ORIGINAL
7 [jpnisad

ADDRESS
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

ne

PRESENTED AT THE ANNUAL MEETING OF THE
U.S, PuBLic HEALTH SERVICE PROFESSIONAL ASSOCIATION
New ORLEANS, LOUISIANA
MarcH 28, 1989
1
(GREETINGS TO HOSTS, GUESTS, FRIENDS, ETC.)

YES, I AM THE SURGEON GENERAL, THE HIGHEST RANKING OFFICER
IN THE U.S. PUBLIC HEALTH SERVICE. BUT I COUNT IT A GREAT HONOR
FOR ME TO BE HERE WITH YOU AT THE ANNUAL MEETING OF OUR OWN
PROFESSIONAL ASSOCIATION,

THIS WILL BE MY EIGHTH AND LAST OPPORTUNITY TO SHARE AN
ANNUAL MEETING WITH YOU IN THE UNIFORM OF THE PUBLIC HEALTH
SERVICE. AND I AM A LITTLE SADDENED BY THAT FACT BECAUSE --
DESPITE THE TIGHT SCHEDULES AND THE CONFUSION AND THE HECTIC PACE
-- THESE ANNUAL GET-TOGETHERS HAVE BEEN VERY ENJOYABLE AND VERY
INSTRUCTIVE.
2
BACK IN 1981, I NEEDED THE INSTRUCTION BECAUSE I MUST ADMIT

THAT IT WAS LIKE MOST AMERICANS ... IGNORANT OF THE WORK AND THE
WORTH OF THE U.S. PUBLIC HEALTH SERVICE,

BUT ~- TO PARAPHRASE MR. ELBERT HUBBARD -- “EVERY DAY IN
EVERY WAY, I GOT TO KNOW YOU BETTER AND BETTER.” AND THE FIRST
MEETING I ATTENDED -- IN 1981, EVEN BEFORE I WAS CONFIRMED BY THE
SENATE -- HELPED BRING INTO FOCUS THE WHOLE PICTURE OF WHO YOU
ARE AND WHAT YOU DO.

AND FROM THEN ON I BECAME A “BELTEVER.” I CAME TO BELIEVE
IN THE MEN AND WOMEN OF THE P.H.S. AND THE IMPORTANT THINGS YOU
NO FOR THE PEOPLE OF AMERICA.
3
YOU ARE EXPERIENCED PROFESSIONALS WHO KNOW THE SCIENCE AND

TECHNOLOGY OF WHAT YOU DO... WHO UNDERSTAND THE POLITICS AND THE
MANAGEMENT AND THE ECONOMICS OF WHAT YOU DO... YET, YOU’RE ABLE
TO FEEL -- AND TO SHOW -- COMPASSION FOR THE PEOPLE YOU SERVE.

 

 

JUST A FEW WEEKS AGO, ON THE 4TH OF JANUARY, WE CELEBRATED
THE FIRST CENTURY OF THE COMMISSIONED CORPS. AND IN ONLY 9 YEARS
WE’LL CELEBRATE THE SECOND CENTURY OF THE PUBLIC HEALTH SERVICE
ITSELF.
4
WE STARTED WITH A RATHER SIMPLE MISSION, AT LEAST BY

PRESENT-DAY STANDARDS. THE MARINE HOSPITAL SERVICE -- AS WE WERE
THEN KNOWN, BACK IN 1798 -- WAS DEVOTED ALMOST EXCLUSIVELY TO
PROVIDING HEALTH AND MEDICAL CARE TO THE OCEAN-GOING MERCHANT
MARINE AND TO THOSE WHO SAILED THE INLAND RIVERS AND CANALS,

BUT THE SERVICE WAS ALSO POISED TO ASSUME A GREATER
LEADERSHIP ROLE IN PUBLIC HEALTH IN THE NEW UNITED STATES OF
AMERICA. AND TRULY THERE WAS MUCH TO DO.

 
5
THE COUNTRYSIDE WAS ALREADY DOTTED WITH THE GRAVES OF

SETTLERS KILLED NOT SQ MUCH BY INDIANS ~- OR EVEN BY OTHER
SETTLERS -- BUT BY YELLOW FEVER AND DIPHTHERIA AND SMALLPOX ...
BY PNEUMONIA, CHOLERA, AND MEASLES ... BY SYPHILIS ... AND BY
MALNUTRITION AND STARVATION,

IN 1776 THOMAS JEFFERSON WROTE OUR DECLARATION OF
INDEPENDENCE, THE AMERICAN CHARTER FOR POLITICAL AND SOCIAL
FREEDOM, IN 1813 PRESIDENT JEFFERSON SIGNED INTO LAW THE “ACT TO
ENCOURAGE VACCINATION,” THE PUBLIC HEALTH CHARTER THAT WOULD
EVENTUALLY FREE AMERICANS FROM MOST CONTAGIOUS DISEASES. IT WAS
ALSO THE FIRST SWEEPING ACT OF PREVENTIVE PUBLIC HEALTH BY THE
NEW U.S. GOVERNMENT,
6
* MEANWHILE, AMERICANS WERE EXPLORING AND SETTLING THE

VAST EXPANSES OF OUR WEST. AND THAT WAS FAR FROM EASY,

THE AVERAGE PIONEER FAMILY HAD BETWEEN 5 AND 7 CHILDREN ...
BUT ONLY 3 OR 4 WERE EXPECTED TO LIVE. AND MATERNAL MORTALITY
WAS ALMOST AS BAD. CLEARLY, FROM THE VERY FIRST DAYS OF OUR
NATIONHOOD, WE HAD MATERNAL AND CHILD HEALTH HIGH ON OUR AGENDA
FOR ACTION,

* THE PRACTICE OF MEDICINE -- AND THE MANUFACTURE OF THE
MEDICINES IN COMMERCE -- WERE CARRIED ON IN THE UNITED STATES AS
THEY WERE IN EUROPE: THAT IS, WITHOUT STANDARDS OF ANY KIND,
FURTHER ENDANGERING THE AMERICAN PEOPLE.

 
/
* STATE AND LOCAL HEALTH DEPARTMENTS WERE A RARITY UNTIL

WELL INTO THE 19TH CENTURY. WHERE THEY EXISTED, THEY WERE MAINLY
CONCERNED WITH THE PURITY OF THE DRINKING WATER SUPPLIES AND
WHERE TO BURY THE DEAN,

WE WERE A “FEDERAL” REPUBLIC ... TRUE ... BUT THE SORTING
OUT OF PUBLIC HEALTH RESPONSIBILITIES AMONG ALL THREE LEVELS OF
GOVERNMENT -- FEDERAL, STATE, AND LOCAL -- HAD YET TO BE DONE.
AND, AS MANY OF YOU WELL KNOW, THAT PARTICULAR JOB HAS
PREOCCUPIED AMERICANS RIGHT UP TO THE PRESENT DAY.
8
* AND THE WORLD WAS JUST ON THE BRINK OF AN INCREDIBLE

REVOLUTION IN BIOMEDICAL RESEARCH, BEGINNING WITH THE WORK OF
ROBERT KOCH AND LOUIS PASTEUR. THAT GREAT ADVENTURE STILL
CONTINUES, OF COURSE, WITH THE HELP -- PRIMARILY, BUT NOT
EXCLUSIVELY -- OF N.J.H., C.D.C., ADAMHA, AND THE F.D.A.

AND THROUGHOUT THESE TWO CENTURIES OF GREAT PROGRESS, THE
U.S. PUBLIC HEALTH SERVICE HAS CONTINUED TO PROVIDE VITAL HEALTH
AND MEDICAL CARE TO OUR COUNTRY’S UNDERSERVED POPULATIONS ... ITS
URBAN AND RURAL POOR, ITS AGED, ITS DISADVANTAGED MINORITIES, ITS
HANDICAPPED, AND ITS CHILDREN.
9
WE RECEIVED THOSE CHALLENGES WITH EVERY NEW PIECE OF

LEGISLATION, AND WE’VE KEPT FAITH WITH OUR HISTORY, AS WELL AS
WITH THE LAW,

BUT IT HAS NOT ALWAYS BEEN AN EASY TIME FOR THE PUBLIC
HEALTH SERVICE OR ITS COMMISSIONED CORPS. THERE HAD BEEN
SEVERAL ATTEMPTS -- AT BOTH ENDS OF PENNSYLVANIA AVENUE -- TO
CHANGE THE MISSION OF THE PUBLIC HEALTH SERVICE AND TO CHANGE OR
TO ABOLISH THE COMMISSIONED CORPS,

BUT THIS KIND OF THING WAS HAPPENING GENERALLY IN GOVERNMENT
AT THAT TIME.
10
MANY OF YOU WERE IN THE P.H.S. I’M SURE IN THE 1960s AND THE

1970s, DURING THE REORGANIZATIONS IN THE EXECUTIVE BRANCH,
INCLUDING THE TRANSFER OF MUCH OF OUR ENVIRONMENTAL HEALTH
EXPERTISE TO THE DEPARTMENT OF THE INTERIOR AND TO THE NEW
ENVIRONMENTAL PROTECTION AGENCY,

SHORTLY AFTER I ARRIVED IN WASHINGTON, IN MARCH 1981, I
WITNESSED THE DISMANTLING OF THE P.H.S. HOSPITAL SYSTEM AND THE
CONCURRENT REDUCTION IN THE STRENGTH OF THE P.H.S. OFFICER
CORPS,

WE WERE PASSING THROUGH, THEN, A PERIOD OF SOME TURMOIL.
IT WAS A TIME WHEN THE CORPS CAME UNDER VERY CLOSE SCRUTINY, BOTH
BY ITS HARSHEST CRITICS AND BY ITS STRONGEST DEFENDERS,
11
BUT I‘D ALSO HAVE TO SAY, ON REFLECTION AND ON BALANCE, THAT

THAT DIFFICULT PERIOD PROVED TO BE BOTH NECESSARY AND HELPFUL FOR
US,

THEN, IN APRIL OF 1987, HEALTH AND HUMAN SERVICES SECRETARY,
DR. OTIS R. BOWEN, REDELEGATED THE PERSONNEL AUTHORITIES FOR THE
COMMISSIONED CORPS TO THE SURGEON GENERAL. AT THE SAME TIME,
SECRETARY BOWEN ASKED ME TO UNDERTAKE A REVITALIZATION OF THE
COMMISSTONED CORPS,
12
THE HARDEST PART WAS SETTING THE AGENDA FOR REVITALIZATION,

OF ALL THE SUGGESTIONS BEING DISCUSSED BOTH INSIDE AND OUTSIDE
THE P.H.S., WHICH ONES HAD TO BE DONE RIGHT AWAY? THAT WAS THE
KEY QUESTION,

WE DECIDED, FOR EXAMPLE, THAT OUR RECRUITMENT EFFORTS HAD A
GLARING WEAKNESS. THE CORPS WAS PREDOMINANTLY -- EVEN
OVERWHELMINGLY -- WHITE AND MALE. AND THAT WASN’T GOOD ENOUGH
ANYMORE.
13
WE WERE JUST NOT BRINGING INTO THE COMMISSIONED CORPS THE

MINORITIES AND THE WOMEN WE NEEDED. AND WE VERY MUCH NEEDED

THEM, IF WE WANTED A COMMISSIONED CORPS THAT WOULD BE TRULY
SENSITIVE TO THE HEALTH CHALLENGES OF THE REST OF THIS CENTURY --
AND THOSE OF THE NEXT.

NEXT, WE WERE IN REAL DANGER OF LOSING SIGHT OF THE IDEA OF
THE CORPS ITSELF, MANY MEMBERS OF THE CORPS WERE STRONG,
IMPORTANT MEMBERS OF P.H.S. AGENCIES. HENCE, THEY WERE INCLINED
TO CONSIDER THEMSELVES TO BE -- FIRST AND FOREMOST -- EMPLOYEES
OF THOSE AGENCIES. THAT’S WHERE THEIR LOYALTIES WERE.
14
THAT WAS UNDERSTANDABLE, CONSIDERING THE GROWTH OF THE

PUBLIC HEALTH MISSION IN THE DECADES FOLLOWING THE SECOND WORLD
WAR. IT WAS UNDERSTANDABLE ... BUT IT WAS NOT ACCEPTABLE.

THE UNITED STATES STILL NEEDED A MOBILE, ALERT ORGANIZATION
DEDICATED TO SAFEGUARDING THE HEALTH OF THE AMERICAN PEOPLE ...
WHEREVER IT WAS IN DANGER.

AND THE COMMISSIONED CORPS OF THE U.S. PUBLIC HEALTH SERVICE
IS SUPPOSED TO BE THAT KIND OF ORGANIZATION,
15
THEREFORE, WE EITHER HAD TO RE-CLAIM THE CORPS WE ALREADY

HAD ... OR WE HAD TO INVENT A NEW ONE, WE WISELY DECIDED TO RE-
CLAIM THE ONE WE HAD. AND I’M GLAD WE DID.

BUT THE RECLAMATION PROCESS WAS NOT SO EASY. WE HAD TO DEAL
WITH A VARIETY OF MANAGEMENT PROBLEMS ... WE NEEDED TO CONFRONT
THE ISSUE OF CAREER DEVELOPMENT FOR OFFICERS ... AND WE NEEDED TO
RE-ESTABLISH AND RE-DEFINE THE CONCEPT OF THE EMERGENCY MOBILI-
ZATION AND DEPLOYMENT OF CORPS PERSONNEL.

THESE THINGS HAVE BEEN DONE.
16
I BELIEVE THE MANAGEMENT OF THE CORPS HAS BEEN IMPROVED ...

THE CAREER SYSTEM HAS BEEN STRENGTHENED, WITH NEW CAREER TRACKS
FOR OFFICERS ... WE HAVE BETTER RELATIONS BETWEEN THE CORPS AND
THE INDIVIDUAL AGENCIES OF THE U.S, PUBLIC HEALTH SERVICE, ALL OF
WHOM WERE VERY HELPFUL DURING OUR REVIEW AND REVISION OF THE
BILLET SYSTEM ... AND WE HAVE A NUMBER OF ENLARGED AND ENHANCED
CO-STEP INITIATIVES.

WE INCREASED THE STRENGTH OF THE COMMISSIONED CORPS BY 1.5
PERCENT. AND AT THE SAME TIME WE INCREASED MINORITY AND FEMALE
COMMISSIONS BY 14.6 AND 8.1 PERCENT RESPECTIVELY,
17
WE HAVE INCREASED THE MOBILITY OF OFFICERS WITHIN POSITIONS

BY 21 PERCENT AND GEOGRAPHIC MOBILITY IS UP BY 13 PERCENT.

WE HAVE INCREASED LEADERSHIP PROMOTIONS, INCLUDING A 25-
PERCENT INCREASE IN FLAG OFFICER PROMOTIONS.

AND WE’VE INCREASED THE PUBLIC VISIBILITY OF THE CORPS AND
ITS ESPRIT,

FOR THESE AND FOR MANY OTHER ACCOMPLISHMENTS, WE HAVE
SURPRISED AND PLEASED OUR CRITICS.
18
FOR EXAMPLE, I NEVER IMAGINED THAT I WOULD EVER READ A

PARAGRAPH, SUCH AS THE ONE I AM ABOUT TO READ NOW. I'M SURE
THAT MANY OF YOU FEEL THE SAME WAY ... THAT THESE SENTIMENTS ARE
NOTHING SHORT OF EXTRAORDINARY.

THE WORDS ARE FROM NOTES TAKEN BY DEPARTMENT REPRESENTATIVES
DURING A RECENT MEETING WITH PERSONNEL FROM O.M.B. THE OCCASTON
WAS AN O.M.B. “PASS-BACK” IN THE COURSE OF THE 1991 BUDGET
DEVELOPMENT PROCESS. THE NOTES SAY...

QUOTE -- “0.M.B CONGRATULATED THE PUBLIC HEALTH SERVICE
COMMISSIONED CORPS AND THE OFFICE OF THE SURGEON GENERAL FOR
THE PROGRESS MADE THUS FAR IN IMPLEMENTING THE SURGEON
GENERAL’S REVITALIZATION INITIATIVE.
19
“O.M.B. EXPRESSED ITS CONTINUING SUPPORT FOR THE INITIATIVE

AND URGED US TO CONTINUE TOWARDS FULL IMPLEMENTATION OF
REVITALIZATION. O.M.B. SPECIFICALLY POINTED OUT THE QUALITY
OF THE COMMISSIONED CORPS NEWSLETTER, HOW IT HAS ENHANCED
THEIR UNDERSTANDING OF THE MANY CHANGES OCCURRING IN THE
CORPS, AND THEIR APPRECIATION FOR REGULARLY RECEIVING THE
NEWSLETTER.” -- CLOSED QUOTE.

SO WE PLEASED 0.M.B. -- NO SMALL FEAT IN ITSELF. BUT WE
ALSO PLEASED SEVERAL OF OUR GREATEST CRITICS OVER THE YEARS ...
THAT IS, OUR SISTER UNIFORMED SERVICES.
20
NOW, THAT’S A BRIEF SNAPSHOT, SO TO SPEAK, OF WHERE WE’VE

BEEN AND WHAT WE'VE ACCOMPLISHED IN THE PAST YEAR OR SO. IT’S
IMPORTANT.

BUT AT THIS TIME, I'D LIKE TO FOCUS MORE ON WHERE WE’RE
GOING ... THAT IS, WHAT'S AHEAD FOR THE U.S. PUBLIC HEALTH

SERVICE GENERALLY AND FOR THE CORPS IN PARTICULAR?

LET ME BEGIN WITH SOMETHING FAMILIAR: HEALTH PROMOTION AND
DISEASE PREVENTION,
21
YOU ARE ALL FAMILIAR WITH THE DOCUMENT HEALTHY PEOPLE

PRODUCED IN 1979 BY THE U.S. PUBLIC HEALTH SERVICE, UNDER THE
LEADERSHIP OF MY PREDECESSOR AND FRIEND, DR. JULIUS RICHMOND.

SINCE THEN WE‘VE PUBLISHED THE 1990 OBJECTIVES AND WE'RE
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.

THERE ARE, HOWEVER, SOME ASPECTS OF THE PROCESS THAT NEED
OUR SPECIAL ATTENTION. ONE IS THE BUSINESS OF DATA.
22
SOME OBJECTIVES CANNOT BE MET -- TECHNICALLY SPEAKING --

BECAUSE WE HAVE NO BASELINE DATA TO WORK FROM, SOMETIMES THIS IS
A FAULT OF OUR DATA-GATHERING PROCESSES AND SOMETIMES IT’S MERELY
A REFLECTION OF THE STATE OF OUR SCIENTIFIC KNOWLEDGE,

BUT WHATEVER THE REASON, WE NEED TO FOCUS MORE OF OUR
ATTENTION ON THE ISSUE OF DATA, BECAUSE OUR WEAKNESS THERE IS A
SPECIAL HANDICAP UPON THE ENTIRE OBJECTIVE-SETTING PROCESS.

ANOTHER AREA IS THAT OF PUBLIC AWARENESS. WITHOUT A GOOD
SENSE OF WHAT THE PUBLIC KNOWS AND DOESN’T KNOW, WE CANNOT
INTELLIGENTLY EVALUATE OUR PUBLIC EDUCATION EFFORTS.
23
THIS KIND OF INFORMATION IS BASIC FOR OUR EFFORTS AGAINST

AIDS ... AGAINST DRUGS .,. AGAINST TEEN-AGE PREGNANCY ... AND SO
ON. IT IS EQUALLY VITAL IN OUR OVERALL EFFORTS TO PREVENT
DISEASE AND PROMOTE HEALTH. PUBLIC AWARENESS IS, AFTER ALL, THE
STARTING-POINT FOR PUBLIC ACTION AND PUBLIC PROTECTION,

I BELIEVE THE EMPHASIS ON HEALTH PROMOTION AND DISEASE
PREVENTION THAT BEGAN IN 1979 WITH THE PUBLICATION OF HEALTHY
PEOPLE WAS ABSOLUTELY RIGHT. IT IS UNQUESTIONABLY THE PRIORITY
DIRECTION WE MUST FOLLOW FOR THE FORESEEABLE FUTURE.

 
24
NOW, LET ME MOVE ON TO AGENDA ITEM NUMBER TWO:

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 A GREAT DEAL OF PROGRESS IN
BILATERAL AND MULTILATERAL ARRANGEMENTS AROUND THE WORLD.

I THINK SOME OF THE THINGS THAT C.D,C. HAS ACCOMPLISHED ...
SOME OF THE RESEARCH SUPPORTED BY N.J.H. ... THE COOPERATIVE WORK
OF THE F.D.A. ... OUR WHOLE INTERNATIONAL EFFORT IN THE MATTER OF
AIDS ... AND SO ON ... ALL THESE ACTIVITIES HAVE MADE US
EXTRAORDINARILY CREDIBLE IN THE COMMUNITY OF NATIONS.
25
AND MOST RECENTLY, WE MADE AN IMPORTANT CONTRIBUTION TO THE

WORLDWIDE HUMANITARIAN EFFORT ON BEHALF OF THE EARTHQUAKE
VICTIMS IN ARMENIA. IN FACT, NINE OF OUR COMMISSIONED OFFICERS
WORKED IN AROUND-THE-CLOCK SHIFTS TO FACILITATE THE EXPORT OF
DRUGS AND DEVICES TO ARMENIA,

OURS IS AN IMPORTANT PIECE OF THE TOTAL MOSAIC OF HUMANI-
TARTAN AID. IT ALWAYS IS, WHETHER IT’S AN EARTHQUAKE IN ARMENIA,
DIARRHEA IN AFRICA, CONTAMINATED OLIVE OIL IN SPAIN, OR BLAST
VICTIMS IN BHOPAL.

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.
26
T REALLY BELIEVE THAT, AND I‘VE TALKED WITH MANY, MANY OF

THE WORLD’S TOP HEALTH LEADERS WHEN THEY HAVE COME TOGETHER IN
GENEVA AT THE ANNUAL WORLD HEALTH ASSEMBLY AND DURING MANY OTHER
TRIPS TO EUROPE, ASIA, AND THE MIDDLE EAST. THESE PEOPLE ALL SAY
THE SAME THING: “P.H.S., WE LOVE YOU.”

YET, I SOMETIMES THINK THAT OUR P.H.S. INTERNATIONAL
CONTRIBUTION IS ALMOST AN AFTERTHOUGHT ... SOMETHING THAT IS PART
OF ANOTHER AGENCY’S POLICY ... THE STATE DEPARTMENT, FOR EXAMPLE,
BUT THAT OUGHT NOT TO BE THE CASE AT ALL,

 
2/
I BELIEVE WE NEED TO FOCUS ON OUR OWN UNIQUE CONTRIBUTION TO

WORLD HEALTH AND TRY TO MAKE IT A STRONGER, MORE COHERENT, AND
MORE RELIABLE COMPONENT OF THIS COUNTRY’S OVERALL NATIONAL HEALTH
POLICY.

IT IS A VERY TIMELY THING TO DO, NOW THAT MORE NATIONS ARE
TRYING TO BE MORE RESPONSIVE TO THE HUMAN NEEDS OF THEIR OWN
CITIZENS. WE CAN HELP THEM ... AND WE CAN LEARN FROM THEM, TOO.

A THIRD AGENDA ITEM RELATES TO SEVERAL ISSUES I’VE DEALT
WITH OVER THE PAST 7 YEARS. THEY CONCERN MONEY AND DEMOGRAPHY.
28
LET’S BEGIN WITH THAT POPULATION GROUP WE CALL “CHILDREN.”

IT INCLUDES EVERYONE FROM NEONATES TO 18-YEAR-OLDS,

FOR 200 HUNDRED YEARS THIS POPULATION GROUP HAS DOMINATED
AMERICAN HEALTH AND WELFARE PLANNING,

BUT THAT’S CHANGING. EACH YEAR, THE PROPORTION OF AMERICANS
WHO ARE UNDER AGE 18 IS SHRINKING, WHILE THE PROPORTION OF THOSE
WHO ARE OVER 65 IS GROWING.
29
BY THE YEAR 2000 -- ONLY 11 YEARS FROM NOW -- THESE TWO

POPULATION GROUPS WILL BE VIRTUALLY IN BALANCE. BUT BY THE YEAR
2010, THE BALANCE WILL GO THE OTHER WAY: FEWER AMERICANS WILL BE
UNDER THE AGE OF 18, COMPARED TO THOSE WHO WILL BE OVER THE AGE
OF 65.

OUR AMERICAN DEMOGRAPHICS ARE IN TRANSITION. AND,
THEREFORE, SO IS OUR HEALTH PLANNING AND RESOURCE ALLOCATION.
YET, THE HEALTH NEEDS OF THE PEOPLE IN BOTH POPULATION GROUPS ARE
JUST AS COMPELLING AS EVER,
30
HENCE, WE’LL HAVE TO WORK HARD TO MAINTAIN PUBLIC SUPPORT

FOR CHILD HEALTH PROGRAMS IN THE 1990s AND BEYOND,

YET, IT WOULD BE WRONG FOR US TO 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.
31
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.

MORE ACCURATELY, THEY ARE THE CHILDREN OF POOR FAMILIES ..,
PARTICULARLY FAMILIES WITHOUT ACCESS TO HEALTH CARE. WHILE THE
AGED POOR MAY HAVE ACCESS TO HEALTH CARE VIA MEDICARE AND
MEDICAID, CHILDREN WHO ARE POOR MAY -- OR MAY NOT -- HAVE ACCESS
TO ANY KIND OF CARE.
32
THE MESSAGE HERE IS THAT WE CANNOT SAY WE ARE CONCERNED

ABOUT CHILD HEALTH IF WE SHOW NO CONCERN FOR THE ISSUE OF ACCESS
TO HEALTH CARE.

IN TODAY’S WORLD, THESE TWO ISSUES ARE NOW TIGHTLY
INTERWOVEN. AND IN TOMORROW'S WORLD ... THEY WILL BE TIGHTER
STILL.

IN AN ERA OF DWINDLING RESOURCES, WE MUST BE AWARE OF THESE
DEMOGRAPHIC REALITIES AND RESPOND CREATIVELY TO THEM, WE MUST
MAKE SURE THAT EACH POPULATION GROUP GETS ITS FAIR SHARE OF
AVAILABLE RESOURCES AND, INDEED, HAS ACCESS TO THOSE RESOURCES
».« BUT NOT AT THE EXPENSE OF ANY OTHER GROUP.
33
CAN WE DO THAT? I SAY THAT WE CAN .,. BECAUSE WE MUST.

MY FOURTH AND LAST ITEM HAS TO DO WITH THE EVOLUTION OF THE
RELATIONSHIP BETWEEN PUBLIC HEALTH AT THE FEDERAL LEVEL AND
PUBLIC HEALTH AT THE STATE AND LOCAL LEVELS OF GOVERNMENT.

FIRST OF ALL, I BELIEVE THAT THE PUBLIC HEALTH LANDSCAPE HAS
CHANGED SIGNIFICANTLY OVER THE PAST 8 YEARS AND THAT THE CHANGE
TS PERMANENT,

THERE IS SUCH A THING AS THE “NEW FEDERALISM,” AS A RESULT
OF THIS “NEW FEDERALISM,” THE PUBLIC HEALTH “CENTER OF GRAVITY”
HAS SHIFTED AWAY FROM WASHINGTON AND TOWARD THE STATES AND
LOCALITIES.
34
WE ASSUME THAT THE SHIFT HAS BEEN GOOD FOR THE HEALTH OF ALL

AMERICANS, IF OUR EPIDEMIOLOGICAL DATA CAN BE TRUSTED, THAT
SEEMS TO BE THE CASE.

HOWEVER, AS I INDICATED EARLIER, WE DO NOT YET HAVE A FIRM
COMMAND OF DATA ... AND THIS IS ONE AREA WHERE WE ARE IN VERY
POOR SHAPE.

THE FACT IS THAT WE DO NOT REALLY KNOW TO WHAT EXTENT THE
STATES AND LOCALITIES HAVE SUCCESSFULLY TAKEN OVER RESPONSI-
BILITY FOR PUBLIC HEALTH PROGRAMS OF EVERY KIND.
35
WE KNOW ABOUT EXPENDITURES AND PATIENT ENCOUNTERS AND SO ON

.«+ BUT WE DON’T HAVE A GOOD HANDLE ON RESULTS. AND THAT'S WHERE
IT ALL COUNTS. RESULTS COUNT, OUTCOMES COUNT.

] BELIEVE OUR FEDERAL ROLE IN THE YEARS AHEAD OUGHT TO BE
HIGHLIGHTED BY A MAJOR NEW EFFORT IN COOPERATIVE DATA COLLECTION
IN ORDER TO BETTER UNDERSTAND THE STRENGTHS AND THE WEAKNESSES OF
THE NEW INTERGOVERNMENTAL RELATIONSHIP IN PUBLIC HEALTH,

THE AMERICAN PEOPLE NEED TO KNOW MORE FROM US THAN JUST OUR
GOOD INTENTIONS,
36
THEREFORE, IT’S TIME WE DEVELOPED A MORE ACCURATE, IN-DEPTH

ASSESSMENT OF WHERE WE ARE, HOW WE*RE DOING, AND WHERE WE‘RE
GOING IN PUBLIC HEALTH ... NOW THAT PUBLIC HEALTH HAS VIRTUALLY
COMPLETED ITS TRANSITION FROM THAT OF A WASHINGTON-CENTERED
ACTIVITY TO THAT OF A NOW-AND-FUTURE STATE-CENTERED ACTIVITY.

I‘VE BEEN INDULGING IN SOME CRYSTAL-BALL GAZING FOR THE PAST
MINUTES AND I APPRECIATE YOUR TOLERANCE ... ESPECIALLY SINCE
EVERYONE’S CRYSTAL BALL IS CLOUDED BY THE FACT THAT OUR
ASPIRATIONS FAR EXCEED OUR RESOURCES.

AS THE MONTHS PASS, OUR FISCAL BELTS GET TIGHTER AND
TIGHTER.
37
NEVERTHELESS, REGARDLESS OF THE STATE OF THE BUDGET, I THINK

EVERY PUBLIC HEALTH PROFESSIONAL NEEDS TO GIVE SOME THOUGHT TO
THESE SEVERAL AREAS I’VE DISCUSSED WITH YOU TODAY: THAT IS ..,

»oe HOW TO DEVELOP A STRONGER DATA BASE FOR HEALTH
PROMOTION AND DISEASE PREVENTION ...

» HOW TO GIVE THE PUBLIC HEALTH PROFESSION A STRONG,
COHERENT, AND LONG-TERM ROLE TO PLAY IN THE INTERNATIONAL
ARENA, ONE NOT DEFINED BY EACH DAY’S EMERGENCY ...

» HOW TO MAKE SURE THAT THE HEALTH NEEDS OF BOTH CHILDREN
AND THE ELDERLY ARE FULLY MET, DESPITE THE DEMOGRAPHIC AND
POLITICAL SHIFTS THAT ARE ALREADY OCCURRING ...
38
.++ AND FINALLY, HOW TO IDENTIFY AND PROPERLY EVALUATE THE

ROLE OF PUBLIC HEALTH UNDER THE TERMS OF THE NEW FEDERAL
PARTNERSHIP OF NATIONAL, STATE, AND LOCAL AUTHORITIES,

IN CLOSING, LET ME SAY “THANK YOU" TO EACH AND EVERY MEMBER
OF THE U.S. PUBLIC HEALTH SERVICE ... “THANK YOU" FROM “CHICK”
KOOP, WHO HAS HAD THE PRIVILEGE OF SERVING AS YOUR SURGEON

GENERAL DURING THESE 8 EVENTFUL YEARS.

AND “THANK YOU” ALSO FROM THE AMERICAN PEOPLE, ON WHOSE
BEHALF I KNOW I SPEAK.

THANK YOU AND GOD BLESS EVERY ONE OF YOU,

HHH HE #