IMPROVING WOMEN'S HEALTH

Overview: Improving women's health is a top priority at HHS. The Department is committed to a comprehensive, science-based approach that will help address longstanding inequities in women's health. Actions include:

• Enhanced funding and major national projects for women's health research, services, and education;
  
  
• Inclusion of women in clinical research trials;
  
  
• Examination of differences between men and women in cause, treatment and prevention of disease;
  
  
• Focus on women's health through the life cycle: adolescence, reproductive and middle years, and older women;
  
  
• Working to eliminate barriers to health care services for underserved American women; and
  
  
• Helping assure that women have equal access to senior positions in health and science careers.

HHS Secretary Donna E. Shalala has provided prominent leadership on women's health issues. In 1993, she led the creation of a National Action Plan on Breast Cancer, bringing together a broad coalition of groups and individuals to provide research, services and education. She also forged a partnership with the Department of Justice to combat domestic violence, including creation of a toll-free HHS hotline and additional research on the extent of the problem. In 1996, she announced an initiative on prevention of HIV and AIDS, including a long-term commitment to the development of microbicides, to help women protect themselves against HIV infection.

A National Focus on Women's Health

The Department of Health and Human Services has focused increased resources and national attention on women's health issues. For FY 1999, direct funding of research and services by HHS is estimated to be $51.4 billion, up almost 21 percent since FY 1995. The President's fiscal year 2000 budget would bring spending on women's health issues to $54.1 billion. All HHS agencies and regions have also established offices or coordinators for women's health. These offices work collaboratively with the PHS Office on Women's Health, which coordinates research, service delivery and education programs across HHS agencies. The office is headed by the Deputy Assistant Secretary for Women's Health, a senior-level position created in 1994.

Women's Health Information. The PHS Office on Women's Health established in November 1998 the National Women's Health Information Center, a combination World Wide Web site and toll-free hotline that serves as a "one-stop shopping" resource for women's health information. The center can be reached at http://www.4woman.gov or 1-800-994-WOMAN.

Including Women in Clinical Trials. All Public Health Service agencies with a focus on research have established policies to ensure that women are included in HHS-sponsored research programs and have appointed a women's health coordinator to focus on women's issues.

Minority Women's Health. The PHS Office on Women's Health sponsored a National Minority Women's Health Conference in January 1997, and has convened a Minority Women's Health panel of experts to identify and implement initiatives to improve the health of women in specific ethnic and racial populations.

Medical School Curricula. The first medical school model curriculum on women's health issues has been developed to bring women's health into the mainstream of medical education. Similar efforts are underway to develop the framework for dental and nursing education curricula. Also, a first-of-its-kind directory of women's health residency and fellowship opportunities in medicine has been prepared and widely disseminated.

Centers of Excellence in Women's Health. HHS has established 18 National Centers of Excellence in Women's Health to serve as models for improving the health care of American women. The 18 centers, located at academic institutions in different areas of the country, are serving as demonstrations that can be evaluated and duplicated throughout the nation. The centers are integrating health care services, research programs, public education, and health care professional training, and forging links with health care services in the community.

National Mentoring Program. The PHS Office on Women's Health has coordinated the development of a national mentoring program for female health professionals in academic medicine, utilizing the expertise of health care experts from government and leading health organizations. The goal is to encourage institutional efforts to overcome current limitations on the advancement of women in medicine. To date, four national Centers of Leadership in Academic Medicine have been designated to serve as models of excellent mentoring programs at academic medical centers.

Compliance with the Patients' Bill of Rights. In February, the President directed federal agencies that manage health care programs, where possible, to come into compliance with the patients' bill of rights outlined by the President's Quality Commission. As a result of actions to bring the plans into compliance, women enrolled in Medicare and Medicaid may seek direct access to their gynecologists without getting a referral from a primary care physician.

Breast Cancer

Every three minutes, a woman in America is diagnosed with breast cancer. Next to skin cancer, breast cancer is the most commonly diagnosed cancer and the second leading cause of cancer deaths among American women. A woman's chances of developing breast cancer increases with age: by age 40, one of every 217 women will face breast cancer. By age 70, one of 14 will be diagnosed with the disease. Despite these numbers, 33 percent of women age 50 to 64, and 45 percent of women age 65 and older, report not having a mammogram in the past two years.

Increased Funding. HHS funding for breast cancer research and programs has increased dramatically under the Clinton Administration. Between FY 1993 and FY 1999, funding increased from $283 million to $599 million. A total of $623 million has been requested for fiscal year 2000.

National Action Plan on Breast Cancer (NAPBC). In October 1993, President Clinton directed Secretary Shalala to establish a comprehensive strategy to fight breast cancer. Two months later, the Secretary convened an historic conference to develop a National Action Plan on Breast Cancer. The result is a major public-private partnership that is working to improve research, treatment, prevention, and public and health care professional education on breast cancer. On October 27, 1996, the third anniversary of the NAPBC, President Clinton launched the NAPBC Web site, which serves as a gateway to information on breast cancer treatment, research, and prevention.

Federal Coordinating Committee on Breast Cancer (FCCBC). HHS established the Federal Coordinating Committee to be a liaison group to the NAPBC. In 1997, the Committee awarded $3 million to fund 23 breast cancer research, outreach, and education programs.

Breast Cancer Gene Research. HHS-supported research led to the isolation of BRCA1 and BRCA2, genes linked to breast cancer in 5-10 percent of cases of the disease. This discovery may lead to new treatment and prevention strategies. On October 27, 1996, President Clinton announced $30 million in new funding for research into the genetic basis of breast cancer.

Privacy of Medical Records. President Clinton has supported bipartisan legislation to prohibit health plans from inappropriately using genetic screening information to deny coverage, set premiums, or distribute confidential information. In diseases such as breast cancer we are beginning to identify genetic alterations that may place a woman at increased risk. Women who test positive may increase cancer detection efforts, may elect to have preventive surgery, or may join a cancer prevention research study. However, genetic testing also can be used by insurance companies and others to discriminate and stigmatize individuals and groups of people. Studies show that one reason women do not get genetic testing for breast cancer is because they fear the information will be used to discriminate against them.

New Mammography Benefit. President Clinton proposed, and Congress adopted, the expansion of Medicare coverage to help pay for annual mammograms for all Medicare beneficiaries age 40 and over. Under this new benefit, Medicare waives the Part B deductible for screening mammograms.

Breast Cancer Prevention Trial. As part of a large North American study conducted by the National Surgical Adjuvant Breast and Bowel Project (NSABP) with support from the National Cancer Institute (NCI), over 13,000 women volunteered to take tamoxifen or an inactive pill to see if the drug would help reduce new cases of breast cancer. On April 6, 1998, NCI announced that there were 45 percent fewer cases of breast cancer reported in the high-risk women in the trial who took the drug versus those on the inactive pill. The study highlighted the fact that while a reduction in new cases is significant, there are risks associated with tamoxifen that must be carefully weighed against the benefits of breast cancer reduction. In September of 1998, a final analysis of the study published in the Journal of the National Cancer Institute showed that women taking tamoxifen had 49 percent fewer cases of breast cancer. On October 29, 1998 the FDA approved tamoxifen for reducing the incidence of breast cancer in women at high risk for developing the disease. In addition, the NSABP and NCI developed the Breast Cancer Risk Assessment Tool, a computer program that women and their health care providers can use to estimate a woman's chances of developing breast cancer based on several recognized risk factors and to help decide whether or not to begin tamoxifen therapy.

Study of Tamoxifen and Raloxifene. On October 21, 1998, Secretary Shalala announced that plans are underway for the largest ever clinical trial of two drugs to reduce women's risk of breast cancer. The trial will begin this spring in 400 sites across North America, with more than 20,000 postmenopausal women taking part. The trial, "Study of Tamoxifen and Raloxifene" (STAR) will evaluate the benefits and risks of the drug raloxifene as compared to tamoxifen in reducing the risk of breast cancer among women at increased risk of breast cancer but who have not had the disease. The STAR study would aim at determining whether raloxifene, recently approved by FDA as an osteoporosis prevention drug for postmenopausal women, is as effective in reducing breast cancer risk as tamoxifen has proven to be.

Office of Cancer Survivorship. On October 27, 1996, President Clinton unveiled the new Office of Cancer Survivorship at the National Cancer Institute. Recent successes in reducing risk with tamoxifen, early detection, and treatment efforts has created a new need: research into the physical, psychological, and economic well-being of the growing number of cancer survivors. The Office of Cancer Survivorship will support research covering the range of issues facing survivors of cancer, including long-term medical and psychological effects; factors that predispose survivors to second malignancies; reproductive problems following cancer treatment; and their unique insurance and employment issues.

Guidance on Mammography. The National Cancer Institute provides science-based guidance on the use of mammography. On March 27, 1997, NCI issued a recommendation that women age 40 and over be screened with mammography every one to two years. In addition, NCI recommends that women at higher risk of breast cancer get medical advice before they are 40 about when to begin screening and about the frequency of their screening.

Mammography Quality Standards. On October 9, 1998, Congress reauthorized the Mammography Quality Standards Act (MQSA). In October 1994, the FDA implemented a program for mammography facilities in the U.S. to ensure that they meet quality standards for equipment and personnel, and are inspected annually. Under the final rules of the Mammography Quality Standards Act (MQSA), published in October 1997, the FDA sets high standards for mammography facilities and certifies those that meet the standards. The names and locations of FDA-certified mammography facilities are available at no charge by calling NCI's Cancer Information Service toll-free at 1-800-4-CANCER. In addition, the FDA has included a list of all FDA certified mammography facilities in the United States on its Internet home page. The address is http://www.fda.gov/cdrh/faclist.html.

Screening for Low-Income Women. The CDC's National Breast and Cervical Cancer Early Detection Program offers free or low-cost mammography and cervical screening to uninsured, low-income, elderly, and minority women nationwide. On October 1, 1996, Secretary Shalala announced the expansion of the program to all 50 states. The goal is to reduce breast cancer deaths among these women by 30 percent, and cervical cancer deaths by more than 90 percent, through increased mammographies and Pap testing.

Imaging Technology. HHS is working with other federal agencies, including NASA, the Defense Department and the CIA, as well as private companies, to adapt high-tech imaging technology to improve the early detection of cancer in women. In September 1996, HHS, in collaboration with the CIA, awarded $1.98 million to the University of Pennsylvania to conduct a multi-site clinical trial of imaging technology used in the intelligence community - originally intended for missile guidance and target recognition - to improve the early detection of breast cancer. In 1997, HHS awarded approximately $1.75 million to six federal technology transfer programs to enhance the imaging, diagnosis, and treatment of breast cancer.

Promoting Mammography for Older Women. In May 1995, First Lady Hillary Rodham Clinton joined HHS in a campaign to educate women over 65 that mammography saves lives -- decreasing breast cancer rates by 30% in this age group. Screening mammography has been covered by Medicare on a biennial basis for the past several years, though the benefit has not been widely used. In October 1998, HHS' Health Care Financing Administration and the National Cancer Institute together launched a campaign to increase awareness of the new annual Medicare mammography benefit and the importance of regularly-scheduled screening mammograms. The new efforts focus on high concentration areas of older women. In addition, HCFA is offering mammogram screenings and/or airing a series of public service announcements geared toward older African-American and Hispanic-American women in the following cities: Atlanta, Chicago, Cleveland, Los Angeles, Philadelphia, San Antonio, and Washington, D.C.

Domestic Violence

Violence against women is an urgent public health problem with devastating consequences for women, children and families. Recent statistics show that 29 percent of all violence against women by a single offender is committed by an intimate -- a husband, ex-husband, boyfriend or ex-boyfriend. Estimates of assaults on women by partners or cohabitants range from 1.8 million to almost 4 million per year.

National Domestic Violence Hotline. In February 1996, President Clinton announced the opening of a 24-hour, toll-free hot-line to provide crisis assistance and local shelter referrals to victims of domestic violence throughout the country. Since its opening, the hotline has received 200,000 calls. Phone number: 1-800-799-SAFE.

Violence Against Women Act. The Violence Against Women Act (VAWA), passed as part of the Crime Act of 1994, combines tough new penalties with programs to prosecute offenders and help victims of violence. VAWA authorizes $1.6 billion over five years to hire more prosecutors and improve domestic violence training for prosecutors, police officers and health and social services professionals. It provides for more shelters, counseling services, and research into causes of violence against women, as well as public education campaigns. HHS programs under VAWA include:

• Grants for battered women's shelters
• Education and prevention grants to reduce sexual assault against women
• Coordinated community responses to prevent intimate partner violence
• Grants to develop educational model curricula
• Education and prevention services to reduce sexual abuse among runaway, homeless and street youth.

Research and Intervention. CDC is developing programs to improve data collection on the incidence of violence against women and to develop strategies to reduce and prevent violence by effective intervention, education, training and public awareness activities. Other HHS agencies, including the National Institute of Mental Health, support research and service programs designed to prevent family violence.

Safe and Stable Families Act. The $1 billion Safe and Stable Families Act, created in 1994, helps states and communities reduce abuse and neglect by serving families at risk or in crisis.

Advisory Council. An Advisory Council on Violence Against Women was created in July 1995. Co-chaired by the Attorney General and HHS Secretary, the council consists of 47 experts -- representatives from law enforcement, media, business, health and social services, victim advocacy and survivors --- helping to steer new efforts to prevent violence against women. In October 1996, the Council distributed a Community Checklist, which includes steps that every part of a community can take to prevent domestic violence.

Reproductive Health

HHS carries out a variety of programs to provide for family planning, preventing sexually transmitted disease, and reducing unintended pregnancies. In particular, efforts are underway to reduce the approximately 1 million pregnancies that occur each year among American teenagers. In addition, through a series of executive and legislative actions, the Clinton Administration has helped ensure that women and men can make their own reproductive health decisions safely and with accurate information.

Family Planning. HHS supports the provision of reproductive health and family planning services through the Title X program. Each year, some 5 million persons receive Title X-supported services. Title X funding for FY 1999 totaled $215 million, an increase of about $41.5 million since FY 1993.

Reducing Teen Pregnancy. In January 1997, the President announced a national strategy to prevent teen pregnancy. Led by HHS, the national strategy is designed to strengthen efforts to prevent out-of-wedlock teen pregnancies and support and encourage adolescents to remain abstinent. Components of the national strategy include:

• Implementing new efforts under welfare reform, such as provisions requiring teen mothers to live at home, or live in an adult-supervised setting, and stay in school
• Supporting promising approaches tailored to the unique needs of communities
• Building partnerships among national, state, and local organizations
• Improving data collection, research, evaluation, and dissemination of information
• Sending a strong abstinence message.

Prevention of Sexually Transmitted Diseases. HHS has provided $18.2 million for FY 1999 to support implementation of the National Infertility Prevention Program to prevent and treat STDs, particularly chlamydia. This program is a collaborative effort between the CDC and the PHS Office of Population Affairs that involves strong collaboration among family planning, STD, and primary health care programs, as well as state laboratories.

RU-486. Action by Secretary Shalala helped facilitate the transfer of U.S. patent rights for mifepristone (RU-486) from a French pharmaceutical firm to an American non-profit organization. The transfer made it possible for the drug to be submitted to the FDA for marketing approval. It is used in France, Sweden and the United Kingdom for early non-surgical termination of pregnancy.

Emergency Contraception. In 1997, the FDA approved the use of certain regimes of birth control pills as safe and effective for use as postcoital emergency contraception. One product, Preven, is already being marketed and just recently the women's Capital Corporation announced that it had submitted a new drug application for a progestin-only emergency contraceptive as a "second generation." Although certain oral contraceptives can currently be used "off label" for postcoital pregnancy prevention, approval of these products allows for information on the appropriate treatment regimen to be added to the labeling for physicians and patients alike.

Improved Information and Access. The Clinton Administration took steps to lift "Gag Rules," thus ensuring that all women cared for through Federal family planning programs have access to uncensored information, including pregnancy option counseling when requested.

Population and Development. The Clinton Administration has acknowledged the tremendous costs of unintended pregnancy -- personal human costs, social costs and health care dollar costs -- both in the United States and internationally. As one of the leaders at the Cairo International Conference on Population and Development, the U.S. helped ensure the adoption of a comprehensive program emphasizing commitment to voluntary family planning as a crucial part of reproductive health care; commitment to gender equity through improved education and development; and achievement of these goals in the context of equitable sustainable development.

Women and HIV / AIDS

Women account for an increasing number of AIDS cases. They represented only 7 percent of all reported AIDS cases in 1985, but reported cases increased to 26 percent by June 1998. In 1997, AIDS was the second leading cause of death among African-American women aged 25-44 and is increasing faster among women than among men. Women of childbearing age account for the vast majority of these cases.

Microbicide Initiative. At the Eleventh International Conference on AIDS in 1996, Secretary Shalala announced a new effort to develop safe and effective topical microbicides to help women protect themselves against HIV infection. The initiative includes a $100 million commitment to research and development over four years.

Counseling Pregnant Women. Physicians are being urged to counsel all pregnant women on the benefit of HIV testing. New guidelines and educational materials have been produced by the Centers for Disease Control and Prevention for women and health care providers in response to evidence that treating HIV-positive pregnant women with the drug AZT will reduce from 25 percent to 8 percent the risk of transmitting the disease to the infant.

Older Women

Women comprise 60 percent of today's population aged 65 and over. By the year 2000, it is expected that there will be five women for every two men over the age of 75. Compared to men, elderly women are three times more likely to be widowed or living alone, spending more years and a larger portion of their lifetimes disabled or residing in a nursing facility. HHS has devoted new resources to meeting the needs of women throughout their life span.

The NIH Women's Health Initiative. This initiative is one of the largest prevention studies of its kind. It has begun examining the major causes of death, disability and frailty in postmenopausal women. It includes a clinical trial of promising but unproven approaches to prevention, an observational study to identify predictors of disease, and a study of community approaches to developing healthful behaviors. This multi-year study is examining the effects of low-fat diets on prevention of breast and colon cancer and coronary heart disease; the effect of hormone replacement therapy on prevention of coronary heart disease and osteoporotic fractures; and the effect of calcium and vitamin D supplementation on prevention of osteoporotic fractures and colorectal cancer. The community prevention trial portion of the study, being conducted with the CDC, will evaluate strategies for adoption of healthful behaviors including improved diet, nutritional supplementation, smoking cessation, increased physical activity, and early detection for women of diverse races, ethnic groups and socioeconomic groups.

Study of Women's Health Across the Nation (SWAN). The National Institute on Aging, NIH, is sponsoring a large-scale national study to examine the health of women in their 40s and 50s. SWAN tracks the health of women during the transitional years of middle age, to measure impacts on later life. The study examines the physical, psychological and social changes that take place at mid-life, and focuses on behaviors such as having children after age 40, diet and exercise, alcohol consumption, and exposure to environmental toxins.

Older Women's Policy and Resource Center. The AoA, through the Older Americans Act and its national aging network, continues to create partnerships designed to address the needs of older women and to address women's capacity to contribute significantly to society throughout their lives. The AoA also established the Older Women's Policy and Resource Center to educate older women at the grassroots level on the importance of addressing issues such as income security, health, housing, domestic violence and caregiving. AoA has recently awarded a grant for the creation of the National Resource and Education Center on Women whose goal is to better educate women of all ages and their employers about the different resources and materials available to them in planning for and living a secure retirement.

Elder Abuse Prevention. Secretary Shalala announced on October 8, 1998 that a new National Center on Elder Abuse will be created to help promote understanding among state and local networks of community workers, physicians, elderly volunteers, and others working to prevent elder abuse. In addition, the new National Center on Elder Abuse will facilitate training of these groups through educational materials and technical assistance and recognize and offer help in cases of abuse and neglect. Older women are abused at a higher rate than older men, according to a recent report.

Elder Nutrition. Recognizing that 85 percent of older individuals have a nutrition-related condition or chronic disease, the Administration on Aging is also continuing to support community nutrition services. Each year, nutrition assistance funds help provide about 240 million meals for older persons. About 70 percent of the meals go to women. Federal spending on these programs is leveraged by state, local and private funds.

Take Time to Care. To help women lead healthier, longer lives, the FDA and the OWH developed "Women's Health: Take Time to Care," a national public awareness campaign aimed at women over age 45 - with the message "Use Medicines Wisely." The campaign strives to make women, who are the principal users of medications and who often administer them for family members, more aware of safer medication use through a variety of materials and interactive events led by pharmacists and other health professionals. In 1998, OWH has taken the program to 15 cities, 13 rural counties and several Indian reservations.

Additional Steps

Reducing Infant Mortality. Due in part to long-standing medical research and social services supported by HHS, infant mortality in the U.S. is at an historic low. The infant mortality rate has dropped from 20 deaths per 1,000 live births in 1970 to 7.1 deaths per 1,000 live births in 1997. In addition, the proportion of mothers getting early prenatal care is at a record high. In 1997, 83 percent of mothers began prenatal care within the first trimester of pregnancy, the seventh consecutive year of increase from 75.5 percent in 1989. Also, several risk factors for infant mortality are on the decline: teen births dropped for the sixth straight year in 1997 and smoking among pregnant women has been decreasing in recent years.

Preventing Birth Defects. In February 1996, HHS and the FDA directed food manufacturers to add the nutrient folic acid to most enriched breads, flours, corn meals, pastas, rice and other grain products to reduce the risk of neural tube birth defects in newborns. Folic acid, or folate, reduces the risk of neural tube birth defects such as spina bifida when consumed in adequate amounts by women before and during early pregnancy.

Preventing Smoking by Children and Teens. Lung cancer is the number one cancer killer of American women, and smoking is the primary risk factor for this disease. Smoking rates are alarmingly high for teenage girls. In August 1996, President Clinton announced a comprehensive plan to protect children from the dangers of tobacco and a lifetime of nicotine addiction with the publication of the FDA's final rule on tobacco and children. The Administration continues to urge Congress to pass comprehensive legislation to reduce teen smoking. Such actions would build on previous actions taken by Congress and others, such as the ban on TV advertising and state laws to prohibit the sale of tobacco to children. Additionally, HHS has initiated an anti-smoking educational partnership with the U.S. Women's Soccer Team, targeted toward adolescent women.

Girl Power! Campaign. In November 1996, HHS launched "Girl Power!", a national public education campaign to help encourage and empower 9- to 14-year-old girls to make the most of their lives. During its first phase, Girl Power! will combine strong "no-use" messages about tobacco, alcohol, and illicit drugs with an emphasis on providing opportunities for girls to build skills and self-confidence in academics, arts, sports, and other endeavors. Additionally, HHS has funded Girl Neighborhood Power!, a five-year grant program designed to help communities develop innovative approaches to promote the positive development, health, and well- being of girls, as well as prevent teen pregnancy and the use of harmful substances.

Mental Health and Substance Abuse. Two HHS agencies, the Substance Abuse and Mental Health Services Administration and the Health Resources and Services Administration, established in FY 1994 a National Women's Resource Center for the Prevention and Treatment of Alcohol, Tobacco and Other Drug Abuse and Mental Illness. The Center provides information dissemination services on women's substance abuse prevention and treatment, as well as on mental health service issues throughout the lifecycle. Other SAMHSA programs support knowledge development and application for substance abuse prevention among adolescent women, and residential substance abuse treatment for women who are pregnant or who have dependent children. For fiscal year 1999, SAMHSA expects to direct about $202.8 million to women's substance abuse and mental health activities, with $207.7 proposed for fiscal year 2000.

Women's Health and the Environment. The PHS Office on Women's Health has established a Federal Interagency Coordinating Committee on the Environment and Women's Health, which is focusing on how home, work, atmospheric pollutants, exogenous hormones, and other environmental factors may contribute to the risk for diseases in women. The committee will develop strategies to eliminate these health hazards from women's lives.

National Osteoporosis Education Campaign. The PHS Office on Women's Health, in collaboration with the National Osteoporosis Foundation, is implementing a national educational program on osteoporosis to educate children, adolescents, and women across the lifespan about this disease. The campaign will target girls from 13 to 18 years old, the prime age for bone development.

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Note: HHS fact sheets are available on the World Wide Web at: http://www.dhhs.gov.