ORIGINAL

 

EYNOTE ADDRESS: CHI E RE IN THE 90
By
C. Everett Koop, M.D., Sc.D,
SURGEON GENERAL
OF THE
U.S. PuBLic HEALTH SERVICE
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Wd
PRESENTED TO THE AMERICAN ACADEMY OF PEDIATRICS
SAN FRANCISCO, CALIFORNIA

OcToBER 17, 1988
1
(GREETINGS TO HOSTS, GUESTS, FRIENDS, ETC.)

I'M DELIGHTED TO BE HERE THIS MORNING TO SHARE IN THE
OPENING CEREMONIES OF THE ACADEMY’S ANNUAL MEETING AND, AT THE
SAME TIME, TO HELP MARK THE 40TH ANNIVERSARY OF THE FOUNDING OF
THE SURGICAL SECTION OF THE A.A.P.

FORTY YEARS IS A LONG TIME, BUT THE MEMORY OF THOSE DAYS HAS
NOT BEEN DIMMED. I WAS A YOUNG MAN OF 31, CLEAN-SHAVEN, HAIR
CAREFULLY TRIMMED, AND -- ALL-IN-ALL -- THE VERY MODEL OF THE
ESTABLISHMENT PEDIATRICIAN,
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EXCEPT FOR ONE THING: I WAS ALSO A SURGEON AND I BELIEVED

VERY DEEPLY IN THE FUTURE OF PEDIATRIC SURGERY,

BUT I WAS BY NO MEANS ALONE, I WAS ONE OF A SMALL BUT
DEDICATED BAND OF PEDIATRIC SURGEONS ... SOME HALF-DOZEN MEN WHO
WERE EXPLORING THIS NEW AND UNCHARTED TERRITORY.

YES, IN THOSE DAYS IT WAS AN ALL~MALE VOCATION. SINCE THEN
-- FORTUNATELY FOR THE PROFESSION AND FORTUNATELY FOR CHILDREN --
WE HAVE MANY OUTSTANDING WOMEN AS WELL. IN FACT, I PROBABLY
TRAINED AS MANY WOMEN IN PEDIATRIC SURGERY AS ANYONE ELSE IN THE
PROFESSION. AND I’M VERY PROUD OF THAT ACCOMPLISHMENT,
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BUT, AS I SAY, IN THE BEGINNING -- 40 YEARS AGO -- WE WERE

A HANDFUL OF MEN STRIKING OUT ON OUR OWN.

T WON'T SAY WE WERE PERSONA NON GRATA AMONG SURGEONS ... BUT
WE WEREN’T EXACTLY PERSONA GRATA EITHER.

BUT I RECALL NO SUCH AMBIVALENCE AMONG OUR PEDIATRIC
COLLEAGUES. THE ACADEMY MADE ROOM FOR US AND IT COLLEGIALLY
SUPPORTED US IN OUR STRUGGLE TO UNDERSTAND AND DEFINE WHAT WE
WANTED TO DO FOR CHILDREN AND HOW WE OUGHT TO GO ABOUT DOING IT.
y
SO I THINK IN A VERY REAL SENSE THIS 40TH ANNIVERSARY IS NOT

ONLY A CELEBRATION OF OUR PARTICULAR SPECIALTY OF PEDIATRIC
SURGERY BUT ALSO A CELEBRATION OF THE VISION AND GENEROSITY OF A
GREAT PROFESSIONAL SOCIETY IN AMERICAN MEDICINE.

ALL THAT’S IMPORTANT ... BUT IT’S ALSO A PREAMBLE TO A FEW
THOUGHTS I WANT TO SHARE WITH YOU THIS MORNING ... THOUGHTS THAT
GROW OUT OF OUR PAST EXPERIENCES, BUT ALSO -- I SINCERELY HOPE
-- THOUGHTS THAT MAY POINT US IN USEFUL DIRECTIONS IN THE YEARS
AHEAD.
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I DON’T MEAN TO BE MAUDLIN ABOUT IT, BUT THIS IS PROBABLY

MY LAST CHANCE TO REVIEW WITH YOU SOME OF THE AREAS IN WHICH THE
ACADEMY AND THE PUBLIC HEALTH SERVICE -- AND I AS ITS SURGEON
GENERAL -- HAVE BEEN ABLE TO WORK TOGETHER TO IMPROVE THE HEALTH
OF ALL OF AMERICA’S CHILDREN,

VERY EARLY IN MY FIRST TERM -- IN THE FALL OF 1982, TO BE
EXACT -- YOU AND I TOOK A HARD LOOK AT THE ISSUE OF CHILD ABUSE
AND FAMILY VIOLENCE IN GENERAL, AS SIGNIFICANT PUBLIC HEALTH
ISSUES IN OUR SOCIETY. YOU LISTENED ... AND YOU RESPONDED.
6
THREE YEARS LATER, AT THE FIRST “SURGEON GENERAL’S

WORKSHOP ON VIOLENCE AND PUBLIC HEALTH,” I WAS ABLE TO PLACE
FAMILY VIOLENCE ON OUR NATIONAL PUBLIC HEALTH AGENDA, THANKS TO
THE STRONG SUPPORT AND WISE GUIDANCE FROM MEMBERS OF THIS
ACADEMY.

AND JUST THIS MONTH, AS THE LATEST ACTIVITY IN THIS LONG-
RANGE PUBLIC HEALTH EFFORT, I HAVE RELEASED A DOCUMENT TITLED THE
“SURGEON GENERAL’S LETTER ON CHILD SEXUAL ABUSE” AND DESIGNED TO
BE OF MOST USE TO THE PRACTITIONER.
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THIS “LETTER” IS THE MOST RECENT EXAMPLE OF OUR COOPERATIVE

RELATIONSHIP IN THIS VERY TROUBLING AREA. BUT I‘M SURE IT WILL
NOT BE THE LAST.

AGAIN, THE COUNTRY OWES A DEBT OF GRATITUDE TO MANY MEMBERS
OF THE ACADEMY WHO DEBATED THE ISSUES AND WHO -- ALONG WITH ME
AND WITH MEMBERS OF THE PUBLIC HEALTH SERVICE -- ALSO SHARED THE
PAIN AND THE DISMAY THAT CHILD SEXUAL ABUSE BRINGS TO OUR
COMMUNITIES AND OUR FAMILIES.
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IT IS MY HOPE -- AND MY SINCERE BELIEF -- THAT THIS

“LETTER” WILL NOT ONLY HELP REDUCE THE INCIDENCE OF THIS CRIME --
AND IT IS A CRIME -- BUT I ALSO HOPE THAT THE “LETTER” WILL HELP
INSURE THAT CHILDREN, THEIR FAMILIES, AND ALLEGED PERPETRATORS
WILL GET PROMPT AND FAIR TREATMENT AT THE HANDS OF PROFESSIONALS
IN HEALTH CARE AND LAW ENFORCEMENT.

ANOTHER EARLY EXAMPLE OF OUR CLOSE RELATIONSHIP IN ACTION
WAS THE “BABY DOE” ISSUE, TO USE THE SHORTHAND TERM,

THE BRIEF LIFE OF “BABY DOE” WAS, FOR ALL ITS MEDICAL
COMPLEXITIES, A PERSONAL HUMAN TRAGEDY NEVERTHELESS, AND WE
RESPONDED TO IT NOT JUST AS PEDIATRICIANS BUT AS SENSITIVE HUMAN
BEINGS.
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"BABY DOE'S” STORY HAS BEEN RECITED OFTEN ENOUGH IN PRINT

AND FROM THE PODIUM SO THAT I DON'T FEEL THE NEED TO REPEAT IT
NOW. BUT ONE PARTICULAR ASPECT IS WORTH REVIEWING,

AFTER ALL IS SAID AND DONE, I THINK THE “BABY DOE” ISSUE
WAS, IN MANY WAYS, A MODEL CASE OF AMERICAN POLITICAL AND SOCIAL
MEDICINE WORKING AT ITS BEST.
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YES, I KNOW, MANY PEOPLE ARE UNCOMFORTABLE WHEN THEY HEAR

TALK OF “POLITICAL MEDICINE” AND “SOCIAL MEDICINE.” PRACTICING
PHYSICIANS ARE SUPPOSED TO BE “ABOVE” SUCH THINGS.

BUT PHYSICIANS ARE ALSO CONCERNED CITIZENS AND THEY HAVE THE
RIGHT -- AND THE RESPONSIBILITY -- TO MAKE SURE THAT THE PRACTICE
OF MEDICINE DOES CONTRIBUTE TO THE OVERALL SOCIAL AND POLITICAL
HEALTH OF THIS NATION, AND NOT ONLY TO THE PHYSICAL AND MENTAL
HEALTH OF ITS PEOPLE.
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WE WRESTLED WITH THE “BABY DOE” ISSUES TOGETHER. WE DEBATED

THE ISSUES OUT IN THE OPEN. WE TOOK OUR VIEWS TO OUR COLLEAGUES
oss TO THE PUBLIC ... TO THE PRESIDENT AND TO THE CONGRESS. AND
FINALLY -- TOGETHER -- WE WERE ABLE TO PUT INTO PLACE A SYSTEM OF
PROTECTION. NOT PERFECT MAYBE ... BUT IT’S THERE AND IT’S OURS.

SEVERAL YEARS HAVE PASSED SINCE THE AGONY OF THAT DEBATE AND
I AM SOMETIMES ASKED, “DR. KOOP, WHO WON THAT ONE?”

AND MY ANSWER IS ALWAYS THE SAME: "THE CHILDREN OF AMERICA
WON THAT ONE.”
12
I REALLY BELIEVE THAT. I BELIEVE THE CHILDREN OF AMERICA

CAME OUT ON TOP OF THE “BABY DOE” ISSUE. NOT THE SURGEON
GENERAL. NOT THE ACADEMY. NOT THE CONGRESS. AND NOT ANY
PARTICULAR PRESSURE GROUP. BUT CHILDREN DID.

IT WAS AN IMPORTANT EXPERIENCE FOR US ALL ... A KIND OF
WATERSHED EVENT IN OUR RELATIONSHIP. FOR SINCE THAT TIME, WE’VE
BEEN ABLE TO WORK TOGETHER ON OTHER ISSUES AND PROBLEMS AND SOLVE
THEM ON BEHALF OF THE CHILDREN OF AMERICA,

I THINK WE HAVE A GOOD RECORD REGARDING THE PROBLEMS OF
HANDICAPPED CHILDREN AND THEIR FAMILIES,
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WE'VE MADE A GOOD START THERE AND I HOPE, LONG AFTER I'VE

LEFT GOVERNMENT, THAT THE MOMENTUM WILL CONTINUE AND EVEN
ACCELERATE TO DO MORE AND TO DO BETTER FOR THESE CHILDREN,

BUT JUST TO MAKE SURE THAT WE KEEP OUR EYES ON THE MAJOR
QUESTIONS BEFORE US, I’VE BEGUN THE PLANNING FOR A “SURGEON
GENERAL’S WORKSHOP” FOR THE SPRING OF 1989. IT WILL HAVE A
SPECIAL AND, I BELIEVE, A UNIQUELY SIGNIFICANT FOCUS.

ONE OF THE MOST DIFFICULT TIMES IN THE LIVES OF A
HANDICAPPED CHILD AND HIS OR HER FAMILY COMES WHEN THAT CHILD
OUTGROWS THE KIND OF CARE PROVIDED BY THE PEDIATRICIAN AND NEEDS
TO BE HANDED ON TO THE WAITING AND CAPABLE HANDS OF A
PRACTITIONER OF ADULT OR FAMILY MEDICINE.
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SOMETIMES THAT TRANSITION WORKS VERY WELL. BUT MOST OF THE

TIME IT DOESN’T. I THINK WE ALL KNOW THAT. AND I THINK WE ALL
WANT TO DO SOMETHING ABOUT IT.

I HOPE THAT MY WORKSHOP IN THE SPRING OF ‘89 WILL GIVE US
THE OPPORTUNITY TO FOCUS SQUARELY ON THIS PROBLEM OF TRANSITION
AND CONTINUITY OF CARE FOR THE GROWING OR GROWN CHILD WHO IS
HANDICAPPED,

AND, AGAIN, I KNOW YOUR ADVICE AND COUNSEL AND EXPERIENCE
WILL BE THE ELEMENTS THAT WILL MAKE THAT WORKSHOP A SUCCESS AND
PRODUCE ANOTHER VICTORY FOR THE CHILDREN OF AMERICA,
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I WOULD BE VERY REMISS IF I DID NOT MENTION THE COOPERATION

AND COLLABORATION WE’VE ALSO ENJOYED -- IF THAT REALLY IS THE
WORD -- IN THIS WHOLE NEW AREA OF AIDS.

WHILE THE NUMBER OF PEDIATRIC AIDS CASES IS NOT VERY HIGH --
ABOUT 1,200 NATIONWIDE -- THESE CHILDREN DO REPRESENT A VERY
SPECIAL MEDICAL AND SOCIAL CHALLENGE WHEREVER THEY ARE.

WE NEED TO LOOK AT THE SPECIAL NATURE OF PEDIATRIC AIDS, NOT
ONLY TO THE EFFECTS ON CHILDREN BUT TO THE EFFECTS UPON
PHYSICIANS AND NURSES AND SOCIAL SERVICES WORKERS AND
ADMINISTRATORS.
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IN THE RECENT PUBLIC EDUCATION CAMPAIGN REGARDING AIDS IN

GENERAL, I CAN’T TELL YOU HOW VALUABLE THE MEDICAL PROFESSION HAS
BEEN -- INCLUDING MEMBERS OF THIS ACADEMY -~ IN HELPING TO
PROVIDE OUR SCHOOLS, OUR FAMILIES, AND OUR SOCIAL AND RELIGIOUS
INSTITUTIONS WITH THE FACTS THAT CHILDREN NEED TO KNOW ... THE
FACTS REGARDING HUMAN REPRODUCTION, HUMAN SEXUALITY, AND THE
TRANSMISSION OF DISEASE -- ESPECIALLY THE DISEASE OF AIDS.

I‘VE SAID IT BEFORE AND I’LL SAY IT AGAIN. WE ALL MUST BE
SADDENED BY THE FACT THAT WE NEED TO TELL YOUNG PEOPLE THE FACTS
ABOUT HUMAN REPRODUCTION AND SEXUALITY IN ORDER TO SAVE THEM
FROM A FATAL SEXUALLY TRANSMITTED DISEASE.
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BUT WE MUST DO IT. AND WE ARE DOING IT. AND, ONCE AGAIN,

THE CHILDREN OF AMERICA ARE GOING TO COME OUT AHEAD.

MOST RECENTLY THE ACADEMY HAS ENDORSED A STRONG STATEMENT ON
DRUNK DRIVING, DRAFTED BY THE SURGICAL AND SCHOOL HEALTH
SECTIONS.

IT'S A HARD-HITTING STATEMENT, WHICH IS WHAT THIS PROBLEM
REQUIRES. THE STATEMENT NOTES THAT DRUNK DRIVERS DON’T SEEM TO
RESPOND TO PUBLIC EDUCATION PROGRAMS SO THAT THE BEST THING WE
CAN DO IS SIMPLY TO GET THEM OFF AMERICA’S STREETS AND HIGHWAYS.
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AS YOU MAY KNOW, THE SECRETARY OF HEALTH AND HUMAN

SERVICES, DR. OTIS R. BOWEN, HAS BEGUN A DEPARTMENT-WIDE
INITIATIVE AGAINST ALCOHOLISM AND ALCOHOL ABUSE.

I’M PLEASED TO ANNOUNCE THAT, IN SUPPORT OF THE SECRETARY’S
INITIATIVE, I WILL BE CONVENING A 3-DAY “SURGEON GENERAL’S
WORKSHOP ON DRUNK DRIVING” IN WASHINGTON ON DECEMBER 15,

I’M POSITIVE THAT MEMBERS OF THE ACADEMY WILL MAKE IMPORTANT
CONTRIBUTIONS NOT ONLY TO THE WORKSHOP BUT ALSO TO THE FOLLOW-UP
ACTIVITIES THAT WILL SURELY TAKE PLACE AFTER THE WORKSHOP ITSELF
IS OVER.
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ALL THAT INFORMATION IS BY WAY OF BRINGING YOU UP TO DATE AS

TO THE KIND OF GOOD WORKING RELATIONSHIP WE’VE HAD OVER THE PAST
7 YEARS, RIGHT UP TO TODAY.

BUT WHAT ABOUT TOMORROW? WHAT ABOUT THE CHILD HEALTH NEEDS
OF THE 1990s AND EVEN BEYOND?

DICK NARKEWICZ ASKED ME TO ADDRESS THAT QUESTION THIS
MORNING AND SO I WILL, BEFORE HE HAS A CHANCE TO CHANGE HIS MIND.
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FIRST, LET ME PUT A “SURGEON GENERAL’S WARNING LABEL” ON MY

OWN SPEECH:

"WHAT I'M ABOUT TO SAY REFLECTS MY OWN THINKING AND MY OWN
PERCEPTIONS. THEY ARE NOT THE CLEANED AND LAUNDERED
POSITIONS OF ANY ADMINISTRATION ... PRESENT OR FUTURE.”

AT ANY RATE, LET’S TAKE A MOMENT TO LOOK AT THAT POPULATION
GROUP THAT WE CALL “CHILDREN.” IT INCLUDES NOT ONLY NEONATES
BUT ALSO ADOLESCENTS THROUGH TO AGE 18,
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FOR 200 HUNDRED YEARS THIS AGE GROUP HAS DOMINATED AMERICAN

LIFE AND THINKING ... AMERICAN GETTING AND SPENDING ... AND
CERTAINLY AMERICAN HEALTH AND WELFARE PLANNING.

BUT THAT POSITION OF DOMINANCE IS CHANGING. FIVE YEARS AGO,
FOR EXAMPLE, 28 PERCENT OF THE AMERICAN POPULATION WERE CHILDREN
UNDER THE AGE OF 18, WHILE ONLY 21 PERCENT WERE ADULTS OVER THE
AGE OF 55,

BUT, BY THE YEAR 2000 -- 11 YEARS FROM NOW -- THESE TWO
POPULATION GROUPS WILL BE VIRTUALLY IN BALANCE. AND THEN, BY
THE YEAR 2010, THE BALANCE WILL GO THE OTHER WAY:
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* 24 PERCENT OF ALL AMERICANS WILL BE UNDER THE AGE OF

18, BUT...
* 26 PERCENT WILL OVER THE AGE OF 55,

OUR AMERICAN DEMOGRAPHICS ARE IN TRANSITION, AND FOLLOWING RIGHT
BEHIND IS THE PARALLEL TRANSITION IN HEALTH PLANNING AND RESOURCE
ALLOCATION,

THROUGHOUT THE YEARS, PEDIATRICIANS HAVE BEEN IN THE
FOREFRONT OF EVERY CAMPAIGN FOR STRONG PUBLIC SUPPORT OF
ESSENTIAL MATERNAL AND CHILD HEALTH PROGRAMS. AND WE'VE FOUGHT
THAT GOOD FIGHT, EVEN THOUGH CHILDREN AND YOUTH HAVE CLEARLY BEEN
THE DOMINANT POPULATION GROUP,
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BUT OUR STRATEGY FOR TOMORROW HAS TO BE A LITTLE DIFFERENT.

TOGETHER WITH OUR ALLIES IN NURSING, HOSPITAL ADMINISTRATION,
CHILD ADVOCACY, AND SO ON, WE MUST WORK HARD TO MAINTAIN -- IF
NOT ACTUALLY INCREASE PUBLIC SUPPORT -- FOR CHILD HEALTH PROGRAMS
IN THE 1990s AND BEYOND.

BUT WE CAN’T FIGHT FOR THIS SUPPORT AT THE EXPENSE OF OTHER
POPULATION GROUPS -- ESPECIALLY THE ELDERLY. RATHER, WE MUST
SPEAK OUT SO THAT CHILDREN ARE PROVIDED WITH AT LEAST -- AND NOT

LESS THAN -- THEIR PROPORTIONATELY FAIR SHARE OF OUR COUNTRY’S
HEALTH RESOURCES.
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BUT THERE’S ANOTHER TWIST TO THIS DEMOGRAPHIC REALITY,

REGARDING THE CHILDREN OF THE 1990s AND BEYOND.

THE LARGEST SINGLE GROUP OF POOR PEOPLE IN THE UNITED
STATES ARE CHILDREN ... 12 MILLION OF THEM ... OR ABOUT 1 OF
EVERY 4 AMERICANS UNDER THE AGE OF 18.

THIS IS SOMEWHAT MISLEADING, SINCE, TO A CERTAIN EXTENT, ALL
CHILDREN HAVE NO REAL ECONOMIC ASSETS OF THEIR OWN AND, THERE-
FORE, THEY ARE ALL “POOR.” HENCE, WHAT WE REALLY MEAN IS THAT
THE SINGLE LARGEST POPULATION OF POOR PEOPLE IN THE UNITED
STATES [S MADE UP OF CHILDREN OF POOR FAMILIES.
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TAKEN TOGETHER, I THINK THESE ARE TWO VERY POWERFUL -- AND

POTENTIALLY NEGATIVE -- INFLUENCES ON THE FUTURE OF CHILD HEALTH
SUPPORT IN THIS COUNTRY:

FIRST, THE FACT THAT CHILDREN WILL NO LONGER DOMINATE OUR
DEMOGRAPHICALLY BASED HEALTH PLANNING, AND...

SECOND, THE FACT THAT A SIGNIFICANT NUMBER OF ALL CHILDREN,
BECAUSE OF THEIR LOW SOCIO-ECONOMIC STATUS, MAY NOT HAVE THE
STRONG HEALTH ADVOCACY THEY REQUIRE.
26
IT SEEMS TO ME THAT THIS ADDS UP TO A MAJOR CHALLENGE FOR

THE LEADERSHIP OF ALL CHILD HEALTH ADVOCATES IN OUR SOCIETY.
AND, LIKE THE “BABY DOE” ISSUE, THIS KIND OF CHALLENGE REQUIRES
OUR VERY BEST EFFORTS IN POLITICAL AND SOCIAL MEDICINE.

ONCE AGAIN, I WANT THE CHILDREN OF AMERICA TO BE THE
WINNERS. AND THEY WILL BE, IF WE MAKE A GOOD STRONG CASE ON
THEIR BEHALF.

THIS, THEN, IS MY SNAPSHOT -- YOU MIGHT SAY -- OF THE
GENERAL DEMOGRAPHIC AND SOCIO-ECONOMIC CONTEXT OF CHILD HEALTH
CARE FOR THE NEXT 10 TO 20 YEARS.
27
BUT NOW, WHAT SHOULD WE BE DOING WITHIN THAT CONTEXT --

TODAY AND TOMORROW -- TO IMPROVE THE HEALTH STATUS OF CHILDREN?
WHAT ARE THE PRIORITIES? WHAT ARE THE GOALS AND OBJECTIVES?

RATHER THAN RUN THROUGH A LONG “LAUNDRY LIST” OF THINGS
YOU'VE ALL HEARD BEFORE, LET ME INSTEAD FOCUS ON THE OVER-RIDING
ISSUE IN PEDIATRIC MEDICINE AND HEALTH CARE: INFANT MORTALITY.
28
EVERY TIME I PICK UP ANOTHER RESEARCH REPORT FROM THE

NATIONAL INSTITUTE ON CHILD HEALTH AND HUMAN DEVELOPMENT, I AM
AGAIN IMPRESSED WITH THE STEADY PROGRESS WE'RE MAKING IN SUCH
AREAS AS THE PREVENTION OF LOW BIRTH-WEIGHT AND RESPIRATORY
DISTRESS SYNDROME, IN CORRECTING MATERNAL-FETAL BLOOD
INCOMPATIBILITY, IN NUTRITIONAL INTERVENTION, FETAL SURGERY, AND
EVEN GENE REPLACEMENT THERAPY ... ALTHOUGH, IN MY BOOK, THAT KIND
OF THERAPY RAISES MORE QUESTIONS THAN IT’S SUPPOSED TO ANSWER.

NEVERTHELESS, THESE ARE ALL VERY EXCITING AND POSSIBLY VERY
IMPORTANT AREAS OF RESEARCH. THEY DESERVE -- AND THEY’RE GETTING
-- STRONG FEDERAL SUPPORT.
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BUT THE STATISTICAL PICTURE ON INFANT MORTALITY IN THIS

COUNTRY CLEARLY INDICATES THAT WE MUST GO WELL BEYOND THE
BIOMEDICAL LABORATORY, IF WE WANT TO CONTINUE TO SIGNIFICANTLY
REDUCE THE TOLL OF 40,000 PREVENTABLE INFANT DEATHS THAT OCCUR
EACH YEAR.

FOR ONE THING, I BELIEVE WE NEED TO TAKE A SECOND AND MUCH
CLOSER LOOK AT OUR OWN INFANT MORTALITY DATA. IN A SOCIETY AS
LARGE AND AS HETEROGENEOUS AS OURS, IT MAKES NO SENSE TO KEEP
QUOTING THE AGGREGATED DATA. THEY ARE HIDING TOO MANY IMPORTANT
BITS OF INFORMATION THAT NEED TO BE TEASED OUT AND ANALYZED.
30
FOR EXAMPLE, OUR STATISTICIANS AT THE NATIONAL CENTER FOR

HEALTH STATISTICS RECENTLY WENT BACK AND TOOK A DETAILED
RETROSPECTIVE LOOK AT A LARGE SAMPLE OF THE 1982 BIRTH COHORT.
THE SAMPLE CAME FROM 9 MIDWESTERN AND NEW ENGLAND STATES,
INCLUDING ILLINOIS, MICHIGAN, INDIANA, MASSACHUSETTS, AND SO ON,

SPECIFICALLY, THE RESEARCHERS FOCUSED ON 10,000 INFANT
DEATHS THAT YEAR, ABOUT 25 PERCENT OF THE NATIONAL TOTAL.

THE MOTHERS OF ALL THE 10,000 INFANTS WHO DIED HAD ONE THING
IN COMMON: THEY WERE ALL 20 YEARS OLD OR OLDER. THE RESEARCHERS
LOOKED AT EDUCATIONAL ATTAINMENT AND RACE, DID SOME CROSS-
TABULATING, AND CAME UP WITH THESE RESULTS:
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FIRST, THEY FOUND THAT THE MORTALITY RATE AMONG INFANTS BORN

TO WHITE WOMEN WITH LESS THAN A HIGH SCHOOL EDUCATION WAS 12...
12 INFANT DEATHS PER 1,000 LIVE BIRTHS. BUT AMONG BLACK WOMEN
11+ SAME AGE -- 20 YEARS OLD OR OLDER -- AND SAME LIMITED
SCHOOLING ... THE INFANT MORTALITY RATE WAS 28, OR BETTER THAN
TWICE THE RATE AMONG THEIR WHITE SISTERS,

THEN THEY LOOKED AT THOSE WOMEN IN THE SAMPLE WHO HAD
COLLEGE DEGREES OR BETTER. THEY FOUND THAT THE MORTALITY RATE

FOR INFANTS BORN TO WHITE, COLLEGE-EDUCATED WOMEN WAS DOWN TO
7.9.
32
BUT THE MORTALITY RATE FOR INFANTS BORN TO BLACK, COLLEGE-

EDUCATED WOMEN WAS 20,6 ... OR NEARLY THREE TIMES THE RATE AMONG
THEIR WHITE SISTERS,

WHY SHOULD THAT BE SO? IS IT CULTURE? RACE? IS IT GENETIC
PREDISPOSITION? IS IT ACCESS? COST? WE DON’T REALLY KNOW.

IN THE ABSENCE OF ANSWERS TO SUCH QUESTIONS, WE KEEP
INVESTING OUR RESOURCES IN TRADITIONAL AND CONVENTIONAL
APPROACHES TO THE INFANT MORTALITY ISSUE. THESE APPROACHES HAVE
OBVIOUSLY WORKED WELL FOR WHITE WOMEN WITH HIGH SOCIOECONOMIC
STATUS, AND THAT'S ALL TO THE GOOD,
33
BUT THEY HAVEN’T BROUGHT ANY COMPARABLE BENEFITS FOR BLACK

AND OTHER MINORITY WOMEN AND THEIR INFANTS RIGHT ACROSS THE
SOCIO-ECONOMIC SCALE.

AND THAT'S NOT ALL TO THE GOOD.

TO GET AT THE TRUTH OF THE MATTER, WE MAY HAVE TO DO WHAT
WE’VE BEEN VERY CHARY OF DOING: THAT IS, WE MAY HAVE TO DISCARD
OUR CONVENTIONAL WISDOM, LOOK AT OUR INFANT MORTALITY DATA IN
GREATER DEPTH, AND GIVE FULL RECOGNITION AND RESPECT TO THE
HETEROGENEOUS POPULATION BASE FROM WHICH THOSE DATA ARE DRAWN.
34
BUT EVEN AS WE WRESTLE WITH THIS APPROACH AND TRY TO MAKE

SOME NECESSARY ADJUSTMENTS, THE ENVIRONMENT IS STILL IN FLUX.
I’M REMINDED, FOR EXAMPLE, OF THE RECENT REPORT OF THE “NATIONAL
COMMISSION TO PREVENT INFANT MORTALITY.”

AMONG OTHER THINGS, THE COMMISSION RECOMMENDED THAT THE
AMERICAN PEOPLE MUST ... “PROVIDE UNIVERSAL ACCESS TO EARLY
MATERNITY AND PEDIATRIC CARE FOR ALL MOTHERS AND INFANTS.” IN
OTHER WORDS, LET'S GET RID OF ANY AND ALL BARRIERS TO HEALTH
CARE FOR EACH AND EVERY MOTHER AND CHILD IN AMERICA.
| 35
BUT THIS RECOMMENDATION AMPLIFIES THE CONCEPT OF “ACCESS”

IN A NEW AND VERY IMPORTANT WAY. IT SAYS THAT ... “EMPLOYERS
MUST MAKE AVAILABLE HEALTH INSURANCE COVERAGE THAT INCLUDES
MATERNITY AND WELL-BABY CARE.”

THE COMMISSION WAS EVENLY BALANCED WITH PHYSICIANS AND NON-
PHYSICIANS ... REPUBLICANS AND DEMOCRATS ... FEDERAL AND STATE
OFFICIALS ... AND SO ON. HARDLY A RADICAL BUNCH BY ANYONE’S
STANDARD.
36
YET, THE MEMBERS CAME OUT FOR A MUCH GREATER ROLE FOR

PRIVATE EMPLOYERS. WHY DID THEY DO THAT? BECAUSE TODAY, OF THE
MORE THAN 56 MILLION AMERICAN WOMEN OF CHILD-BEARING AGE, ROUGHLY
16 TO 44, ALMOST 28 MILLION OF THEM ARE EMPLOYED FULL-TIME IN

THE AMERICAN WORK-FORCE. THAT'S 50 PERCENT OF ALL WOMEN IN THAT
CRUCIAL CHILD-BEARING AGE GROUP.

IN ADDITION, WELL OVER HALF OF ALL MOTHERS OF SMALL CHILDREN
-- KIDS THREE YEARS OLD OR YOUNGER -- ARE WORKING FULL-TIME.

WITH ALL DUE RESPECT TO THE ACADEMY AND ITS MEMBERS, ON A
DAY-TO-DAY BASIS, IT IS NOW CLEARLY THE MANAGEMENTS OF BUSINESS
AND INDUSTRY WHO EXERCISE THE MOST CRITICAL INFLUENCE UPON THE
HEALTH OF AMERICA’S MOTHERS AND CHILDREN.
37
HENCE, WHEN WE INVOKE THE PHRASE, “PRIVATE SECTOR,” WE

INVOKE SOMETHING THAT STANDS FOR MORE THAN JUST THE AMERICAN
ACADEMY OF PEDIATRICS, THE SAN FRANCISCO MARCH OF DIMES, AND THE

Y.W.C.A,

TODAY WE ALSO MEAN TRANSAMERICA AND UNITED AIRLINES, AT&T
AND STANFORD UNIVERSITY, MARRIOTT, HOLIDAY INN, AND RUBY FO00’S,

WE MEAN ALL THOSE PRIVATE SECTOR INTERESTS WHO CONTROL
PAYROLLS AND WORKING CONDITIONS AND WHO INFLUENCE COMMUNITY
SENTIMENT AND CONTRIBUTE HEAVILY TO THE TAX BASE.
38
THEY ALL MUST COLLABORATE IN OUR NATIONAL HEALTH STRATEGY,

IF WE REALLY WANT TO REDUCE INFANT MORTALITY AND IMPROVE MATERNAL
AND CHILD HEALTH IN THE 1990s ... AND BEYOND.

I'VE GONE ON AT SOME LENGTH THIS MORNING AND YOU‘VE BEEN
VERY GENEROUS WITH YOUR TIME AND PATIENCE, SO LET ME SUM UP THESE
FEW IDEAS AND BRING MY REMARKS TO A CLOSE,

FIRST, I BELIEVE THAT THE DEMOGRAPHIC SHIFTS GOING ON AMONG
OUR POPULATION MAKE IT NECESSARY FOR THOSE OF US IN PEDIATRIC
MEDICINE TO STRENGTHEN OUR ROLE AS CHILD ADVOCATES SO THAT
AMERICA’S CHILDREN WILL RECEIVE THEIR FAIR SHARE OF THE AVAILABLE
HEALTH RESOURCES IN THE YEARS AHEAD. NOT NECESSARILY MORE. BUT
CERTAINLY NOT LESS THAN THEY NEED AND DESERVE,
| 39
SECOND, IN THE MATTER OF INFANT MORTALITY, I BELIEVE WE

MUST GO BACK TO OUR DATA AND TRY TO UNDERSTAND THEM WITHIN THE
CONTEXT OF THE DIVERSITY AND HETEROGENEITY OF OUR NATIONAL LIFE.
LIKE SOQ MUCH ELSE WE DO, THAT ALSO COULD WELL BE AN ACT OF
POLITICAL AND SOCIAL COURAGE,

BUT THE LONGER WE POSTPONE THAT KIND OF ANALYSIS, THE MORE
INNOCENT LIVES WILL BE LOST. AND THAT HAS TO BE A FAR HEAVIER
LOAD FOR OUR CONSCIENCE TO CARRY.
40
AND THIRD, WE NEED TO EXPAND OUR COMMUNITY OF MATERNAL AND

CHILD HEALTH ADVOCATES TO INCLUDE THE FOR-PROFIT AS WELL AS THE
NOT-FOR-PROFIT WING OF THE PRIVATE SECTOR. THE SOCIAL AND
ECONOMIC REALITIES ARE NOW TOO OBVIOUS TO IGNORE.

HENCE, IN THE 1990s AND BEYOND, WE NEED TO HAVE THE
PARTICIPATION AND THE DIRECT CONTRIBUTION OF EMPLOYERS IN THE
EVOLUTION OF IMPROVED MATERNAL AND CHILD HEALTH PROGRAMS,

AND I KNOW OF NO BETTER GROUP OF MEN AND WOMEN TO MAKE THIS
CASE TO THE EMPLOYERS AND MANAGERS OF THE AMERICAN MARKETPLACE
THAN THOSE WHO ARE IN THIS ROOM THIS MORNING: AMERICA’S CONCERNED
AND COMMITTED PEDIATRICIANS.
41
ONCE AGAIN, THANK YOU FROM THE BOTTOM OF MY HEART FOR BEING

ACTIVE PRACTICING MEMBERS OF A COURAGEOUS, GENEROUS, AND
DEDICATED PROFESSION.

SOMETIME NEXT YEAR, I’LL BE BACK AGAIN IN MUFTI, MY UNIFORM
CLEANED AND PRESSED FOR THE LAST TIME. I’LL LOOK BACK -- I HOPE
-- AT A JOB WELL DONE, OR DONE AS WELL AS POSSIBLE.

BUT I’M GOING TO LOOK AHEAD TO THE JOB THAT’S STILL TO BE
DONE ... SOME OF THE THINGS I‘VE TALKED ABOUT HERE TODAY ... SOME
OF THE THINGS THAT WILL COME UP AS THE HOURS PASS AT THIS
MEETING.
42
AND I‘M LOOKING FORWARD TO WORKING WITH YOU ON THESE VERY

IMPORTANT MATTERS FOR THE GOOD OF OUR CHILDREN ... AND OUR
COUNTRY.

WE'VE WORKED WELL TOGETHER OVER THE PAST 7 YEARS. AND, IF
THEY COULD, I KNOW THE CHILDREN OF AMERICA WOULD SAY, “THANK

YOU. THANK YOU VERY MUCH,”

Hee HE #