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An AGENDA FOR PUBLIC HEALTH
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

CLO

PRESENTED TO THE AMERICAN PuBLIC HEALTH ASSOCIATION
Boston, MASSACHUSETTS
NovemMBER 14, 1988
1
(GREETINGS TO HOSTS, GUESTS, FRIENDS, ETC.)

I’M TRULY GRATEFUL FOR THE RECOGNITION YOU'VE GIVEN ME
TODAY. THIS IS, AFTER ALL, THE ASSOCIATION WHOSE MEMBERS FORM
THE BASE OF OUR AMERICAN SYSTEM OF MAINTAINING AND IMPROVING THE
HEALTH STATUS OF ALL OUR CITIZENS,

AS SURGEON GENERAL, I’VE ALWAYS BEEN AWARE OF THE PRIMARY
FUNCTION OF MY OFFICE, WHICH IS THAT OF PUBLIC PERSUASION ... IN
OTHER WORDS, CONVINCING PEOPLE THAT THEY SHOULD DO THE THINGS
THEY OUGHT TO DO -- OR OUGHT NOT TO DO -- FOR THEIR OWN GOOD.
2
BUT, EARLY ON, I REALIZED THAT YOU, THE MEMBERS OF THE

A.P.H.A., WERE ON THE FRONT LINE OF PUBLIC HEALTH. I COULD TALK
ABOUT A PARTICULAR HEALTH ISSUE ... I COULD GET OTHERS TO TALK
ABOUT IT ... AND I COULD PLANT IT IN THE CONSCIOUSNESS OF THE
NATION.

BUT IF YOU WERE INVOLVED IN SOME PUBLIC HEALTH ACTIVITY,
THEN IT WOULD GET DONE AND PEOPLE WOULD BENEFIT.

I THINK WE'VE BOTH COME A LONG WAY IN UNDERSTANDING EACH
OTHER OVER THE COURSE OF THE PAST 7 YEARS. AND JUST IN THE NICK
OF TIME, TOO, IF I MAY SAY SO, BECAUSE, BY THIS TIME NEXT YEAR, |
WILL BE A CIVILIAN AGAIN, BACK IN MUFTI, AND THIS EXTRAORDINARY
EXPERIENCE WILL BE BEHIND ME.
3
SO THIS IS MY LAST A.P.H.A. MEETING AS YOUR SURGEON GENERAL.

AND I INTEND TO TAKE FULL ADVANTAGE OF THAT FACT. 1 WANT TO
TALK WITH YOU ABOUT SOME OF THE THINGS THAT ARE -- OR OUGHT TO
BE -- ON THE PUBLIC HEALTH AGENDA,

AND THAT WOULD INCLUDE SOME THINGS THAT EACH OF YOU MIGHT
THINK ABOUT, WHATEVER YOUR PROFESSIONAL POSITION, AND A FEW
THINGS THAT THE A.P.H.A. ITSELF MIGHT THINK ABOUT.

BILL McBEATH SAID 1 COULD ONLY HAVE A HALF-HOUR. THAT SORT
OF CRAMPS THINGS A BIT, BUT 1’VE MADE SOME DRASTIC CUTS IN MY
LIST SO THAT WE CAN GET OUT IN TIME TO SEE THE 11 O'CLOCK NEWS.
4
LET ME BEGIN WITH SOMETHING FAMILIAR: HEALTH PROMOTION AND

DISEASE PREVENTION.

I SUPPOSE BRINGING THIS UP IS LIKE CARRYING COALS TO
NEWCASTLE, IF ANYONE REMEMBERS WHAT THAT MEANS. AFTER ALL, THE
A.P.H.A. DID HELP THEN-SURGEON GENERAL RICHMOND AND THE U.S,
PUBLIC HEALTH SERVICE PRODUCE THE LAND-MARK “SURGEON GENERAL’S
REPORT” TITLED HEALTHY PEOPLE.

THAT WAS IN 1979,
5
SINCE THEN WE‘VE PUBLISHED THE 1990 OBJECTIVES AND WE ARE

NOW IN THE PROCESS OF FORMULATING THE OBJECTIVES FOR THE YEAR
2000. I’M DELIGHTED WITH THE WAY THE NATION HAS TAKEN UP MANY OF
THESE OBJECTIVES AND I HOPE THE PROCESS CONTINUES,

BUT THERE ARE TWO ASPECTS OF THE PROCESS THAT NEED
ATTENTION. THE FIRST RELATES TO DATA.

IF YOU’VE BEEN FOLLOWING THE PROCESS AT ALL, YOU KNOW THAT
SOME OBJECTIVES CANNOT BE MET BECAUSE WE STILL HAVE NO BASELINE
DATA TO GIVE US A HANDLE ON THOSE PARTICULAR HEALTH ISSUES.
6
IN SOME INSTANCES, THE PROBLEM IS ONE FOR OUR SCIENTISTS,

THEY HAVE TO COME UP WITH A NEW METHODOLOGY FOR SECURING THE
MISSING DATA.

THIS HAS BEEN THE CASE WITH MEASURING AVERAGE DAILY SODIUM
INGESTION, FOR EXAMPLE, OR FOR DETERMINING THE PREVALENCE OF
FETAL ALCOHOL SYNDROME. AND OUR PHYSICAL SCIENTISTS AND
EPIDEMIOLOGISTS ARE COMING UP WITH GOOD, NEW STUDIES IN THESE AND
OTHER AREAS. BUT PROGRESS IS SLOW AND THAT HAS TO BE A CONCERN.
7
ANOTHER AREA WHERE THE LACK OF DATA IS ESPECIALLY ACUTE IS

THE AREA OF PUBLIC AWARENESS. WITHOUT A GOOD SENSE OF WHAT THE
PUBLIC KNOWS AND DOESN'T KNOW, WE CANNOT INTELLIGENTLY EVALUATE
OUR PUBLIC EDUCATION EFFORTS.

THEY ARE COSTLY. YET, THEY MAY -- OR MAY NOT -- BE
EFFECTIVE. WE SIMPLY DON’T KNOW.

IN ANY CASE, THERE IS A GAP BETWEEN OUR GOALS, AS WE EXPRESS
THEM IN RHETORIC, AND OUR GOALS, AS WE EXPRESS THEM IN HARD DATA.
RIGHT NOW, I’M AFRAID WE MAY BE RELYING TOO MUCH ON RHETORIC.
AND THAT’S JUST NOT GOOD ENOUGH.
8
BASE
OUR LACK OF A STRONG DATA ACROSS THE BOARD IS NOT A NEW

PROBLEM AND I CERTAINLY DON’T PRETEND THAT I DISCOVERED IT. BUT
I RAISE IT NOW, BECAUSE I BELIEVE IT WILL BE SOLVED WHEN ALL THE
DISCIPLINES WITH A STAKE IN PUBLIC HEALTH AGREE TO FOCUS ON THE
ISSUE -- TOGETHER -- AND BRING THEIR COMBINED INTEREST AND
STRENGTH TO THE DEVELOPMENT OF BETTER INFORMATION RELATIVE TO
HEALTH PROMOTION AND DISEASE PREVENTION.

WE’RE STILL ESSENTIALLY USING THE DISEASE MONITORING MODEL,
WHICH HAS BEEN SO SUCCESSFUL FOR US THROUGHOUT THE PAST CENTURY’S
WAR ON INFECTIOUS DISEASE,
9
IT IS ALSO THE MODEL WITH WHICH MOST OF US RECEIVED OUR

PROFESSIONAL TRAINING. IT’S FAMILIAR AND IT STILL SEEMS TO WORK
FOR MUCH OF THE NON-PREVENTION ACTIVITY IN PUBLIC HEALTH,

HOWEVER, I DON’T BELIEVE IT’S AN ADEQUATE MODEL FOR THE
DEVELOPMENT OF DATA APPROPRIATE TO PREVENTION AND HEALTH
PROMOTION,

WE NEED INNOVATION IN THIS AREA OF DATA DEVELOPMENT, AND I
WOULD ASSUME THAT THE MEMBERS OF THIS ORGANIZATION WOULD BE THE
PRIMARY INNOVATORS.
10
IT AM REMINDED OF THE WORK DONE ABOUT 10 YEARS AGO BY MRS,

DOROTHY RICE, WHEN SHE WAS THE DIRECTOR OF THE NATIONAL CENTER
FOR HEALTH STATISTICS. YOU MAY RECALL HER EFFORTS TO MEASURE THE
“BURDEN OF ILLNESS.” IT WAS A VERY IMPORTANT STEP FORWARD IN THE
WHOLE AREA OF MORBIDITY MEASUREMENT.

BUT WE HAVEN'T TRAVELED MUCH FARTHER ALONG THE PATH FIRST
SKETCHED OUT BY MRS. RICE AND HER N.C.H,.S. COLLEAGUE, DR. JACK
FELDMAN,
11
MY CONCERN IS THAT THIS KIND OF “CULTURE LAG” IN DATA

DEVELOPMENT AND COLLECTION STILL PERSISTS AND IT IS SERIOUSLY
RESTRICTING OUR OVERALL EFFORT TO STRENGTHEN HEALTH PROMOTION AND
DISEASE PREVENTION ACTIVITIES THROUGHOUT PUBLIC HEALTH,

BUT LET ME LEAVE THIS PARTICULAR “AGENDA ITEM” WITH A FINAL
COMMENT .

] BELIEVE THE EMPHASIS THAT BEGAN IN 1979 -- THE NEW AND
STRONG EMPHASIS ON PREVENTION AND ON HEALTH PROMOTION -~ WAS
ABSOLUTELY RIGHT. AND, DESPITE SOME HANDICAPS IN DATA AND IN OUR
LEVEL OF SCIENTIFIC KNOWLEDGE IN THESE AREAS, WE’VE MADE
TREMENDOUS PROGRESS ON BOTH FRONTS.
12
T CONGRATULATE THE PUBLIC HEALTH PROFESSION FOR ACHIEVING SO

MUCH IN JUST A DECADE OF EFFORT.

NOW, LET ME MOVE ON TO AGENDA ITEM NUMBER TWO.

AS YOU KNOW, ONE OF THE FEW THINGS A SURGEON GENERAL
ACTUALLY OPERATES IS THE LITTLE P.H.S. OFFICE OF INTERNATIONAL
HEALTH. FORTUNATELY FOR THE COUNTRY AND FOR THE WORLD, EACH
AGENCY OF THE U.S. PUBLIC HEALTH SERVICE HAS ITS OWN
INTERNATIONAL PROGRAM AND SO WE’RE ABLE TO MAKE SOME PROGRESS IN
BILATERAL AND MULTILATERAL ARRANGEMENTS AROUND THE WORLD.
13
I THINK SOME OF THE THINGS THAT C.D.C. HAS ACCOMPLISHED ...

SOME OF THE RESEARCH FUNDED BY N.I.H. ... THE COOPERATIVE WORK OF
THE F.D.A. «+. AND SO ON ... THOSE P.H.S. EFFORTS HAVE BEEN VERY

IMPORTANT NOT ONLY FOR THE INDIVIDUALS AND THE NATIONS INVOLVED,

BUT FOR THE CAUSE OF PEACE AS WELL.

T REALLY BELTEVE THAT. AND I’VE TALKED WITH MANY, MANY OF
THE TOP HEALTH LEADERS OF THE WORLD, DURING MY VISITS TO GENEVA
FOR THE ANNUAL WORLD HEALTH ASSEMBLY AND IN THE COURSE OF MANY
OTHER TRIPS TO EUROPE, ASIA, AND THE MIDDLE EAST. AND THEY ALL
SAY THE SAME THING: “P.H.S., WE LOVE YOU.”
14
NEVERTHELESS, OUR INTERNATIONAL HEALTH EFFORT IS ALMOST AN

AFTERTHOUGHT, AS FAR AS OVERALL PUBLIC HEALTH POLICY IS
CONCERNED. AND AT SOME OF THE HIGHER LEVELS OF OUR DEPARTMENT,
IT HAS BEEN SEEN AS LITTLE MORE THAN AN EXCUSE TO GET OUT OF THE
OFFICE AND OUT OF THE COUNTRY FOR A WEEK OR TWO.

AND I’M TOLD THIS HAS BEEN TRUE FOR MANY, MANY
ADMINISTRATIONS,

I THINK THIS OFF-HAND, LOW-PRIORITY APPROACH TO
INTERNATIONAL HEALTH IS A GRAVE WEAKNESS OF AMERICAN PUBLIC
HEALTH POLICY.
15
THE ONE AREA WHERE WE’VE DONE EXTREMELY WELL IS IN

REFERENCE TO AIDS. WE'’VE SHARED OUR RESEARCH WITH OTHERS AND
WE‘VE RECEIVED MUCH COOPERATION AND COLLABORATION IN RETURN.

IT'S VERY REMINISCENT OF THE CAMPAIGN TO ERADICATE SMALLPOX,
AND I CERTAINLY HOPE AND PRAY THAT WE'RE AS SUCCESSFUL IN THE
GLOBAL FIGHT AGAINST AIDS AS WE WERE IN THE FIGHT AGAINST
SMALLPOX,

BUT WE CAN’T HOP FROM ONE MAJOR INFECTIOUS DISEASE TO
ANOTHER AND SAY THAT WE HAVE A “POLICY” FOR THE LONG TERM THAT IS
APPROPRIATE TO THE NEEDS OF OUR GOVERNMENT, OF OUR CITIZENS, AND
OF OUR FELLOW VOYAGERS ON THIS PLANET. IT JUST ISN’T.
16
AND IF WE REALLY BELIEVE THAT PREVENTION AND HEALTH

PROMOTION ARE THE “WAVE OF THE FUTURE,” WHY DON’T WE DO MORE 10
EXPORT THOSE CONCEPTS TO OUR PUBLIC HEALTH COLLEAGUES AROUND THE
WORLD?

AND IF IT’S EXCITEMENT YOU’RE LOOKING FOR, I CAN TELL YOU
THAT GOING OVERSEAS WITH A STRONG ANTI-TOBACCO AND ANTI-ALCOHOL
MESSAGE WILL PROVIDE YOU WITH MANY THRILLING ENCOUNTERS.

BUT MY POINT IS THAT OUR COUNTRY HAS A GREAT DEAL TO OFFER
OTHER COUNTRIES IN RESPECT TO PUBLIC HEALTH -- AND WE HAVE A
GREAT DEAL TO LEARN FROM THEM AS WELL.
17
BUT WE‘LL NEVER HAVE THAT AS A COHERENT ELEMENT OF OUR OWN

NATIONAL PUBLIC HEALTH POLICY, UNLESS PUBLIC HEALTH PROFESSION-
ALS, SUCH AS YOU, GET BEHIND THE IDEA AND DEMAND THAT IT HAPPEN,

I MUST TELL YOU -- MORE IN SORROW THAN IN ANGER -~- THAT I’VE
BEEN LOBBIED QUITE HARD BY MANY DIFFERENT AND CONTENDING HEALTH
INTERESTS OVER THE PAST 7 YEARS. BUT RARELY HAVE I BEEN LOBBIED
BY PUBLIC HEALTH PEOPLE ON AN INTERNATIONAL MATTER.

THAT DOESN‘T MEAN I WOULD NECESSARILY HAVE CHANGED MY MIND
ON THIS OR THAT INTERNATIONAL HEALTH ISSUE. YOU KNOW ME BETTER
THAN THAT.

 
18
BUT THE NEXT SURGEON GENERAL MAY BE MORE RECEPTIVE. IN ANY

CASE, I STRONGLY URGE ALL PUBLIC HEALTH PROFESSIONALS TO GIVE
MORE ATTENTION TO ISSUES OF INTERNATIONAL HEALTH AND TO MAKE
YOUR VIEWS KNOWN TO YOUR GOVERNMENT.

THIS IS A CASE WHERE THE SURGEON GENERAL CAN HAVE A LOT OF
GOOD IDEAS, BUT PRESSURE FROM THE OUTSIDE IS WHAT WILL MAKE A
DIFFERENCE. AND I HOPE YOU WILL THINK ABOUT THIS AND THAT YOULL
SUPPORT A STRONGER, MORE VISIBLE APPROACH TO INTERNATIONAL
HEALTH BY OUR GOVERNMENT.
19
A THIRD AGENDA ITEM RELATES TO SEVERAL ISSUES I’VE DEALT

WITH OVER THE PAST 7 YEARS. IT HAS TO DO WITH MONEY AND IT HAS
TO WITH THE GENERAL SHIFT IN THE DEMOGRAPHY OF OUR COUNTRY.

LET’S BEGIN BY LOOKING AT THAT POPULATION GROUP THAT WE
CALL “CHILDREN.” IT INCLUDES NOT ONLY NEONATES BUT ALSO
ADOLESCENTS THROUGH TO AGE 18.

FOR 200 HUNDRED YEARS THIS AGE GROUP HAS DOMINATED AMERICAN
LIFE AND THINKING AND CERTAINLY AMERICAN HEALTH AND WELFARE
PLANNING.
20
BUT THAT‘S CHANGING. FIVE YEARS AGO, FOR EXAMPLE, 28

PERCENT OF THE AMERICAN POPULATION WERE CHILDREN UNDER THE AGE OF
18, WHILE A SMALLER PROPORTION -- 21 PERCENT -- WERE ADULTS OVER
THE AGE OF 55,

BUT, BY THE YEAR 2000 -- ONLY 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:

* 24 PERCENT OF ALL AMERICANS WILL BE UNDER THE AGE OF
18, BUT...

* A HIGHER PROPORTION -- 26 PERCENT -- WILL BE OVER THE
AGE OF 55,
21
OUR AMERICAN DEMOGRAPHICS ARE IN TRANSITION. AND FOLLOWING

RIGHT BEHIND IS THE PARALLEL TRANSITION IN HEALTH PLANNING AND
RESOURCE ALLOCATION.

THROUGHOUT THE YEARS, THE PUBLIC HEALTH PROFESSION HAS
CAMPAIGNED HARD FOR ESSENTIAL MATERNAL AND CHILD HEALTH PROGRAMS.
AND THE DEMOGRAPHIC STATISTICS HAVE ALWAYS SUPPORTED OUR CASE:
CHILDREN AND YOUTH COMPRISED THE DOMINANT POPULATION GROUP.

BUT OUR STRATEGY FOR TOMORROW HAS TO BE DIFFERENT. WE’LL
HAVE TO WORK HARD TO MAINTAIN -- MAYBE NOT EVEN BE ABLE 10
INCREASE -- PUBLIC SUPPORT FOR CHILD HEALTH PROGRAMS IN THE 1990s
AND BEYOND.
22
BUT WE MUST NOT 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.

BUT THERE’S ANOTHER TWIST TO THIS DEMOGRAPHIC REALITY.

THE LARGEST SINGLE GROUP OF POOR PEOPLE IN THE UNITED

STATES IS MADE UP OF CHILDREN .., 12 MILLION OF THEM ... OR ABOUT
1 OF EVERY 4 AMERICANS UNDER THE AGE OF 18.
23
THIS IS SOMEWHAT MISLEADING, SINCE ALL CHILDREN LACK

TANGIBLE ECONOMIC ASSETS OF THEIR OWN AND, THEREFORE, THEY ARE
ALL “POOR.” HENCE, WHAT WE REALLY MEAN IS THAT THE SINGLE
LARGEST POPULATION OF POOR PEOPLE IN THE UNITED STATES IS MADE UP
OF CHILDREN OF POOR FAMILIES.

TAKEN TOGETHER, I THINK THESE ARE TWO VERY POWERFUL ~~ AND
POTENTIALLY NEGATIVE -- INFLUENCES ON THE FUTURE OF CHILD HEALTH
SUPPORT IN THIS COUNTRY:
24
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
WILL BE AT THE LOW END OF THE SOCIO-ECONOMIC SCALE.

1 THINK THIS ADDS UP TO A MAJOR CHALLENGE FOR PUBLIC HEALTH
LEADERSHIP IN OUR SOCIETY. IN AN ERA OF TIGHTENING RESOURCES, WE
MUST BE AWARE OF CERTAIN DEMOGRAPHIC REALITIES -- BUT NOT BE
DIVIDED BY THEM,
25
WE NEED, THEREFORE, TO EVALUATE ALL OUR PRIORITIES AND MAKE

SURE THAT THE PARTICULAR POPULATION GROUP YOU IDENTIFY WITH IN
YOUR OWN PROFESSIONAL LIFE DOES GET ITS FAIR SHARE OF AVAILABLE
RESOURCES ... BUT NOT AT THE EXPENSE OF ANY OTHER GROUP.

MY LAST AGENDA ITEMS -- TWO OF THEM -- HAVE TO DO WITH THE
FUTURE ROLE OF THE PUBLIC HEALTH PROFESSION ... EVEN OF THIS
ASSOCIATION ITSELF.

THESE ITEMS WERE STIMULATED BY THE RECENT REPORT OF THE
INSTITUTE OF MEDICINE ENTITLED THE FUTURE OF PUBLIC HEALTH.
26
LET ME SAY AT THE OUTSET THAT I BELIEVE MANY PARTS OF THE

REPORT WERE UNFAIRLY NEGATIVE TOWARD PUBLIC HEALTH PERSONNEL.

AND FRANKLY I'M DISAPPOINTED THAT THERE WERE PUBLIC HEALTH PEOPLE
WHO WERE ON THE I.,0.M, COMMITTEE WHO APPARENTLY SUPPORTED THE
FULL REPORT AND THE STATEMENTS IN IT.

1 DO NOT. HOWEVER, I WILL USE ITS APPEARANCE AS A POINT OF
DEPARTURE TO RAISE MY LAST TWO AGENDA ITEMS.

FIRST, I DO BELIEVE THAT THE PUBLIC HEALTH LANDSCAPE HAS
CHANGED SIGNIFICANTLY OVER THE PAST 8 YEARS AND THAT THE CHANGE
TS PERMANENT.
2/
IN OTHER WORDS, PRESIDENT REAGAN WAS ABLE TO COMPLETE THE

SHIFT TO A “NEW FEDERALISM,” AN ARRANGEMENT IN WHICH THE “CENTER
OF GRAVITY” OF HEALTH POLICY AND PLANNING SHIFTED AWAY FROM
WASHINGTON AND TOWARD THE STATES AND LOCALITIES.

I SAY THAT PRESIDENT REAGAN “COMPLETED” THIS SHIFT BECAUSE,
AS YOU KNOW EVEN BETTER THAN I, THE SHIFT BEGAN UNDER PRESIDENT
NIXON AND CONTINUED UNDER PRESIDENT CARTER.

THE 1.0.M, REPORT CITES THE “DISARRAY” IN PUBLIC HEALTH, BUT
I SUSPECT THAT MUCH OF THIS SO-CALLED "DISARRAY" IS MORE APPARENT
THAN REAL AND IS NOT SO MUCH “DISARRAY” AS IT IS THE NATURAL --
ALBEIT MESSY -- PROCESS OF READJUSTMENT AND REALIGNMENT ON A
NATIONAL SCALE.
28
1‘D SAY THAT THE I1.0.M. COMMITTEE WAS HAMPERED IN ITS WORK

BY THE LIMITED INFORMATION AVAILABLE CONCERNING NOT ONLY THE
EXTENT TO WHICH THE STATE-BY-STATE REALIGNMENTS HAVE OCCURRED,
BUT ALSO THE EXTENT TO WHICH THOSE REALIGNED PROGRAMS ARE WORKING
AT THE STATE AND LOCAL LEVEL.

 

1 DON’T THINK ANYONE REALLY KNOWS ALL THE FACTS YET,
RELATIVE TO THE “NEW FEDERALISM” IN PUBLIC HEALTH. AND NO ONE
SEEMS TO BE SPENDING VERY MUCH TIME TO FIND OUT, EITHER.

BUT THERE IS A RESERVOIR OF SUCH INFORMATION AND IT IS RIGHT
HERE IN THE A.P.H.A. HERE ALSO ARE THE PEOPLE -- THE BROAD RANGE
OF PUBLIC HEALTH PROFESSIONALS -- WHO HAVE THE STRONGEST
MOTIVATION TO GET THE TRUE STORY OUT TO THE AMERICAN PEOPLE,
29
AND I BELIEVE YOU SHOULD TAKE UP THE CHALLENGE LAID DOWN BY

THE 1.0.M. COMMITTEE.

I DO NOT BELIEVE THAT THE CURRENT PUBLIC HEALTH SYSTEM IS “A
SHATTERED VISION.” WE‘RE ACHIEVING AMAZING THINGS FOR THE
AMERICAN PEOPLE IN TERMS OF HYPERTENSION SCREENING, PRENATAL
CARE, SAFE DRINKING WATER, EMERGENCY MEDICAL SERVICES, DENTAL
HEALTH, HIGHWAY SAFETY, SERVICES TO HANDICAPPED CHILDREN, AND
MUCH MORE.

THAT'S HARDLY THE RECORD OF A SYSTEM THAT‘S “A SHATTERED
VISION” ... A SYSTEM THAT’S IN “DISARRAY” ... OR ONE THAT IS
STYMIED BY SO-CALLED “BARRIERS TO EFFECTIVE ACTION,”
4MINK 30
T JUST DON'T THAT'S SO. AND I DON’T THINK YOU DO, EITHER.

BUT I DO THINK WE OUGHT TO PAUSE AND ASK WHY SUCH A REPORT
COULD HAVE BEEN WRITTEN? I BELIEVE THE ANSWER LIES IN THE FACT
NOBODY HAS DONE THE TOUGH HOMEWORK TO GET AT THE TRUTH OF THE
SITUATION,

AND WHAT PEOPLE ARE BETTER EQUIPPED THAN THE MEMBERS OF
THIS ASSOCIATION?
31
I BELIEVE IT IS IN YOUR OWN BEST INTEREST -- AS WELL AS THE

COUNTRY’S -- TO GAIN AN ACCURATE, IN-DEPTH ASSESSMENT OF WHERE WE
ARE AND HOW WE‘RE DOING IN PUBLIC HEALTH ... NOW THAT THE
TRANSITION IS VIRTUALLY COMPLETE OF PUBLIC HEALTH AS AN

ERSTWHILE WASHINGTON-CENTERED ACTIVITY TO A NOW-AND-FUTURE STATE-
CENTERED ACTIVITY,

AND NOW FOR MY FINAL AGENDA ITEM, AND, AGAIN, IT PERTAINS
TO YOU AS PROFESSIONALS AND TO THE ROLE OF THE A.P.H.A. ITSELF.
32
FIRST, LET ME SAY THAT ONE OF OUR PROBLEMS IN HEALTH CARE IS

THAT THAT VERY PHRASE -- “HEALTH CARE” -- HAS BECOME VIRTUALLY
SYNONYMOUS WITH THE PHRASE “MEDICAL CARE.” IN FACT, WHEN THE
PUBLIC RAISES QUESTIONS ABOUT THE “HIGH COST OF HEALTH CARE,”
THEY REALLY MEAN THE “HIGH COST OF MEDICAL CARE.”

AND, TO A CERTAIN EXTENT, THE AUTHORS OF THE I.0.M. REPORT
HAVE MEASURED THE “HEALTH CARE DELIVERY SYSTEM” AGAINST A
STANDARD THAT IS MORE PROPERLY THAT OF THE NARROWER, MORE
SPECIFIC, AND MORE EASILY MEASURABLE “MEDICAL CARE DELIVERY
SYSTEM.”
33
WHY IS THERE THIS CONFUSION, WHEN YOU AND I KNOW THERE IS A

DIFFERENCE BETWEEN “HEALTH CARE” AND “MEDICAL CARE”?

WELL, YOU AND I MAY KNOW ... BUT THE REST OF THE COUNTRY
DOES NOT KNOW, AND YOU CAN’T BLAME THEM FOR NOT KNOWING, BECAUSE
THE FAULT IS REALLY OURS.

WE’VE ALLOWED THIS CONFUSION TO TAKE PLACE BECAUSE WE
OURSELVES HAVE NOT TRULY FOCUSED ON PUBLIC HEALTH PRACTICE IN A
SYSTEMATIC WAY. FOR EXAMPLE ...
34
* WE'VE NOT TRIED TO IDENTIFY THE BOUNDARIES OF THE

HEALTH CARE DELIVERY SYSTEM. QUITE THE CONTRARY, WE’VE
ALLOWED OTHERS -- AND OURSELVES -- TO ERASE THE FEW
BOUNDARIES THAT MAY HAVE EXISTED.

* SIMILARLY, WE‘VE NOT INSISTED ON DISCRETE AND
CONSISTENT DEFINITIONS FOR THE PRACTITIONERS WITHIN THAT
DELIVERY SYSTEM. ON THE ONE HAND, THAT APPROACH HAS
PROVIDED US WITH GREAT GROWTH AND FLEXIBILITY; ON THE OTHER
HAND, SUCH AN APPROACH MAKES IT DIFFICULT TO DEFEND OUR
FIELD AGAINST THE KIND OF CRITICISM FOUND IN THE I.0.M.
REPORT,
35
* AND RELATED TO THIS IS THE FACT THAT, UNLIKE THE

"MEDICAL CARE SYSTEM,” WE DO NOT HAVE AN ACCREDITATION
PROGRAM FOR GRADUATES OF “PUBLIC HEALTH" EDUCATIONAL
INSTITUTIONS WHICH WOULD ASSURE THE AMERICAN PEOPLE THAT
THEY HAVE INDEED ATTAINED A CERTAIN MINIMUM LEVEL OF SKILLS
AND KNOWLEDGE AND HANDS-ON EXPERIENCE.

* AND FINALLY, WE DO NOT HAVE A PROGRAM OF CREDENTIALING
WITH MANY SUPERVISED PRACTICE SITES IN WHICH FUTURE PUBLIC
HEALTH PRACTITIONERS MAY BE OBSERVED AND EVALUATED BEFORE
THEY ARE PERMITTED, AS LICENSED PROFESSIONALS, TO DELIVER
HEALTH CARE TO THE PUBLIC.

 
36
IN OUR OWN PUBLIC HEALTH SERVICE, FOR EXAMPLE, WE HAVE

PHYSICIANS, NURSES, PHARMACISTS, SANITARY ENGINEERS, AND SO
ON -- 11 DISCIPLINES IN ALL -- WHICH REQUIRE SOME TYPE OF
STATE LICENSING OR CREDENTIALING. BUT THERE IS NO SUCH
REQUIREMENT FOR THE PRACTITIONER OF THE KEY DISCIPLINE OF
PUBLIC HEALTH: THAT IS, THE MASTER OF PUBLIC HEALTH.

I] THINK IT MIGHT BE TIME TO LOOK SQUARELY AT THAT ISSUE.

YOU MAY RECALL THAT, IN 1910, ABRAHAM FLEXNER PRODUCED A
REPORT ON THE STATUS OF MEDICAL PRACTICE. ITS CLEAR AND HARD-
HITTING CONCLUSIONS WERE RESPONSIBLE FOR THE RE-SHAPING OF
MEDICINE, RAISING IT FROM A HAPHAZARD VOCATION TO AN ORGANIZED
AND TRUSTED PROFESSION,
37
I DON’T SEE THE 1.0.M, REPORT AS BEING IN THE SAME CATEGORY

AS THE “FLEXNER REPORT.” BUT I DO SEE ITS POTENTIAL FOR GETTING
US STARTED ALONG THE PATH OF REEXAMINIATION OF THE PUBLIC HEALTH
SYSTEM, WITH THIS OBJECTIVE:

TO RECOGNIZE THAT THERE IS SOMETHING THAT CAN BE CALLED
“PUBLIC HEALTH PRACTICE” AND THAT IT CAN BE AS CREDIBLE, AS
ORGANIZED, AND AS TRUSTED AN ACTIVITY AS “MEDICAL PRACTICE”
IS TODAY.
38
IF WE CAN FOCUS ON THIS TASK, THEN I BELIEVE WE‘LL BE ABLE

TO SAY TO THE AMERICAN PEOPLE THAT ALL THE INDIVIDUALS WHO
DELIVER PUBLIC HEALTH SERVICES HAVE HAD THE FORMAL TRAINING AND
THE SUPERVISED EXPERIENCES -- AND HAVE THEREFORE EARNED THE
APPROPRIATE CREDENTIALS -- TO MAKE THEM ELIGIBLE TO PERFORM THEIR
IMPORTANT TASKS,

I THINK THIS IS A HIGH-PRIORITY ISSUE FOR THE SCHOOLS OF
PUBLIC HEALTH ... FOR THE PEOPLE IN THE PROFESSION ... AND FOR
THIS ASSOCIATION ITSELF.
39
AGAIN, I DON’T RAISE THIS QUESTION AS A WAY OF RESPONDING TO
THE 1.0.M. REPORT. IT’S NOT AN ADEQUATE RESPONSE BY ITSELF.

HOWEVER, SOME OF THE CRITICISMS IN THE REPORT MAY NOT HAVE
BEEN WRITTEN -- OR MAY HAVE SUBSTANTIALLY MUTED ~-- IF THERE WERE
LESS CONFUSION ABOUT SUCH TERMS AS “PUBLIC HEALTH PRACTICE” AND
"HEALTH CARE DELIVERY.”

AND NOW, I KNOW I‘VE TAKEN UP A GREAT DEAL OF YOUR TIME, SO
I'LL CLOSE MY REMARKS WITH THIS OBSERVATION ... AND IT’S A
PERSONAL ONE.
40
WHEN I ARRIVED IN WASHINGTON SOME 7 YEARS AGO, THE

ATMOSPHERE WAS HIGHLY CHARGED AND BITTER. 1 WAS TOLD I WAS TOO
OLD ... TODNARROW-MINDED ... TOO INEXPERIENCED TO BE SURGEON
GENERAL.

AND FOR A WHILE I WAS SWEPT INTO THIS ACRIMONIOUS DEBATE.

DURING THAT PERIOD 1 DID NOT HAVE MUCH OF A CHANCE TO GET TO

KNOW AND MEET THE PEOPLE WHO CONDUCT THE PUBLIC HEALTH AFFAIRS OF
OUR COUNTRY ... FEDERAL, STATE, LOCAL, AND PRIVATE PHILANTHROPIC.
41
FORTUNATELY THAT BITTER PERIOD CAME TO AN END AND 1 WAS ABLE

TO GET ON WITH MY JOB AND ABLE TO GET TO KNOW PEOPLE AND RESPECT
THE COMMUNITY OF PUBLIC HEALTH PROFESSIONALS.

AND IT HAS BEEN A VERY REWARDING EXPERIENCE EVER SINCE.
I'VE COME TO KNOW YOUR COUNTERPARTS IN OTHER COUNTRIES AND OTHER
CULTURES ... AND YOU ALL BURN WITH THAT SAME BRIGHT FLAME OF
DEDICATION TO THE CAUSE OF HELPING EVERY HUMAN BEING LIVE A

HEALTHIER, SAFER, AND LONGER LIFE.
42
FOR A FEW YEARS, IT’S BEEN MY PRIVILEGE TO HAVE BEEN WARMED

BY THAT FLAME ... TO HAVE SHARED IN YOUR PROFESSIONAL LIVES ...
TO HAVE ADOPTED YOUR GOALS FOR THE HEALTH OF OUR PEOPLE ... AND
TO HAVE SEEN THE WORLD THROUGH THE SAME LENS OF HOPE THAT IS YOUR
LENS,

I’M TRYING TO PUT DOWN ON PAPER SOME OF THE THINGS I‘VE
LEARNED ALONG THE WAY, AND I HOPE TO GET DOWN SOME OF THE GOOD
THINGS I‘VE LEARNED ABOUT THE PUBLIC HEALTH PROFESSION AND ABOUT
THE PEOPLE WHO SERVE IN IT.
43
BUT I’M A DOCTOR, NOT A WRITER, AND I MAY NOT GET IT ALL

DOWN JUST RIGHT, SO, JUST TO MAKE SURE YOU UNDERSTAND, LET ME
SAY “THANK YOU" TO THE AMERICAN PUBLIC HEALTH COMMUNITY FOR
BEING THERE ... YESTERDAY, TODAY, AND TOMORROW,

THANK YOU.
HHH H #