Center for the

Vol. 4, No. 3
February 1982

Study of Aging
Newsletter

UNIVERSITY OF PENNSYLVANIA

CENTER FOR THE STUDY OF AGING

3906 Spruce Street H1, Philadelphia, PA 19104
215-243-3174

Surgeon General Koop Draws Attention
To Long-Term Care, Senile Dementia

Lorraine Hanaway

“That's the first interview I’ve ever had
where I was approached as a member of the
aged population,” declared C. Everett
Koop, M.D., the new Surgeon General of
the United States and Director of the Public
Health Service, following a conversation in
mid-December, shortly after his confirma-
tion in office.

“I don’t feel aged at all,” the former
Surgeon-in-Chief of Children’s Hospital of
Philadelphia said with the hint of a smile. “I
feel like I did at forty-five.”

That feeling, however, does not diminish
his enthusiasm for wrestling with the prob-
lems of aging and the aged. He recognizes
the concerns of a graying America as his
own concerns, and one of his first duties
was attending the White House Conference
on Aging. He is chairman of the Long-Term
Care Work Group, with Dr. Robert Butler
of the National Institute on Aging as vice
chairman.

“One of the things that I have enjoyed
most in Washington is working with Bob
Butler,” he said. “We're very much on the
same wave length. [This task force] is going
into [long-term care] in as much depth as
we can. You know these task forces have
met with every administration. The trouble
is they write a report and nothing ever hap-
pens. We're determined that something is
going to happen.”

Charles Everett Koop was born October
14, 1916 in Brooklyn, New York. He was
graduated from Dartmouth College and
received his M.D. degree from Cornell Uni-
versity Medical College in 1941. After serv-
ing as an intern at Pennsylvania Hospital,
he pursued postgraduate training at the
University of Pennsylvania School of Medi-
cine, Boston Children’s Hospital, and the
Graduate School of Medicine here, where
he received an Sc.D., in 1947. He was
named Assistant Surgeon at the Hospital of
the University of Pennsylvania that year,

 

—DHHS photo
C. Everett Koop, M.D. .

and in 1948 he became Surgeon-in-Chief at
Children’s Hospital of Philadelphia. He
joined the faculty of the University of Penn-
sylvania School of Medicine in 1942, and
became Professor of Pediatric Surgery in
1959, gaining that rank at the Graduate
School in 1960.

Dr. Koop is considered a pioneer in the
development of surgery of newborn babies.
The C. Everett Koop Surgical Center on the
fourth floor of Children’s Hospital attests

 

to his stature in the medical community. He
and his wife, Elizabeth, now live in Wash-
ington, although they have a home in

INSIDE

¢ Impact of Hospital Stress on the Well-

Gladwyne, Pennsylvania, where this inter- Being of Older Men
view took place. ¢ Accuracy of Death Certificate Ages for
For the past thirty-five years he has been the Extreme Aged

concerned with the health and well-being of
(continued on page 2)

* Update on the Older Americans Act

 
Surgeon General Koop Draws Attention
To Long-Term Care, Senile Dementia

(continued from page 1)

children. When asked what changes in
work “style” he might have to make in
moving from the hands-on narrower role of
a pediatric surgeon to the broader role of
Director of the Public Health Service, he
said that the transition from the old to the
new is not as dramatic as one might expect.

“I have been involved in some very
broad health problems. In my old job I
acted, in a sense, as an advocate for indi-
vidual patients and for their families in time
of distress and had a lot to do with finding
the answers to the problems myself. In my
new job I still act as advocate, but I do it for
segments of the population: children, the
disabled, the elderly, and I am not able to
do the things myself that I can do for indi-
vidual patients, but I can bring to bear
upon the problems at hand the expertise of
my colleagues in the Public Health Service
and, therefore, this is a rewarding response
to a challenge and not quite as different
from my old life as you might think.”

He anticipated questions about a philoso-
phy of aging and early on in the conversa-
tion made it clear that at least two special
concerns of gerontologists—improvement
in long-term care and alternatives to nurs-
ing homes—were among his own priorities.
Emphasizing a desire to see research in the
areas of senile dementia and incontinence
expanded, he cited the fact that many per-
sons in institutions are there because of
dementia and that if individuals who are
otherwise healthy could be helped so they
could stay at home, we could remove a
heavy burden on our resources.

A year ago he was named Deputy Assis-
tant Secretary of Health and it was made
known that the President intended to nomi-
nate him Surgeon General, a position then
restricted to an appointee under sixty-five.
Enabling legislation thus was needed to per-
mit his appointment. Following are his
comments.

Center for the Study of Aging (CSA):
Dr. Koop, how do you react to the delay in
your appointment caused by your age?

Dr. C. Everett Koop (CEK): “Well, the
delay was caused mainly by my age
because the appointment needed legislation
removing the age restriction. But it was also
caused by my stand on abortion; the press
attacked me for my stand on abortion.”

CSA: At 65 many persons do retire, and
it is probably safe to say that few have an
opportunity to accept the kind of exciting

2

challenge that faces you. How do you feel
about this challenge and the fact that it
comes to you at “retirement” age?

CEK: “It is an exciting challenge and a
wonderful opportunity. I am very pleased
to serve the country and to put some of the
skills that I have developed to work in a
slightly different fashion rather than just
retiring and not being active any longer in

the field of health.”

CSA: As an active surgeon you frequent-
ly had an opportunity to feel the reward of
success. But the problems facing you now
are immense and broad with the prospect
that frustration may frequently be the
reward. How do you react to the possibility
of frustration after a lifetime of success?

CEK: “Well, first of all, let me say that
my former life as a surgeon was not free of
frustration. The second thing that I would
say is that although I did spend my profes-
sional career working one-on-one with chil-
dren, and being of counsel to their families,
there were other broader aspects to it that
really were, in a sense, public health as that
field pertains to children. So, the switch is
not nearly as different as one might pre-
sume at first. Although the frustration level
is high in government, working with slow-
moving bureaucracies, I do have to say that
there are things that one can do where an
immediate result is seen, and therefore,
there are rewards day by day in this job,
just as there were in my old one.”

CSA: Would you define your job as you
understand it.

CEK: “Well, that's very hard to do
because I don't think my job is totally
defined yet by the Secretary [of Health and
Human Services, Richard S. Schweiker].
You see the person who was the last Sur-
geon General was also Assistant Secretary
of Health and it has not been since 1966 that
there has been the separation of these
responsibilities into two jobs: that of Assis-
tant Secretary of Health and that of Sur-
geon General. However, the Surgeon Gen-
eral has traditionally been the spokesman
for health for the country. He stands, in a
sense, at the narrow part of the hourglass
between the public and the government in
reference to health. He talks for the govern-
ment to professional medical and health
societies and he goes back to the govern-
ment with the concerns of those societies.

He is mandated by statute to promote
health of the American people and to pre-
vent disease and to speak out on whatever
occasion he finds it necessary to do so to
see that the mandate is carried out.

“In addition, there are all sorts of things
that the Surgeon General assumes for the
period of his appointment.

“There are also special assignments. One
of these has to do with the disabled and one
of them has to do with the elderly. Insofar
as the disabled are concerned, I am
attempting to draw a road map of the avail-
able services for the disabled so that we can
eliminate overlap and duplication because I
think only in this way can we provide qual-
ity of service with the reduced budgets that
we face in days to come. Insofar as the
elderly are concerned, I have been working
closely with Dr. Robert Butler of the NIA,
have represented the Public Health Service
in part at the White House Conference on
Aging, and look forward to doing whatever
I can to help this country develop a philos-
ophy about aging.”

CSA: What do you identify as the most
important health care issues for the aged,
and overall, what are your priorities as far
as older Americans are concerned?

CEK: “Well, I would love to see this
country develop a philosophy about aging.
Now, what I mean by that might be better
described with an analogy. If you are dis-
cussing abdominal pain as a symptom in
children you can focus in on abdominal
pain and get lost in ‘looking at trees because
you don't see the forest.’ On the other
hand, if you try to develop in a young pedi-
atrician a philosophy about abdominal
pain in children, he sees the symptom of
abdominal pain as one of the heralding
problems in many childhood illnesses and
therefore, gets the whole system in perspec-
tive. So it is with aging. Caring for old peo-
ple just isn’t a very popular thing. In one of
the recent surveys that the AMA did only
six physicians in a thousand acknowledged
a particular interest in gerontology. We
have to start early on, perhaps even in pre-
medical education, but certainly in medical
school, revising the attitude that medical
students, .and therefore, later the whole
profession, have toward older people. They
have to recognize, first of all, that aging is
part of growing older, and that everyone
who is now young will be aged, and the
problems that now look distant will indeed

(continued on page 6)
Surgeon General Koop Draws Attention
To Long-Term Care, Senile Dementia

(continued from page 2)

be that individual's in days to come. Sec-
ondly, we have to teach medical students
and young physicians that some of the most
fascinating problems come in elderly people
as they face the derangement of physiologic
processes that now have gotten out of
whack. You can't take the attitude that
somebody who has been admitted to the
hospital, at age seventy, for the tenth time,
is an old crock.

“As to specifics, I think we have to focus
in on some alternatives to long-term care in
institutions. If we could keep people inde-
pendent, take care of their incontinence, we
could prevent the problems of institutional-
ization, which are so abhorrent to many.
And of course, whenever anyone speaks of
independence, you have to talk about the
support of research, because if we could get
down to the basics of the cause and there-
fore the treatment or prevention of some-
thing such as senile dementia of the
Alzheimer’s type, then we could maintain a
tremendous number of otherwise physi-
cally healthy people in an independent
state.”

CSA: What specific efforts will you be
directing toward long-term care improve-
ment?

CEK: “Well, one of the things that I
would like to look at is an experimental
model directed toward incontinence. Last
year the United States government spent
about $32 billion on long-term care in insti-
tutions. This wasn’t all for the elderly, but
the bulk of it was. I think that approxi-
mately half of that expenditure has been
estimated to be associated in some way
with incontinence and its complications.
One is by biofeedback methods that teach
individuals to stay clean and dry, and the
other is by surgical procedures which either
provide a new type of continence or substi-
tute a different type of arrangement for an
incontinent rectum or an incontinent blad-
der. Certainly if I were incontinent and in
my present state of physical health, I would
be willing to do anything in order to remain
clean and dry and to stay active and inter-
ested in what goes on in society.

“This is certainly one effort that we could
mount that would prove how much better
it would be for the quality of life for the
individuals concerned as well as for their
families, and also there would be economic
benefits. Just think how many people, who
are in institutions only because they are
incontinent, could be much better and more
cheaply cared for in the midst of their fami-

6

lies if incontinence were not a problem.

“So frequently I hear of families who are
caring for an elderly person only to have
them say, ‘I had to put grandma in a nurs-
ing home because she became incontinent.’
Certainly if I became incontinent today and
the choice was having a colostomy and
staying with the family or going into a
nursing home, I would certainly choose the
colostomy. I think so often we build tre-
mendous fears around colostomies because
in days gone by they were seen as a prelude
to terminal illness and so on, but colosto-
mies can be managed in such a way today
that they make life extraordinarily better
than incontinent life with one’s own anat-
omy. The same of course could be said for
techniques in managing urinary inconti-
nence and | have not even mentioned the
newer operations that are available for
direct attacks upon incontinence.”

CSA: A modest estimate is that families
give seventy-five percent of the home
health care received by the aging. It is clear
that this Administration wants to keep
older people independent. You are well-
known for your support of families; what
do you have in mind to encourage families,
to support them in their efforts for the
elderly? Will a policy regarding families
emerge?

CEK: “I think it is inevitable that a policy
about families will emerge and I think it
will come about, as so many things will in
the future, because of economic necessity.
A family can take care of an elderly person
at home, which is better for the elderly per-
son, for about one-third of what it costs to
institutionalize that person. Now obvi-
ously, families need help to do this, and
when I say ‘family’ I don’t necessarily
mean just the family that we know tradi-
tionally, but even an extended family. I
think what it means in the long run is that
we are going to have to provide help for
families at home so that elderly people can
be taken care of at home at a lower cost
than is possible in an institution. I think
that is the wave of the future: we have to be
more flexible and not just focus in on health
care only if it is institutionalized. This may
mean that we have to train helpers the way
we now have mothers’ helpers to assist a
mother overburdened with several chil-
dren, take care of her newborn when it
comes by having someone come in and take
care of the older children.

“Although your question didn’t quite
address this, I would like to raise one of my

great concerns. People who are about the
age of my children [three children in their
thirties] are seeing increasing numbers of
divorce in reference to marriage. That
means that families do not have a long time
to become cohesive units, and it also means
that children of today may end by having
been through not just four grandparents,
but perhaps eight or even more grandpar-
ents. I can’t help but believe that this will
add one further problem down the road as
we look to families to take care of grand-
parents because the loyalties, I think, will
be somewhat attenuated and we will have
to find some way of addressing this issue
and make the larger so-called family with
all these grandparents somewhat more
cohesive so that the older folks do not fall
in the middle between two sets of younger
people who say this is the other group's
responsibility.”

CSA: If Medicaid is to cover home
health care it could mean further stretching
of those funds. There are limits being put
on Medicaid expenditures and even if the
level of funding is kept the same, it is going
to be a shrinking resource because of infla-
tion. How do you reconcile these limits
with the needs?

CEK: “If Congress doesn’t appropriate
the money because of their concerns about
fiscal problems, we have to make do with
what we have and that requires innovation,
new ideas, help from the private sector,
help from nonprofit groups and as several
people at the White House Conference said,
we are so intent on the separation of church
and state that we have neglected one of the
great sources of help, which is the church.
And initially, a century ago, it was the
church that did all the things that we're
talking about. | think that this is a tremen-
dous resource that has to be tapped and
there are already instances where we in the
Department of Health and Human Services
providing, say, health care for migrants,
have relied on the churches and it works
very well in the partnership. Also, I have a
feeling that things in the future are going to
be somewhat the way they were when I first
started in medicine and that is that we did
an awful lot of free care.”

CSA: Many of our readers, whether bio-
medical or social scientists, are engaged in
research projects and would like to know to
what extent you will be supporting research
and training programs. With budget cuts,

(continued on page 8)
Surgeon General Koop
(continued from page 6)

where do you think research efforts should
be directed?

CEK: “Well, I have already mentioned
some of the areas. I certainly would to the
best of my ability support not just the
present, but an expanded expenditure for
research, not only in the clinical investiga-
tion of some of the problems of aging, but
particularly in basic research directed
toward senile dementia.”

CSA: Let us suppose that there were no
shortage of money to spend. What would
you do for older people in such a case?

CEK: “In carrying on from where I left
off, I think the first thing I would do would
be to expand the amount of funds for
research into aging and I would concentrate
more on molecular biology because of the
‘exciting things that are being learned in that
field, and I would try to direct them toward
the study of dementia.

“Secondly, I would do some experimental
models on the control of continence and I
would try to be as original as possible along
those lines.

“And finally, I would try to set up, com-
munity by community, systems of what I
would call responsibility so that elderly
people would not feel that they were
shelved but that they had a purpose in our
society, and I would do my best to find
ways and means experimenting with the

delivery of the expertise of the elderly to
service for other people. It would have an
added dividend: much of it could be done
on a volunteer, but organized basis, and
this would do a lot to relieve expenditures
for other aspects of social service, so we
would win on both ends.”

CSA: One last question, Dr. Koop,
would you comment on your own aging.
How do you feel about this stage of life,
and what encouragement can you pass on
to others?

CEK: “TI have already said that I feel like I
did at forty-five, and it’s very hard for me
to believe that I am in that category of peo-
ple called aged or elderly because I don’t
feel any different about it at all. I think that
there are two-—‘goals’ I guess—that keep
you young. One is to feel contemporary
with younger people, which I do, and I
associate with younger people all the time,
and the other thing is never to give up hav-
ing some goal or some project in life. I have
seen so many of my contemporaries, those
five years older than I, look forward to
retirement and all they think about is fish-
ing and hunting and reading and in about
three months they have the screaming
meemies and they wish they could get back
to doing something. So | think that even if
it is just voluntary work, you have to find
something that gives you a purpose in life
and has a rewarding outcome for you.”