Ms. CANADY. I am not personally, no.

Mr. CONYERS. Well, the answer to that is that they are opposed. Do you know why? Because there is little value in really preventing the spread of AIDS through mandatory testing. Besides, the State is open to a tidal wave of litigation when they find out and do not tell anybody else, and then it continues to spread, because they have that information that no one else has.

Final question. And I know you are new on board there, but you will take this back to my good friend, the director. What is the program or the strategy to reduce homosexual conduct in the prison itself?

Ms. CANADY. I cannot speak to the exact strategy. I will share that I have had discussions with the director, and with his administrative staff. There is some difficulty in that it is hard to quantify the amount of homosexuality occurring. We do recognize, and I am not blind to the fact, that it does occur, and are again open to discussing that, and looking for opportunities to decrease that behavior.

Mr. CONYERS. Will you stay in touch with me on this subject, and allow the chairman of this subcommittee to determine whether he wants to incorporate any further discussion we have in writing about this subject into the record?

Ms. CANADY. Certainly.

Mr. CONYERS. All right. Mr. Weiss.

Mr. WEISS. Thank you very much, Mr. Chairman.

Dr. Crane, much of your testimony was disturbing. It should have been. I found particularly disturbing your statement as to the waiting period for some patients for slots in the drug treatment programs. Earlier today we had testimony from city and State representatives and I had the occasion to say it was not so bad; it was not paradise, but 2 to 4 weeks waiting was not so bad. If, in fact, it is months, not weeks, then it is the same story as it is in the rest of the country, which is terrible. And I know that they were not deliberately giving me information that is incorrect, but the fact that they do not know that is the case is disturbing. It should be because, who knows what else the city and State think incorrectly is happening out there, and that bothers me.

Dr. CRANE. Well, Mr. Weiss, I think that it should only be fair to point out we have networked very closely with the city, and particularly with Mr. Talley, neighborhood services, and when we identify an indigent HIV infected person, we are able to cut through some of the red tape and get that person into treatment almost immediately. On the other hand, I do believe in general it takes weeks to months for an indigent drug addict, regardlessthey may be HIV negative, to get into treatment, No. 1. And No. 2, is that there is yet-if you have no money, there is no way for you to get treatment for cocaine addiction in this city.

Mr. WEISS. I heard you say that.

At a recent hearing held by this subcommittee in Washington, health care providers from Newark, Miami, and New York reported that their resources are now stretched paper thin, and that they can scarcely manage to care for the patients that they are faced with. Now, those three cities happen to be at the center of the

crisis. What is your experience, and Dr. Fisher's experience, in that regard?

Dr. CRANE. Mr. Weiss, we are getting killed. It takes me—it now takes about-since I have been sitting I have had five pages on my beeper, and four of those I know will have to do with AIDS. It takes currently 2 to 3 months for a person to come into my clinic unless they call one of my nurses directly, and somehow we try to pull some strings to get that person in quickly. And we are literally seeing people that have made appointments to see us in the clinic show up on our doorstep with full blown pneumocystis pneumonia and dying because we did not have the time to see these-our patients early enough.

And I think it illustrates the problem with Medicaid, and with our current health care system. Our system emphasizes illness, and reimburses for illness and not for wellness. And if we had an opportunity to have adequate and just outpatient reimbursement for our activities, and we were able to expand the number of clinicians available to take care of patients, I would submit that we would probably be able to save a lot of admissions and prevent a lot of illness with HIV infected people right at the outset. But as I pointed out earlier in my prepared testimony, this system does not allow us to do that.

My overhead where I work is $35 a visit. Medicaid is paying me $17. On the other hand, I can actually turn a profit, believe it or not, on an AIDS admission on Medicaid in my hospital. Now, that does not make sense to me. That really does not make sense. There is something wrong with our system when we are encouraging people to get sick so that we can get paid.

Mr. WEISS. Dr. Fisher.

Dr. FISHER. We need more doctors and other health care workers willing and able to take care of people with HIV, and I think they have been a little spoiled in the past by Larry, myself, and Dr. Markowitz, my colleague, taking care of such a tremendous percent of the people with HIV in Michigan, especially in southeastern Michigan, but we are overburdened now, and we need people to come to the fore, and we will be happy to tell them how we do it, and we have handouts, and educational material, and all this sort of thing.

So that is what we are trying to push, but I think this Medicaid reimbursement thing is absolutely true. I mean, if you see a lot of outpatients on Medicaid, you are just going to lose a tremendous amount of money, and this is the disincentive to other physicians to want to see patients with-I mean, AIDS is more time consuming than the average patient visit, and when the reimbursement for Medicaid-of our inpatients with AIDS, overall 38 percent are on Medicaid, but if you look at people at the time of their final admission, over half are on Medicaid. So this again is a strong disincentive to private health care providers to take care of HIV.

Mr. CONYERS. Would the gentleman yield? First, I think you are telling us we need to reexamine the reimbursement requirement, and that I can assure you we are going to do in trying to get an amended copy.

The second thing is that a number of us here locally would like to join with you in putting together a general strategy for appeal

ing to many of the other physicians who are probably beginning to think that they should be, as you suggest, playing a larger and more meaningful role in trying to handle this epidemic. Thank

you.

Mr. WEISS. Thank you, Mr. Chairman. And just as a followup on that, the Public Health Service estimates that there are currently 40,000 persons across the country who have AIDS and need medical care. They also report that by the end of 1991 the numbers will increase fivefold, some 200,000 who will be needing care. Detroit will undoubtedly see its share of this increase.

Now, given that as a fact, and all the other projections so far unhappily have proven to be correct, I cannot see how three doctors can continue to handle the problem for the entire city. I think that Mr. Conyers' suggestion is extremely solid. I assume that you have raised this issue with the various city and State officials as to what you see happening. What efforts have they taken to involve more physicians?

Dr. FISHER. Well, I think the Michigan State Medical Society, and certainly you have worked with the Detroit Medical Society, has undertaken AIDS education programs, has offered continuing medical education to physicians on HIV. And we are not the only three physicians. There are some other physicians who have taken care of a fair number of patients as well, but we certainly have seen the most among us. So there is some effort in that regard.

Of course, I would like to see things like AIDS continuing medical education, a certain number of hours made mandatory, as it now is in Florida, for example, every year that all physicians would have to take a certain amount of AIDS education. That does not mean they cannot sleep their way through, but certainly the majority would probably be awake at least part of the time. And then some increasing numbers of people who could come and actually work with us for a short period of time to gain some of the clinical skills that just a lecture alone cannot impart. But one needs some funding if one is asking a physician to take a considerable period of time off from a practice. You cannot do that with no reimbursement. A few CME hours, yes, but not a greater commitment in time. But I think there needs to be maybe some sort of statewide planning effort that goes beyond the State Medical Society because they have limited powers as far as that is concerned.

Mr. WEISS. Are you seeing an increased number of women with AIDS in your facilities?

Dr. FISHER. Yes.

Dr. CRANE. Yes, absolutely.

Dr. FISHER. And we are just seeing the beginning of the big upswing of that related to intravenous drug abuse, so we are just seeing the beginning of the upswing in women and children right now that the spread has not been as rapid in Detroit, but it is up.

Mr. Pope mentioned the-you know, one facility, I think he was talking about our facility, of intravenous drug users presenting themselves to our clinic, only having gone from 13 to 16 percent seropositive over a 3-year period from 1985 to 1988. Our latest figure in that, which is not published yet, is now 22 percent, so there has been a big jump in the last year. That is for 1989.

Mr. WEISS. What is happening with the increased number of infants with AIDS?

Dr. FISHER. Well, we have 3 infants in our institution with CDC defined AIDS, and I think 10 others that are still positive. There is a larger number at Childrens Hospital. It still has not been the big numbers that you see in New York with the tremendous number of border babies, but certainly we have all had the border baby situation with relatively small numbers. At the present time we do not have any border babies at our hospital. They all are either in foster care, or with a grandmother.

Dr. CRANE. The Detroit Medical Center, with Childrens Hospital on campus, has cared for most infant cases of HIV infection. Currently they are following the 78 seropositive mothers and their infants, and it is in this-funded subcontract to the State of Michigan that they are doing this.

Border babies have not been a problem here, I think, because of the very aggressive program of home visitation by nurse clinicians very soon after a mother delivers a baby and takes the baby home. And most of the time they are identifying the infected babies after the mother is discharged from the hospital, so they have to-very often the nurse clinician is bringing the mother back to the clinic to have the news broken. By that time I think that a lot of bonding has occurred, and we do in these programs do everything possible to encourage the baby to be cared for by the mother at home.

Mr. WEISS. The problem, of course, as you know, is that in many of those instances the mother herself is likely to die before the child.

Dr. CRANE. And that has been a problem. We have had that happen now several times, and that does present a dilemma, and that is precisely the problem that we are just coming to grips with here in Detroit.

With all due respect, I do think that in this State there has been a lot of money spent on prevention, and not enough money spent on care of patients. I would like to see developed in this State programs similar to that which have been developed in New Jersey, and in New York, where the city and the State are funding physician and nurse salaries for delivery of care for persons with HIV infection. As you know, in New York this has been a very extensive program, and to a large extent, I think, has curtailed some of the stresses that have been put on that health care system, although obviously not all of them.

Mr. WEISS. The information that we received at a number of our hearings indicates that, as I said, the facilities and the resources, are just stretched paper thin, and they are surviving to a significant extent because they are receiving demonstration program grants. But there is nothing permanent about this type of funding. We have not been able to get the administration to focus on providing a steady flow of money to health care providers rather than forcing them to rely on demonstration grant programs.

Dr. CRANE. To date, all of the nurses, and clinicians that I have working with me, are paid out of research funds that I have generated from private industry, a little bit from the Government, and I think that not one nickel has been forthcoming for patient care from either the city or the State.

Mr. WEISS. I thank you very much for your testimony. You are at the front lines of the funding crisis, and I think that what we were trying to accomplish with our questioning of the city and State officials was to demonstrate that there must be a greater sense of urgency about this problem because I do not think that there is full appreciation of how massive the problem is going to become in the next couple of years, even here in Detroit.

Thank you, sir.

Mr. CONYERS. Thank you, Mr. Weiss. Mr. Don Payne.

Mr. PAYNE. Thank you.

I, too, could not agree more with Congressman Weiss. This is just the beginning currently in one of our hospitals in Newark. We have 1 out of every 22 babies born with the HIV infection, and that is just an enormous amount. I believe we had over 300 deaths of babies because of the tremendous number that have been born, about 50 percent mortality rate. So this whole question, which has really been addressed very little in this overall hearing, the whole question of pediatrics AIDS, I think is really the most devastating part of this-of the future as relates to what we do to contain this problem.

I would just like to indicate that I, too, feel coming from local government, a former councilman, a former county official, and a State health official, that we have to really-in New Jersey, the State, the Governor cut back on funds that would directly go into AIDS. We have not seen local governments put funds in. Evidently in Detroit the same thing is happening. There is the question of whether the-to put some money into housing or for AIDS, and housing is going to get it.

The Federal Government has a $150 billion debt also, but we have seen an increase in the amount of funds that are going to be dispensed in this area, not enough, but a continued increase that in the face of a severe deficit, I think local people have to become a little more vocal to their local officials and their State officials.

See, people do not run for office on this issue, and so it is not an attractive issue, as we all know. But we have just got to think, shake our consciousness level of our officials, not only in Michigan, but in New Jersey, and New York, because when we declare a crisis-we saw $150 billion bailout for the S&L's, savings and loans, a week or two ago, someone said it was a crisis, and because it was a crisis there was $157 billion to be rolled into the system to save savings and loans.

We see the Federal budget, as the councilwoman mentioned earlier, just hovering around $300 billion, and the military people are all dismayed at how much they are being squeezed. But then we see programs like this where no civic money is going, no Federal-I mean, no county money, and the moneys are the community development block grants we heard the councilwoman talk about. You know, just coming from being a city councilman, I know that CDBG grants are not local dollars. That is the Federal dollars you give, and decide what you are going to put your Federal money into, and I am still waiting to hear what the local initiative is going to be.

So I would just-I think—I am very happy to see that the social workers, the psychiatrist, the psychologist, are really getting in