 As with infant mortality rates, there is also a significant racial disparity between maternal mortality rates, as black women are four to five times more likely to die of complications during pregnancy.57

Nonmarital childbearing In addition to the physical effects of unhealthy pregnancies, out-of-wedlock births can present a major challenge to raising healthy children. Studies show that children growing up in a home without a married mother and father are about twice as likely to drop out of school and 50 percent more likely to abuse controlled substances.58 Unfortunately, out-of-wedlock childbearing in the United States has increased to a rate of over 1.2 million births per year.59 In fact, 33 percent of all infants are now born to unwed mothers, an increase of 5 percent since 1990 and over 20 percent since 1970. Black mothers continued to have the highest rate of nonmarital childbearing, at 68.5 percent, although that rate has consistently but slowly dropped since its all-time high of 70.4 percent in 1994. Several other racial and ethnic groups also show large disparities in nonmarital childbearing rates from those of white mothers, whose rate in 2000 rose to 27.1 percent.60

Future Direction Healthy pregnancy In addition to the continued commitment to increase access to prenatal care and other quality health services, the United States continues to fund and support public and private organizations that fight infant mortality. Two of these organizations are the

20 National Healthy Mothers, Healthy Babies Coalition (HMHB) and the March of Dimes. HMHB, a recognized leader and resource in maternal and child health, is a coalition of over 100 state, local, and national organizations whose purpose is to improve the health and safety of mothers, babies and families through education and collaborative partnerships of public and private organizations.61 The March of Dimes is a collaboration of researchers, volunteers, educators, outreach workers and advocates who all work to fight infant mortality and the causes that lead to it.62 Through public education campaigns, research grants, and passion for the cause, organizations like the HMHB and the March of Dimes work with the government of the United States to ensure that one day, all babies will grow into healthy adults. To battle maternal mortality, the CDC within HHS has launched the Safe Mother Initiative. Estimates project that up to half of all deaths from pregnancy complications could be prevented through broader access to health care, better quality of care, and changes in health and lifestyle habits.63 In 2001, HHS and its partners held the first U.S. Summit on Safe Motherhood, which brought together a broad coalition of agencies, organizations, and professionals dedicated to improving maternal health and coordinating actions to make it a national priority. Furthermore, HHS is committed to gathering strong, useful data and conducting innovative research on maternal mortality, and educating and training others on how to prevent pregnancy complications.64

Healthy families President Bush is committed to increasing the number of children raised in households headed by married parents. Children raised in these households fare, on average, better than children who grow up in other family structures.65 While one-parent families are also a source of comfort and reassurance, a family with a mom and dad who are committed to marriage and devote themselves to their children helps provide children a sound foundation for success. Government can support families by promoting policies that help strengthen the institution of marriage and help parents rear their children in positive and healthy environments.66 Therefore, the Bush Administration proposed to establish a $100 million annual fund to conduct research and demonstration projects, as well as to provide technical

21 assistance to focus on family formation and healthy marriage activities. While reforming the welfare system, renamed Temporary Assistance for Needy Families (TANF) in 1996, Congress recognized that two-parent, married families offer the ideal environment for raising children. The President’s proposal further amends TANF to establish an overarching purpose to improve the well-being of children, and clarifies the encouragement of healthy marriages as a TANF goal.67 In all, President Bush has requested $300 million from Congress to support healthy marriage programs.68

Section 7. Adolescent Reproductive Health

Prevalence of sexuality and child-bearing today The birth rate for teenagers between the ages 15-19 in 1999 declined for the ninth consecutive year, to 48.5 births per 1000 women aged 15-19 years, an all-time low for the nation. This decline was consistent across all racial categories. Among these categories, black mothers recorded the largest drop, at 1.6 births per 1000.69 However, two out of three high school students report having had sexual intercourse before graduating.70

Priority Issues Pregnancy rates among teenagers in the United States have fallen steadily over the past decade. However, every year there are nearly one million teenage pregnancies.71 For teenagers, the problems associated with pregnancy are compounded, and the consequences are well documented. Teenaged mothers are less likely to get or stay married, less likely to complete high school or college, and more likely to require public assistance and to live in poverty than their peers who are not mothers. Infants born to teenaged mothers, especially mothers under age 15, are more likely to suffer from low birth weight, neonatal death, and sudden infant death syndrome. These infants may be at greater risk of child abuse, neglect, and behavioral and educational problems at later stages.72 Many factors contribute to the problem of teenage pregnancy in the United States, including peer pressure, inadequate access to proper information, and the erosion of the family. In one poll conducted in 1994, adolescents aged 12-17 reported that the pressure

22 to have sex was the most significant threat to their well-being. Another poll of 1000 girls in an adolescent clinic in Atlanta revealed that among all topics, 84 percent of the girls most desired to discuss how to say “no” to their boyfriends’ requests to have sex without losing the boyfriend or hurting his feelings. The same study reported that greater supervision and discipline by parents would reduce the sexual activity of teens.73

Future Direction In 1996, Congress appropriated $50 million to fund abstinence education programs in the states. Every state eventually applied for this funding, and this past April, Mathematica Policy Research, Inc. released a federally funded interim report on the success of the programs. It found that most states are using the funding to create innovative programs to promote abstinence as the healthiest choice for youth. In addition, the programs offer more than the single message of abstinence. Most of the programs surveyed also addressed larger issues, such as healthy relationships, self-worth, good decision-making, and effective communication that work in conjunction with the abstinence message.74 Initial findings show that most participants view the programs favorably, and they appreciate programs that “deliver an intensive set of youth development services to enhance and support the abstinence message.”75 Cognizant of the consequences of teenage sexual activity and childbearing, the Bush Administration has focused on a policy that stresses abstinence among adolescents. President Bush recognizes that abstinence is the surest and only completely effective way to prevent unwanted pregnancies and sexually transmitted disease. In a speech this past February, he remarked, “Government should not sell children short by assuming they are incapable of acting responsibly. We must promote good choices.”76 To execute this strategy, the Bush Administration is recommending that the abstinence education program begun in 1996 be reauthorized without any reduction in funding.77 In addition, the President’s 2003 budget increases funding for the Human Resources and Services Administration within HHS, administered by Community-Based abstinence education grants, by 83 percent, or $33 million. This increase will ensure that many more communities across the country will be

23 able to more effectively communicate the message that abstinence is the only way to guarantee prevention of teen pregnancy, abortion, and transmission of STIs, including HIV/AIDS. Furthermore, the budget proposal continues funding to the Adolescent Family Life abstinence program, another effort at promoting abstinence education, primarily in schools.78

Section 8. Demographic, Economic and Social Impact of HIV/AIDS

Prevalence and mortality of HIV/AIDS The rate of AIDS mortality in the United States since 1996 has dropped dramatically, ever since the widespread introduction of highly active antiretroviral therapy.79 In 2000, the total number of deaths from AIDS in the United States was estimated to be 15,245, which represents nearly a 70 percent drop from the peak of 51,117 deaths in 1995. From 1999 to 2000, the number of estimated deaths among persons infected with AIDS declined 11 percent, which followed a 42 percent drop between 1996 and 1997. The current rate of decline appears to be stabilizing.80 The rate of incidence of AIDS in the United States has similarly been dropping, as 40,106 people were estimated to have contracted the disease in 2000. This represents nearly a 34 percent drop since 1996, when approximately 60,747 people were infected. However, the rate of decline in incidence also slowed, as the rate of incidence in 2000 was only a 1.4 percent decrease over the previous year.81 The cumulative number of AIDS cases in the U.S. to date is estimated at 793,026, and the total deaths to date from the disease are 457,667. As of 2000, there were 322,865 people who were reported to be living with AIDS82, although it is estimated that up to half of all people living with HIV in the United States are either unaware of their infection or not receiving care.83

Impact Demographic

24 Demographically, no single racial, ethnic, or age group has been unaffected by the prevalence of HIV/AIDS. In the United States, 41 percent of all people living with AIDS are black, 38 percent white, and 20 percent Hispanic. Among adults, 79 percent are men. Geographically, all regions of the United States are also affected, but the Southern United States had the most new cases with 16,688 new people infected (approximately 42 percent of the total new cases). Prevalence was also high in the Northeastern United States, and approximately 71 percent of all new AIDS cases occurred in the Northeast and South. Prevalence was lowest in the Midwest, as only 9.3 percent of all new cases occurred there.84

Economic Economically, the impact of HIV/AIDS has been devastating. Approximately 74 percent of all AIDS cases have been contracted by people between the ages of 25 and 44, which are generally some of the most productive years of life.85 Since AIDS can be such a debilitating disease, an incalculable amount of productivity has been lost because of this horrible epidemic. Furthermore, the expenses on health care and insurance services that are necessitated by the prevalence of the disease put additional strain on private savings, government revenue, and the economy.86

Future Direction In February, President Bush announced that he was increasing HHS funding to fight HIV/AIDS to a total of $12.9 billion for fiscal year 2003. This increase will represent an 8 percent increase over the previous year, and it bumps total U.S. spending on HIV/AIDS to over $16 billion for 2003.87 The President’s budget includes an increased focus on several key areas, including research, prevention, and improved care for those affected, in addition to international funding, which will be discussed in a later section.

Research The HHS budget will allocate $2.8 billion to the NIH to conduct important research. The NIH research focuses on both finding a vaccine and treatment, and the

25 2003 budget represents a $255 million, or 10 percent, increase over the 2002 funding level, and a $500 million increase since 2001. Of these funds, $422 million will go toward conducting research on for an AIDS vaccine, which is a 24 percent increase over 2002 and triple the 1998 funding level.88

Prevention The fiscal year 2003 budget allocates $937 million89 to the CDC within HHS for efforts to stop the spread of HIV/AIDS. Of this funding, $795 million is earmarked to support domestic HIV prevention programs, including efforts to reduce the number of people at high risk for acquiring or transmitting the virus; increase HIV testing efforts; link infected individuals with proper care and treatment; and strengthen the nation’s ability to monitor the epidemic and respond effectively.90 The CDC also works in collaboration with many other governmental and nongovernmental partners at all levels to implement, evaluate, and further develop and strengthen effective HIV prevention efforts nationwide. In addition to this, the abstinence programs mentioned in the previous section on Adolescent Reproductive Health stress to young people that abstaining from sexual intercourse is the only guaranteed way to avoid transmission of STIs including HIV/AIDS.

Improved access to care The fiscal year 2003 budget continues to fund the Ryan White treatment programs at a level of $1.9 billion. Each year these programs provide care and services to an estimated 500,000 Americans. Of this funding, approximately $639 million will be available for the AIDS Drug Assistance Program, which provides vital medications to about 85,000 people with HIV/AIDS. Spending for the Ryan White treatment programs has grown rapidly in the last several years, at a rate of almost 66 percent since 1998.91 Furthermore, the Bush Administration remains committed to ensuring funding for HIV services reaches minorities affected by HIV/AIDS in proportion to the impact of the HIV epidemic on those communities. This commitment includes ensuring the strengthened community health centers that serve minority communities have HIV/AIDS

26 capacity, as well as targeting prevention efforts at communities most at risk of the HIV/AIDS epidemic.

Section 9. Gender Equality and Development

Women’s legal rights and social roles Women in the United States enjoy the same legal rights as men. Women share with men the equal opportunity to train for and work in any career they desire. Women are increasingly represented in traditionally male fields such as engineering, accounting, medicine, and law. Of course, many women also choose to delay or limit participation in the paid labor force in order to devote more time to raising their children. Such choices are fully respected in the United States. Most American women expect to be equal partners in decision-making, both inside the home and among co-workers. Most married women who work full-time outside the home also expect their husbands to share equally in the housework. The real situation, of course, varies from family to family and, to some extent, from workplace to workplace. The government is striving to promote women’s rights. In recent years laws have been strengthened to prosecute perpetrators of domestic violence, to enforce child support payments to custodial single parents, and to combat discrimination and sexual harassment in the workplace.

Education and employment In 2000, 60 percent of women worked outside the home, composing 47 percent of the total workforce. Of people working full-time and year-round, women earned 73 percent as much as men. Among women in their late twenties and early thirties who have never had a child, a recent study showed that their earnings were approximately 98 percent of male earnings.92 High-school completion rates were equal between men and women (83.4 percent). For the total population ages 25 and over, the percentage of men with a bachelor’s degree or more slightly exceeded that of women (27.5 percent for men compared to 23.1 percent for women). However, the educational attainment levels of women under 30 exceeded those of men in the same age group.93

27 Health, pregnancy, and poverty Women have generally equal access to health care, and, as is common, women in the U.S. have a longer lifespan than men. Although there are roughly equal numbers of male and female children below the U.S. poverty line, elderly women living alone and young female single parents make up a substantial portion of the population that is deemed to be poor. Living in a single parent family has further negative consequences for children, as they are more likely to live in poverty, more likely to drop out of high school, and more likely to get in trouble with the law. Only one-third of unmarried teenage mothers complete high school.94 A popular culture that promotes an expectation that teens will engage in premarital sex undermines their confidence and their ability to say “no.” With rates of sexually transmitted infections at one in four among sexually active youth,95 reproductive health information programs should fully inform youth about the facts, the risks, and the consequences. Society must promote fidelity not only to one’s spouse, but also to one’s future spouse, long before that person has been chosen. Unmarried teens must be encouraged to remain faithful to their future. By disseminating the facts, promoting fidelity, and encouraging youth to remain faithful to their future, public information campaigns can make a significant difference in the rates of STIs, single parenthood, and poverty.

Section 10. Behavioral Change Communication and Advocacy and Information Communications Technology as Tools for Population and Poverty Reduction

The most effective means of reducing STIs and unplanned pregnancy is through education and information campaigns, based on scientific facts. When people know the facts, they make better decisions. Such education campaigns should disseminate fact-based, scientific information, while being careful not to implicitly endorse high-risk behavior. When public information campaigns and reproductive health programs accept a popular culture that

28 assumes teens will engage in premarital sex, they can inadvertently reinforce those expectations, reducing teens’ confidence and ability to make healthy choices. Given the high rates of sexually transmitted infections among sexually active youth, reproductive health programs for youth should, first and foremost, reinforce teens’ ability to say “no”. Three of four teenage girls report that the reason girls have sex is because their boyfriends want them to.96 Society as a whole must expect that teens can make more responsible decisions. Condoms can help reduce risk for certain STIs, but the danger cannot be ignored. Certain contraceptive methods reduce the risks of some diseases but have not been proven effective in reducing the risk of infection by the human papillomavirus and several other STIs. Evidence suggests some contraceptives, such as the birth control pill, may actually increase high-risk sexual behaviors associated with the acquisition of STIs, including HIV. Adolescents are highly vulnerable to acquiring STIs and their complications because of biological and behavioral factors. Although abstinence remains the most effective strategy for preventing pregnancy and STIs, adolescents should be educated about the dangers of high-risk behaviors and seek advice about such behaviors. Age and developmentally appropriate counseling strategies as well as careful assessment are needed to provide adolescents with directed educational messages.97 In the United States, campaigns to inform the public about the risks of STIs, particularly HIV/AIDS, have helped people make better decisions. For the last decade, the HIV/AIDS pandemic has been in the forefront of media and public information campaigns, and now a better-informed public is making better-informed decisions, resulting in a steady decline in the number of new cases. In addition, school-based abstinence programs and frank, open discussion about the risks and consequences of premarital sex are making a tremendous impact on teens’ choices. Teen pregnancy rates have dropped steadily since 1990. In the United States, broken families and teen pregnancy are leading causes of poverty. A wealth of information on abstinence and contraception is available on the Internet, but the most effective way to reach young people remains one-on-one discussions with someone they trust. Parents are still by far the most influential people in a young person’s life. Open, honest discussion between parents and teens about sex and

29 its consequences is by far the best way to reduce teen pregnancy and help young people remain faithful to their future.

Section 11. Data, Research and Training

USAID is the world’s single largest donor for population research. In addition to researching the best practices for service delivery, the USAID Population Research Division focuses on developing innovative methods of family planning and improving existing methods. USAID is dedicated to meeting couples’ family planning needs through a broad range of choices, and to improving existing methods to make them safer, more effective, more acceptable, and less costly.

New Developments in Birth Control and Family Planning USAID currently is in the early stages of testing various chemicals to act as microbicides to kill HIV and other viruses that cause STIs. USAID also tests products widely believed to be effective. Earlier tests of Noxynol-9, a chemical typically used as a lubricant for condoms, proved only moderately effective as a spermicide and not effective at all against HIV or other pathogens. USAID is conducting phase-I and phase- II clinical trials on other chemicals to test for their safety and effectiveness in actual use, as well as to try to identify new chemical entities that have both spermicidal and microbicidal properties. USAID also participated in the development and testing of Jadelle, a two-rod version of Norplant, which was recently approved by the Federal Drug Administration (FDA) within HHS. Jadelle is easier to insert and remove than Norplant, which has six rods. USAID support of clinical trials also resulted in FDA approval for a new female condom. Many couples around the world prefer to use natural methods of family planning because they do not require cumbersome barrier devices, have no side effects, and are accepted by all major religions. Natural family planning involves “tuning in” to an

30 individual woman’s natural cycle of fertility and non-fertility, and using that knowledge to choose whether to conceive or not conceive at that time. Natural family planning has evolved a great deal as scientists have learned more about a woman’s reproductive cycle. Early attempts to determine natural cycles of fertility and non-fertility included the calendar rhythm method, developed in the 1930s. Calendar rhythm, also called the “safe period,” was based on an average woman’s cycle, whereby a woman could guess that she was probably fertile during a certain period of time, as long as her menstrual cycles were very regular and predictable. It did not work well for women with irregular cycles, or even for women who were regular most of the time but occasionally had an irregular cycle. In the late 1960s, scientists discovered how to eliminate the guesswork. They found that women exhibited clear, observable symptoms of fertility and non-fertility. By learning to recognize these symptoms, a woman easily could know exactly when she would ovulate, regardless of the regularity or irregularity of her menstrual cycle. In 1978, the WHO completed a two-year study of the Billings Ovulation Method in five countries and found that when couples understood the method and used it correctly, it was 97 percent effective.98 Moreover, the Billings Method is effective for women with highly irregular cycles, because it involves recognizing the actual symptoms of individual fertility and is not based on averages or statistics. Like any family planning method, the Billings Method has advantages and disadvantages. Its advantages are that it is highly effective, does not involve cumbersome barrier devices, and has no side effects. Since the method is knowledge- based instead of product-based, there are no supplies to replenish. Once couples are trained, they become independent users and no longer rely on a steady supply of contraceptive products. One disadvantage is that couples have to be willing to abstain from sexual intercourse during the woman’s fertile phase—typically five to nine days, depending on her individual cycle. Another disadvantage is that it involves training for each user, which is significantly more costly than a quick injection. Small-scale programs, even among illiterate populations, have proven successful, but the larger initial investment required to train each user can be a hurdle for large-scale family planning programs.

31 USAID developed a simple new method of family planning called the Standard Days Method (SDM), which has proven to be very effective in clinical trials and is currently being piloted in programs around the world. SDM was designed to take advantage of scientific advances in fertility awareness to offer a practical, cost-effective option among low-literacy populations with little or no reproductive health education. Unlike the Billings Method, SDM does not require a large initial investment in training, making it a cost-effective option for large-scale family planning programs. USAID developed SDM by tracking the fertility cycles of 5000 women using the Billings Method over a period of three years. Researchers used a statistical analysis of the data to develop a simple set of color-coded beads that indicate a woman’s fertile and non-fertile phases. By extending the period of potential fertility to 12 days, this simple method accommodates women with cycles varying between 26 and 32 days. During the fertile phase, the couple can either abstain or use a barrier method, such as a condom. In July 2002, USAID concluded a six-month trial in which SDM was found 95 percent effective. The method is easy to use, natural, and free of side effects. It also can be used as an introduction to reproductive health education, helping women understand their reproductive cycles while familiarizing themselves with other family planning options.

Improving Existing Methods USAID also works to improve existing methods of contraception. USAID is testing various new materials for both male and female condoms. It is trying to make male condoms more acceptable, and female condoms less costly. Since the existing female condom (REALITY) is relatively expensive, many women in developing countries wash and re-use it, even though the product is labeled for single use, thus possibly exposing themselves to infections. USAID is exploring various cleansing regimens to successfully remove microbes that might remain on the female condom after use. Meanwhile, USAID continues to search for ways to make the product less expensive, to improve its design, and to make it more acceptable. Recent studies in Nepal and Mexico have shown that vasectomy, as currently practiced in developing countries using ligation and excision techniques, is not as

32 effective as originally claimed. USAID is currently researching several other techniques to improve the effectiveness of vasectomy.

Improved Understanding of Existing Methods USAID conducts long-term epidemiological studies to further knowledge regarding the use and benefits of existing contraceptive methods. Recent studies funded by USAID and the NIH have shown that vasectomy does not increase the risk of prostate cancer and that intrauterine devices (IUDs) are safe for use in nulliparous women and have no negative impact on fertility. Research has also shown that IUDs are safe for use by HIV-positive women and do not increase viral shedding. USAID supported many clinical trials that showed low-dose oral contraceptives are as effective and safer than higher-dose formulations. Past studies supported by USAID were instrumental in delineating other health benefits of oral contraceptives, such as protection against cervical and endometrial cancer.

Improving Service Delivery through Operations Research A major part of USAID’s research portfolio is devoted to improving family planning and reproductive health. One focus of USAID’s operations research is improving access to information and care for vulnerable groups such as adolescents and rural populations. USAID is at the forefront of research to identify the most cost- effective mechanisms to reach youth in schools and in the community. USAID is also exploring various strategies to improve the involvement of men in family planning and reproductive health for the benefit of the men themselves as well as their female partners. Past research funded by USAID led to the development of the community based distribution strategy for increasing access for women in rural and marginalized areas to contraceptives. USAID has also funded studies to show that clients in developing countries are willing and able to pay for services, thus allowing organizations to develop better strategies for increasing sustainability. A major area of emphasis in USAID’s operations research is improving the quality of services. USAID has developed many tools and approaches to improve client- provider interaction and to improve all aspects of service delivery systems. Past research

33 has shown that different levels of service providers, such as auxiliary nurses and community volunteers, are able to provide many contraceptive methods effectively and as well as clinic-based personnel. No single method of family planning is likely to be the best choice for every couple. That is why USAID is dedicated to expanding the range of available choices. By offering more choices, more couples will be able to find something appropriate for their own needs.

Section 12. Partnerships and Resources

The United States is currently the world’s largest bilateral donor to the developing world. While many donors provide economic assistance, the United States provides resources both to strengthen security and foster economic growth. Congress appropriated $17.1 billion to support these activities in fiscal year 2002. In addition, the U.S. is the world leader in humanitarian assistance and food aid ($2.5 billion), charitable donations ($4 billion), and Official Development Assistance ($11 billion).99 Because the United States views itself as a member of the global community, it remains committed to developing partnerships and providing aid to developing countries.

USAID Since its permanent inception in 1961, USAID has been the principal U.S. agency to extend assistance to countries recovering from disaster, trying to escape poverty, and engaging in democratic reforms. Along with broader health sector resources, USAID is working with HHS and other partners to reduce deaths, nutritional insecurity, and complications from pregnancy and childbirth.100 U.S. assistance to developing countries helps to alleviate the consequences of poverty and health problems, including HIV/AIDS. These efforts include reducing poverty through economic development aid and combating the worldwide epidemic of disease, including HIV/AIDS, through vaccination, research, and prevention programs.

Economic development and poverty reduction

34 On March 14, 2002, President Bush announced a proposal to increase U.S. core assistance to developing countries by 50 percent over the next three years, resulting in a $5 billion annual increase over current levels by fiscal year 2006. This increased assistance will go to a new Millennium Challenge Account (MCA) that funds initiatives to improve the economies and standards of living in qualified developing countries. The goal of the MCA is to reward sound policy decisions that support economic growth and reduce poverty.101 The MCA recognizes that economic development assistance can be successful only if it is linked to sound policies in developing countries. In countries where poor public policy dominates, aid can actually harm the very citizens it is meant to help, by crowding out private investment and perpetuating failed policies. Therefore, the funds in the MCA will only be distributed to developing countries that show a strong commitment toward the health and education of their people, good government, and sound economic policies that foster enterprise and entrepreneurship.102

HIV/AIDS incidence reduction Estimates project that by the year 2010, 44 million children around the world will have lost one or both parents to AIDS.103 With nearly 40 million people worldwide estimated to be infected with AIDS, this problem cannot be ignored. Therefore, the Bush Administration has committed an unprecedented amount of funding to research, prevention, and education programs in the developing world. This commitment is clearly evident in the U.S. efforts to lead the establishment of the Global Fund to Fight AIDS, Tuberculosis and Malaria. So far the U.S. has provided $500 million to the Fund, which is a sterling example of public-private cooperation, personal philanthropy, corporate generosity and public compassion.104 One tragic consequence of the HIV/AIDS epidemic is mother-to-child transmission of the disease. In June 2002, President Bush announced the creation of the International Mother and Child HIV Prevention Initiative. This initiative is funded at a total of $500 million over the initial three years, and its goal is to reduce mother-to-child transmission of HIV by 40 percent within five years or less in 12 African countries and

35 the Caribbean. This program will complement the efforts of the Global Fund, and it represents the next essential step in the global struggle against AIDS.105 Finally, innovative abstinence programs funded by USAID have often proven to be very effective. For example, programs such as ABC (Abstinence, Be Faithful, Use Condoms if A and B fail) have had much success. Since the abstinence-based program was introduced in Uganda, the incidence rate of HIV has fallen from 30 percent (in 1992) to 12 percent, and some estimates for 2002 place it at 6 percent.106 Condoms have never been very popular in Uganda, so the government stressed the importance of A and B, and it put substantial resources into fidelity, abstinence, and delay of sexual debut.107 In a speech to the First AIDS Congress in East and Central Africa, Ugandan President Yoweri Museveni rejected the common misperception that condom use is by itself the key to successful HIV/AIDS prevention programs. He stated that “Condoms have a role to play as a means of protection, especially in couples who are HIV-positive, but they cannot become the main means of stemming the tide of AIDS.”108 Clearly, the ABC program has enjoyed much success in Uganda, and other abstinence-based educational programs such as this show great promise.

References:

36 1 U.S. Census Bureau, U.S. Department of Commerce. U.S. Summary: 2000. Census 2000 Profile. July 2002.

2 PAHO/WHO, Program on Health Situation Analysis, Division of Health and Human Development. Basic Indicators, 2000. Washington, D.C. 2000.

3 Dalaker, Joseph. U.S. Census Bureau. Poverty in the United States: 2000. September 2001.

4 Ibid.

5 Ibid.

6 Ibid.

7 Transforming the Federal Role in Education. Available at: http://www.whitehouse.gov/infocus/education.

8 Ibid.

9 Ibid.

10 HHS Study Shows Poverty, Welfare Dependence Drop. Available at: http://www.hhs.gov/news/press/2002pres/20020603a.htm.

11 New Report Shows that Welfare Reform Really Works. Available at: http://www.whitehouse.gov/news/releases/2002/06/print/20020603.html.

12 Centers for Disease Control and Prevention, National Center for Health Statistics. Health, United States, 2002. With Chartbook on Trends in the Health of Americans. Hyattsville, Maryland: 2002.

13 Office of Population Affairs, U.S. Department of Health and Human Services. Healthy People 2010—Objectives for Improving Reproductive Health. October 2001.

14 Ibid.

15 President’s Phone Call to March for Life Participants, January 22, 2002. Available at: http://www.whitehouse.gov/news/releases/2002/01/print/20020122-10.html.

16 International Conference on Population and Development. Programme of Action. Cairo, Egypt, September 5-13, 1994.

17 Office of Family Planning website at: http://opa.osophs.dhhs.gov/titlex/ofp.html.

18 Centers for Disease Control and Prevention, National Center for Health Statistics. Health, United States, 2002. With Chartbook on Trends in the Health of Americans. Hyattsville, Maryland: 2002.

19 Ibid.

20 Ibid.

21 Ibid. 22 Ibid.

23 Ibid.

24 Ibid.

25 Ibid.

26 Bush, George W., President of the United States. HealthierUS: The President’s Health and Fitness Initiative. June 2002.

27 HHS targets efforts on Diabetes. Website at: http://www.hhs.gov/news/press/2002pres/diabetes.html.

28 Bush, George W., President of the United States. HealthierUS: The President’s Health and Fitness Initiative. June 2002.

29 Ibid.

30 Age-adjusted percent of persons under 65 years old without health insurance coverage, by sex and race/ethnicity: United States, 2001. Website at: http://www.cdc.gov/nchs/about/major/nhis/released200207/table01_3.htm

31 Centers for Disease Control and Prevention, National Center for Health Statistics. Health, United States, 2002. With Chartbook on Trends in the Health of Americans. Hyattsville, Maryland: 2002.

32 Healthy People 2010: A Systematic Approach to Health Improvement. Website at: http://web.health.gov/healthypeople/Document/HTML/uih/uih_bw/uih_2.htm.

33 Background on the President’s Health Care Agenda. Website at: http://www.whitehouse.gov/news/releases/2002/03/print/20020314-3.html.

34 HHS Awards $16.1 million to 28 Health Centers to Improve Access to Health Care Services. Available online at: http://www.hhs.gov/news/press/2002pres/20020516a.html.

35 Policies in Focus website: http://www.whitehouse.gov/infocus/medicare/health-care/health- budget.html.

36 Thompson, Tommy G., Secretary of Health and Human Services. Address to the World Health Assembly. Geneva, Switzerland, May 14, 2002.

37 Bush, George W., President of the United States. HealthierUS: The President’s Health and Fitness Initiative. June 2002.

38 U.S. Census Bureau, U.S. Department of Commerce. U.S. Summary: 2000. Census 2000 Profile. July 2002.

39 U.S. Census Bureau. Coming to America: A Profile of the Nation’s Foreign Born (2000 Update). Census Brief. February, 2000.

40 Administration on Aging, U.S. Department of Health and Human Services. A Profile of Older Americans: 2001. 2001. 41 Ibid.

42 Mid-session Review—Medicare Trust funds. Available at: http://www.whitehouse.gov/omb/budget/fy2002/msr03.html.

43 Ibid.

44 Ibid.

45 Ibid.

46 Carbonell, Josefina G. Assistant Secretary for Aging, U.S. Department of Health and Human Services. Remarks at the Second World Assembly on Ageing, Madrid, Spain. April 8-12, 2002. Available at: http://www.aoa.gov/pressroom/speeches2002/waa-plenary.htm.

47 Description of the National Family Caregiver Support Program available at: http://www.aoa.gov/carenetwork/NFCSP-description.html.

48 NIA Director’s Statement FY 2003. Available at: http://www.nia.nih.gov/about/legislation/fy2003/ds.htm.

49 U.S. Department of Health and Human Services, Office of International and Refugee Health. America’s Children: Our Challenge, Our Future. USA Report on Progress Toward the Goals of the 1990 World Summit for Children. Rockville, MD: U.S. Department of Health and Human Services, PSC-AOS, September 2001.

50 Centers for Disease Control and Prevention, National Center for Health Statistics. Health, United States, 2002. With Chartbook on Trends in the Health of Americans. Hyattsville, Maryland: 2002.

51 U.S. Department of Health and Human Services, Office of International and Refugee Health. America’s Children: Our Challenge, Our Future. USA Report on Progress Toward the Goals of the 1990 World Summit for Children. Rockville, MD: U.S. Department of Health and Human Services, PSC-AOS, September 2001.

52 Ibid.

53 Office of Population Affairs, U.S. Deptartment of Health and Human Services. Maternal, Infant, and Child Health. Healthy People 2010—Objectives for Improving Reproductive Health. October 2001.

54 Ibid.

55 U.S. Department of Health and Human Services, Office of International and Refugee Health. America’s Children: Our Challenge, Our Future. USA Report on Progress Toward the Goals of the 1990 World Summit for Children. Rockville, MD: U.S. Department of Health and Human Services, PSC-AOS, September 2001.

56 Centers for Disease Control and Prevention, National Center for Health Statistics. Health, United States, 2002. With Chartbook on Trends in the Health of Americans. Hyattsville, Maryland: 2002. 57 Centers for Disease Control, U.S. Department of Health and Human Services. Safe Motherhood: Promoting Health for Women Before, During, and After Pregnancy. 2002.

58 Working toward Independence: Promote Child Well-Being and Healthy Marriages. Website at: http://www.whitehouse.gov/news/releases/2002/02/print/welfare-book-05.html

59 U.S. Census Bureau, U.S. Department of Commerce. Fertility of American Women: June 2000. U.S. Department of Commerce, Economics and Statistics Administration. October 2001.

60 Centers for Disease Control and Prevention, National Center for Health Statistics. Health, United States, 2002. With Chartbook on Trends in the Health of Americans. Hyattsville, Maryland: 2002.

61 Information about Healthy Mothers, Healthy Babies is available at: http://www.hmhb.org/who.html

62 Information about the March of Dimes is available at: http://www.modimes.org/4220.htm

63 Centers for Disease Control, U.S. Department of Health and Human Services. Safe Motherhood: Promoting Health for Women Before, During, and After Pregnancy. 2002.

64 Ibid.

65 http://www.whitehouse.gov/news/releases/2002/02/print/welfare-book-05.html

66 National Family Week Proclamation by President George W. Bush, November 21, 2001, available at: http://www.whitehouse.gov/news/releases/2001/11/20011121-1.html

67 Ibid.

68 Reforming Welfare to Increase Independence & Strengthen Families Fact Sheet, available at: http://www.whitehouse.gov/infocus/welfarereform/fact-sheet.html

69 Centers for Disease Control and Prevention, National Center for Health Statistics. Health, United States, 2002. With Chartbook on Trends in the Health of Americans. Hyattsville, Maryland: 2002.

70 Klaus H, Dennehy N, Turnbull J. Undergirding Abstinence Within a Sexuality Education Program. Presented at Teen Pregnancy Prevention Conference, Pennsylvania State University, State College, PA, October 21, 2001. Obtained online at http://www.teenstar-international.org/page.asp? DH=15.

71 Office of Population Affairs, U.S. Deptartment of Health and Human Services. Healthy People 2010—Objectives for Improving Reproductive Health. October 2001.

72 Ibid.

73 Klaus H, Dennehy N, Turnbull J. Undergirding Abstinence Within a Sexuality Education Program. Presented at Teen Pregnancy Prevention Conference, Pennsylvania State University, State College, PA, October 21, 2001. Obtained online at http://www.teenstar-international.org/page.asp? DH=15.

74 Devaney, B, et al. The Evaluation of Abstinence Education Programs Funded Under Title V Section 510: Interim Report. Submitted by Mathematica Policy Research, Inc. to Division of children and Youth Policy, Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, April 2002.

75 Ibid.

76 Bush, George W., President of the United States of America. Remarks on Welfare Reform, Washington, D.C., February 26, 2002.

77 Working Toward Independence: Encourage Abstinence and Prevent Teen Pregnancy. Website at: http://www.whitehouse.gov/news/releases/2002/02/print/welfare-book-06.html.

78 Ibid.

79 Centers for Disease Control, U.S. Department of Health and Human Services. HIV/AIDS Surveillance Report. Midyear Edition, Volume 13, No. 1, 2001.

80 Ibid.

81 Ibid.

82 Ibid.

83 Thompson, Tommy G., U.S. Secretary of Health and Human Services. Fighting HIV/AIDS: An International Effort, A Global Priority. Speech delivered at the XIV International AIDS Conference, Barcelona, Spain, July 9, 2002.

84 Centers for Disease Control, U.S. Department of Health and Human Services. HIV/AIDS Surveillance Report. Midyear Edition, Volume 13, No. 1, 2001.

85 Ibid.

86 International Labour Office. HIV/AIDS: A Threat to Decent Work, Productivity and Development. Document for Discussion at the Special High-Level Meeting on HIV/AIDS and the World of Work. Geneva, Switzerland, June 8, 2000.

87 Department of Health and Human Services Press release found at: http://www.hhs.gov/news/press/2002pres/20020204a.html

88 Ibid.

89 Ibid. The actual figure listed in the HHS press release was $939 million, but we have since learned that the CDC erroneously was approximately $2 million high in its budget estimate.

90 Ibid.

91 Ibid.

92 Furchtgott-Roth, Diana and Stolba, Christine. Women’s Figures. 1999.

93 U.S. Census Bureau. Data available at: http://www.census.gov/population/www/socdemo/educ- attn.html. 94 Maynard, R.A. Kids Having Kids: A Robin Hood Foundation Special Report on the Costs of Adolescent Childbearing. Robin Hood Foundation. New York, 1996.

95 The Medical Institute for Sexual Health. Sexually Transmitted Diseases in America: How Many, and at What Cost? Austin, Texas, 2000.

96 EDK Associates for Seventeen magazine and the Ms. Foundation for Women. Teenagers Under Pressure. 1996.

97 U.S. Department of Health and Human Services, Office of International and Refugee Health. America’s Children: Our Challenge, Our Future. USA Report on Progress Toward the Goals of the 1990 World Summit for Children. Rockville, MD: U.S. Department of Health and Human Services, PSC-AOS, September 2001.

98 Burger, H. Proceedings of International Seminar on Natural Family Planning. Dublin, October 1979.

99 Millennium Challenge Account Update, Fact Sheet available at: http://www.usaid.gov/press/releases/2002/fs_mca.html.

100 U.S. Department of Health and Human Services, Office of International and Refugee Health. America’s Children: Our Challenge, Our Future. USA Report on Progress Toward the Goals of the 1990 World Summit for Children. Rockville, MD: U.S. Department of Health and Human Services, PSC-AOS, September 2001.

101 Millennium Challenge Account Update, Fact Sheet available at: http://www.usaid.gov/press/releases/2002/fs_mca.html.

102 Ibid.

103 Thompson, Tommy G., U.S. Secretary of Health and Human Services. Fighting HIV/AIDS: An International Effort, A Global Priority. Speech delivered at the XIV International AIDS Conference, Barcelona, Spain, July 9, 2002.

104 Thompson, Tommy, Secretary of Health and Human Services. Address to the World Health Assembly. Geneva, Switzerland, May 14, 2002.

105 President Bush’s International Mother and Child HIV Prevention Initiative, available at: http://www.whitehouse.gov/news/releases/2002/06/print/20020619-1.html.

106 U.S. Agency for International Development, Population, Health and Nutrition Programs HIV/AIDS Division and Implementing AIDS Prevention and Care (IMPACT). Uganda and HIV/AIDS. June 1999.

107 Green, Edward C., Ph.D., Takemi Fellow, Harvard University. What are the Lessons from Uganda for AIDS prevention? Presentation to Christian Connections in International Health. May 27, 2002.

108 Ibid.