SPEECH WEST CHESTER UNIVERSITY WEST CHESTER, PA NOVEMBER 2 1989 C.EVERETT KOOP, MD UIr & - fAtry GREETINGS, ETC. - IT'S ALWAYS NICE TO BE BACK IN PENNSYLVANIA, AS A PRESIDENTIAL APPOINTEE, I WAS ABLE TO KEEP MY RESIDENCE IN PENNSYLVANIA FOR THE PAST 9 YEARS WHILE LIVING IN WASHINGTON. 1 CHANGED ALL THAT Last MONTH BY BUYING A HOME IN MARYLAND. ALREADY | FEEL A LITTLE INSECURITY IN NOT BEING ABLE TO CALL THIS GREAT COMMONWEALTH HOME. AND THANK YOU, PAUL, FOR THAT WARM INTRODUCTION. THIS 15 MY FIRST LECTURE TO A UNIVERSITY AUDIENCE IN MY NEW LIFE, T HAVE MANY SCHEDULED FOR THE NEXT SEVERAL MONTHS, AND I'M NOT SURE, EXACTLY, WHAT UNIVERSITY STUDENTS WANT TO HEAR, SO YOUR QUESTIONS WILL HELP ME SHAPE MY LECTURES IN THE FUTURE. BUT LET ME SAY THAT I HOVE GREAT CONFIDENCE IN YOU. AS I HAVE WATCHED ‘THIs GENERATION OF COLLEGE STUDENTS GROW UP WER THE LAST 8 VEARS, I LIKED WHAT I SAW, IT'S A LITTLE HARD TO GET USED TO THESE CLOTHES, FOR IT'S BEEN ONLY ONE MONTH SINCE I HUNG IN MY CLOSET THE UNIFORM OF THE SURGEON GENERAL, NEVER TO PUT IT ON AGAIN. TAM, OF COURSE, GRATEFUL TO RONALD REAGAN FOR NOMINATING ME AND THEN RENOMINATING ME TO THE OFFICE OF SURGEON GENERAL. BEFORE THEN, I HAD ENJOYED, FOR 40 YEN A WONDERFUL CAREER AS SURGEON-IN-CHIEF AT THE CHILDRENS' HOSPITAL OF PHILADELPHIA, AS WELL AS TWO PROFESSORSHIPS AT THE UNIVERSITY OF PENNSYLVANIA. -T THOUGHT THAT NOTHING COULD EVER COMPARE WITH THAT, BUT THE JOB OF SURGEON GENERAL DID. 1 LOVED EVERY MINUTE OF IT... . WELL, ALMOST EVERY MINUTE, NOW T ENTER THE PRIVATE SECTOR, FEELING THAT PUBLIC SERVICE 15 ITS OWN REWARD, ESPECIALLY WHEN IT IS APPRECIATED. T INTEND TO CONTINUE TO SPEAK OUT WHEN I CAN TO IMPROVE THE HEALTH QF THE AMERICAN PEOPLE. I DON'T HAVE THE POWER OF A PUBLIC OFFICE NOW, BUT I DON'T HAVE ITS CONSTRAINTS EITHER. EVEN AS SURGEON GENERAL I USED TO SAY SOMEWHAT FACETIOUSLY THAT | HAD NO POWER AND NO BUDGET. THAT IS CORRECT. BUT I ACCOMPLISHED MUCH BY SPENDING OTHER PEOPLE'S MONEY. AND I HAD THE POWER OF MORAL SUASION TO CHANGE PUBLIC POLICY. 1 NAY HAVE HAD THE REPUTATION FOR STRAIGHT AND FRANK TALK, BUT BELIEVE ME I NEVER SHOT FROM THE HIP. T WOULD NOT HAVE HAD THE POWER OF MORAL SUASION IF MY PREDECESSORS HAD NOT JEALOUSLY GUARDED THE OFFICE OF THE SURGEON GENERAL [0 MAKE IT PERHAPS THE MOST CREDIBLE IN GOVERNMENT. AT TIMES, THE ENVY OF PRESIDENTS, I MIGHT ADD. NY APPOINTMENT BY RONALD REAGAN DID NOT MEET WITH UNQUALIFIED ~ ENTHUSIASM. TO CALL MY APPOINTMENT AS SURGEON GENERAL "CONTROVERSIAL" IS A GROSS UNDERSTATEMENT. I WAS ATTACKED BY THE PRESS AS BEING UNQUALIFIED, AN IDEOLOGUE, AND THE WORST APPOINTMENT AS SURGEON GENERAL IN THE HISTORY OF THE OFFICE, IN THE SHORT TIME WE HAVE TOGETHER THIS EVENING, I'D LIKE TO HIT OUME QF THE HIGH SPOTS OF MY d VEARS AS SURGEON GENERAL, AND THEN LOOK TO THE FUTURE. THAT SHOULD PROVIDE A BASIS FOR YOUR QUESTIONS, ALTHOUGH YOU DON'T NEED TO CONFINE YOUR QUESTIONS TO THE SUBJECTS I MENTION. 10 FIRST, LET ME SAY A WORD ABOUT A SUBJECT MANY OF YOU HAVEN'T THOUGHT ABOUT YET: AGING, BUT MAYBE YOU HAVE THOUGHT ABOUT IT. I'M SURE THAT SOME OF YOU HAVE THOUGHT ABOUT YOUR PARENTS, AND YOU WONDER WHO WILL LOOK AFTER THEM WHEN THEY ARE OLD AND SICK, YOU CAN'T STOP THEIR AGING, BUT YOU CAN HELP THEIR HEALTH. 11 IF RIGHT NOW YOU STUDENTS COULD CONVINCE YOUR PARENTS TO TAKE CHARGE OF THEIR HEALTH BY ADOPTING HEALTHY LIFE STYLES, THEY COULD AGE WITHOUT THE ILLNESS MOST OFTEN ASSOCIATED. WITH OLD PEOPLE. ie THE PRESCRIPTION IS SIMPLE: NO SMOKING, ALCOHOL ONLY IN MODERATION, EXERCISE AND DIET APPROPRIATE TO AGE, CHECK BLOOD PRESSURE AND CHOLESTEROL, AND SEE THE DOCTOR IF THEY ARE ABNORMAL. 13 IF YOUR PARENTS DO THAT THEY COULD CLIMB THE HILL TO AGE 40, BUT INSTEAD OF STARTING DOWNHILL AT 63, THEY COULD LIVE UP THERE ON THAT PLATEAU. AND ENJOY A QUALITY OF LIFE AS A SENIOR CITIZENS AGING HAS SPECIAL MEANING FOR ME. YOU MAY RECALL THAT, WHEN PRESIDENT REAGAN FIRST NOMINATED ME TO BE HIS SURGEON GENERAL , BACK IN 1981, A GREAT HUE AND CRY WENT UP THAT I WAS TOO OLD. I WAS JUST A YOUNGSTER OF 645. BUT ALL MY CRITICS SAID THAT 65 WAS THE AGE AT WHICH SURGEONS ENTER IT FOR THE FIRST TIME, OF COURSE, THIS DID NOT SIT VERY WELL WITH THE MAN WHO NOMINATED ME. PRESIDENT REAGAN HAD JUST CELEBRATED HIS 70TH BIRTHDAY AND DID NOT TAKE KINDLY TO THE SERVICE. 19 NOW, AT AGE 73, I AM SURELY QUALIFIED TO BE COUNTED AS ONE OF AMERICA’S SENIOR CITIZENS. AND I'M VERY PROUD TO BE AMONG THAT COMPANY. . THERE ARE MORE OF US EVERY DAY. IN, SAY, 15°OR 20 YEARS -- A SUBSTANTIAL PORTION OF THE AMERICAN POPULATION, CLOSE TO 20 PERCENT, WILL BE OVER THE AGE OF 65, AND WITHIN THAT GROUP, THE ABOVE. 1é SQ LET'S GET A FEW THINGS STRAIGHT: © GRAY OR WHITE HAIR IS NOT A SIGN OF DISEASE. NEVER HAS BEEN. NEVER WILL BE. DRY SKIN TS A NATURAL PHENOMENON OF AGING. WE DON'T KNOW WHY IT HAPPENS ... BUT IT'S NOT THE RESULT OF DISEASE. — 17 TAKING THINGS A LITTLE EASIER IS NOT A DISEASE CONDITION, IT'S MORE LIKE A SIGN OF MATURITY. AND GETTING A STRONGER PRESCRIPTION FOR YOUR EYEGLASSES OR BEING FITTED FOR A HEARING AID IS NOT EVIDENCE THAT YOU HAVE ONE FOOT IN THE GRAVE AND ANOTHER ON A BANANA PEEL. IT JUST ISN'T. 18 IN THE PAST YEAR OR SO, I HAD PERSONAL EXPERIENCE WITH HEARING LOSS. AFTER SEVERAL YEARS IN WASHINGTON I WAS BEGINNING TO FEEL MORE COMFORTABLE WITH THE JOB. 1 BEGAN TO LIKE MORE PEOPLE IN THE CONGRESS, AND ACTUALLY ENJOYED COMMITTEE MEETINGS AT THE WHITE HOUSE. SUDDENLY I REALIZED WHY: I WAS LOSING MY HEARING. 19 SERIOUSLY, THOUGH, I REALIZED THAT I WAS MISSING A LOT. AND I WAS MAKING INAPPROPRIATE RESPONSES, SQ 1 GOT TWO HEARING AIDS. GETTING A HEARING AID SHOULD BE JUST LIKE GETTING EYEGLASSES. 20 AGE PREJUDICE 1S STILL FAR TOO COMMON IN AMERICA. OLD AGE NEED NOT BE A TIME OF CHRONIC AND PROLONGED INCAPACITY. AND FOR MOST PEOPLE OVER THE AGE OF 65 IT IS NOT. WE NOW UNDERSTAND THAT -- MEDICALLY SPEAKING -- THERE 1S SUCH A THING AS. A DISEASE-FREE AGING PROCESS ... A PROCESS DURING WHICH ALL SYSTEMS IN A PERSON'S BODY CONTINUE TO FUNCTION NORMALLY, el AND THAT'S THE WAY IT'S GOING TO BE FOR MOST OLDER PEOPLE IN THE FUTURE, --MOST OF YOU, I HOPE -- BECAUSE TOMORROW'S ELDERLY ARE TODAY'S BIKERS, JOGGERS, AND SWIMMERS ... THEY'RE THE PEOPLE WHO SNACK ON SALAD AND YOGURT ... WHO'VE GIVEN UP CIGARETTES AND HARD LIQUOR ... WHO WEAR SEAT-BELTS AND SENSIBLE SHOES ... AND WHO DO MORE ABOUT MANAGING STRESS THAN JUST POP ANOTHER VALIUM. ec Oe cree ee ee eee eee ame ere ee ae te cr ee ee cee re ee ee ee cee we ee OTHER PERIOD IN ONE'S LIFE, IF WE TAKE THE RIGHT STEPS IN PREVENT IVE HEALTH CARE. eg THERE HAS BEEN A REVOLUTION IN THE WAY WE LOOK AT HEALTH IN AMERICA, TWO CONCEPTS FORM THE BASIS FOR THIS REVOLUTION. AWAY THE GREATEST IMPROVEMENTS IN THE HEALTH STATUS OF AMERICANS. c4 SOME ANALYSTS EVEN SAY THAT PREVENTION AND HEALTH PROMOTION CAN Pos the we PRESET up TO 70 PERCENT OF ALL PREMATURE DEATHS, WHEREAS THE TRADITIONAL CURATIVE AND REPARATIVE APPROACH OF MEDICINE CAN Pos7pewé PREVENT NO MORE THAN 10 TO 15 PERCENT OF SUCH DEATHS. EVEN IF THEY'RE ONLY MALE RIGHT, THAT'S QUITE A DIFFERENCE IN SOCIAL PAy- OFFS. ed SECOND 15 THE RECOGNITION THAT THESE TWO APPROACHES TO HEALTH -- THAT 15, DISEASE PREVENTION AND HEALTH PROMOTION -- ARE THE PRIMARY RESPONSIBILITIES OF EACH INDIVIDUAL. PHYSICIANS AND ee ree cee mm Re a eh mew ee CY eA wh We eae SS ere Se ne ee cee nt ee eee eee Oe ee os met ee ee THERAPISTS AND PHARMACISTS AND NURSES CAN PROVIDE INFORMATION AND ALL KINDS OF SERVICE. BUT THE CHOICES REST WITH THE INDIVIDUAL. AND THEY ARE FREE CHOICES IN NEARLY EVERY CASE, NOT MANDATED BY LAW -- AT LEAST NOT YET, 26 THIS TWO-FOLD CHANGE IN THE WAY WE LOOK AT HEALTH IN AMERICA HAS NOT YET BEEN FULLY ABSORBED BY THE AMERICAN PEOPLE, ALTHOUGH THEY SEEM WILLING ENOUGH TO LEARN, NOW, IT'S TRUE THAT AMERICAN PUBLIC HEALTH HAS ALWAYS HAD A STRONG PREVENTIVE BASE: WE WERE BROUGHT UP ON VACCINATION PROGRAMS AND WATER FLUORIDATION AND BLOOD PRESSURE CHECK-UPS AND SO ON. 07 NEVERTHELESS, I THINK THE OVERALL PERCEPTION AMONG THE AMERICAN PEOPLE 15 STILL AN OLD-FASHIONED ONE: THAT IS, THAT PUBLIC HEALTH AND MEDICAL AND NURSING PERSONNEL ARE REALLY ON THE JOB TO ea eT cee AN ceeY om Cee Se NY A SREY Sn RR Sy RE SO NY Ment Sie ED une mm seme meas Se Se eae ete es tm SD a oe co Sates eal ele GS mI ke Se ate Sis oD sees Me mes ete OTHER WORDS, THE PATIENT IS PASSIVE AND THE HEALTH SYSTEM IS THE ONLY ACTIVE PARTY. 28 I THINK THE PUBLIC STILL ADHERES TO THE IDEA THAT THE PATIENT IS SUPPOSED TO "FOLLOW THE DOCTOR'S ORDERS," A PHRASE WHICH HAS EVEN BECOME A CLICHE OF THE LANGUAGE. OF COURSE, BY "FOLLOWING THE DOCTOR'S ORDERS," THE PATIENT WILL DO THOSE THINGS THAT WILL HELP HIM OR HER REGAIN THE LOST STATUS OF FULL. HEALTH. 29 WE IN THE PUBLIC HEALTH PROFESSIONS HAVE BEEN DILIGENTLY TRYING TO TURN THAT CONVENTIONAL WISDOM AROUND. Awd 7 7HIW WE Are. ] THINK WE'RE MAKING GREAT STRIDES IN THE ANTI-SMOKING AREA, THE PERCENTAGE OF THE ADULT POPULATION WHO SMOKES IS STEADILY DECLINING AND THAT'S EXCELLENT. 30 THERE'S ALSO BEEN A DROP IN THE CONSUMPTION OF HARD LIQUOR, WITH A SHIFT TO BEER AND WINE -- OR SIMPLY WATER. AS 2 RESULT, THERE'S BEEN A DRAMATIC DROP IN CHRONIC LIVER DISEASE AND CIRRHOSIS MORTALITY IN GENERAL. PEOPLE SEEM 70 BE EATING LESS FAT, PARTICULARLY SATURATED FAT AND CHOLESTEROL . THE DROP IN CIGARETTE SMOKING AND THE REDUCTIONS IN FAT IN THE AVERAGE PERSON'S DIET HAVE COMBINED TO CONTRIBUTE TO THE DECLINE IN HEART DISEASE AND STROKE DEATHS OVER. THE PAST. 10 10 15 YEARS AS WELL. THERE'S NO DOUBT ABOUT THAT. di SO I THINK WE CAN FEEL ENCOURAGED ABOUT THE TRENDS SO FAR, THE BIG QUESTION REMAINS, HOWEVER: ARE THEY REALLY TRENDS ... OR ARE THEY TEMPORARY ARTIFACTS OF A DYNAMIC CULTURE? WE NEED TO MAKE THE RIGHT CHOICES ABOUT LIFESTYLE, ABOUT PHYSICAL EXERCISE, ABOUT DIET. 32 WHEN WE CONVINCE OURSELVES TO EAT A PROPER DIET, TO AVOID FOODS HIGH IN FAT, SUGAR, AND SODIUM, TO SAY "NO!" TO DRUGS LIKE ALCOHOL AND NICOTINE, WE TAKE CHARGE OF OUR HEALTH. 330 WHEN WE SAY THAT THE BEST WAY TO BEAT HEART DISEASE IS THROUGH ROUTINE EXERCISE, NO SMOKING, AND A HEALTHFUL DIET, THAT'S JUST ANOTHER WAY OF TELLING PEOPLE, "DON'T RELY COMPLETELY ON HIGH-COST HIGH-TECH MEDICINE TO SAVE YOUR LIFE, BY-PASS, " 34 WE KNOW, HOWEVER, THAT HEART DISEASE IS PROGRESSIVE: THAT IS, IT'S BEGINNING TO DEVELOP RIGHT NOW, EVEN IN SOME OF YoU, IF YOU ARE OVERWEIGHT NOW... IF YOUR CURRENT DIETARY INTAKE 1S HIGH IN SODIUM, CHOLESTEROL, AND SATURATED FATS ... IF YOU LEAD A GENERALLY SEDENTARY EXISTENCE, IF YOU'RE A “COUCH-AND-ARHCHA POTATO" ... IT IS HIGHLY LIKELY THAT THIS COULD BE YOUR LIFESTYLE AT AGE 30 ... AT AGE 40 ... AND AT AGE 50. 30 AND THE QDDS OF YOUR REACHING AGE 60, MUCH LESS AGE 70 OR 80, WILL BE SMALL. BUT YOU CAN RAISE THOSE ODDS CONSIDERABLY BY GETTING CONTROL OF YOUR DIET AND BY FITTING IN TIME FOR EXERCISE EVERY WEEK. J6 DOES THAT MEAN YOU WILL BE IMMORTAL AND NEVER DIE? NO, I'M AFRAID NOT. EVERY LIVING THING IN THE PLANT AND ANIMAL KINGDOMS HAS A LIMIT OF SOME KIND TO THE LENGTH OF LIFE. WE DON'T KNOW MUCH MORE ABOUT IT THAN THAT. WE KNOW THAT THE CALIFORNIA GIANT REDWOOD TREE@ LIVES TO A MAXIMUM OF ABOUT 2,000 TO 3,000 YEARS. AND THEN IT STOPS ... AND DIES. WHY? NO ONE REALLY KNOWS. 37 BUT THE MAPLE TREE 1S DIFFERENT. A MAPLE HAS A LIFE-SPAN OF ABOUT SO YEARS. AT THAT AGE, A MAPLE BEGINS TO “DIE BACK." IT IS AN IRREVERSIBLE PROCESS. WE KNOW THAT HAPPENS, BUT -- AGAIN -- WE DON'T REALLY KNOW WHY, AND WE DON'T KNOW WHY HUMAN BEINGS SEEM TO "RUN OUT OF TIME" BETWEEN THEIR 465TH AND 85TH YEARS. 38 WE MAKE SURE THEY HAVE AMPLE SUPPLIES SUNLIGHT, CLEAN AIR, FRESH WATER, AND CERTAIN SOIL-BASED MINERALS. SIMILARLY, WE KNOW THAT THE PREMATURE DEATH OF HUMAN BEINGS CAN ALSO BE PREVENTED, IF THEY DON'T SMOKE ... DON'T ABUSE DRUGS -~ INCLUDING ALCOHOL AND NICOTINE. . MAINTAIN A REGULAR ROUTINE OF EXERCISE ... AND WATCH THEIR DIET. 39 THERE DOESN'T SEEM TO BE ANY SPECIAL ORGAN THAT AFFECTS THE LIFE OF A TREE, BUT THERE CERTAINLY IS ONE THAT AFFECTS THE LIFE OF THE HUMAN BEING. AND IT'S THE HEART. AND THE FEW RULES I JUST MENTIONED -- DIET, EXERCISE, AND SO ON - ~ WILL ALLOW YOUR HEART TO DO ITS JOB "FOR AS-LONG AS IT IS PREPARED TO FUNCTION." THAT'S THE BEST WAY I CAN PUT IT, SINCE NO ONE KNOWS HOW LONG THAT IS, 40 TF YOU BELIEVE YOU CAN LIVE ANY WAY YOU PLEASE WHILE YOU'RE YOUNG AND THEN DEAL WITH YOUR HEART LATER ON ... YOU ARE TRAGICALLY MISTAKEN. WHEN IT HAS BEEN ABUSED FOR ANY LENGTH OF TIME, THE HUMAN HEART HAS A TENDENCY TO THROW A FIT. AND STOP. I HOPE YOU WON'T WAIT THAT LONG TO PAY ATTENTION TO THIS MYSTERIOUS BUT ABSOLUTELY VITAL ORGAN, 4] IN THE FUTURE AMERICANS WILL SIMPLY NOT HAVE THE DOLLARS TO PAY THE VERY HIGH PRICE EXACTED BY LIFESTYLES OF THOUGHTLESSNESS AND HIGH RISK. I KNOW THIS SOUNDS TERRIBLY CHEERLESS, BUT I DON'T THINK IT HAS TO BE. 42 TO BORROW A MOTTO FROM AN EARLIER AGE: "LIVING WELL IS THE BEST REVENGE." LIVING WELL ... LIVING SENSIBLY ... LIVING A HEALTHY LIFESTYLE -++ LIVING ACCORDING TO AN ETHIC OF PREVENTION ... THIS IS YOUR "BEST REVENGE" AGAINST THE 3 D'S OF DISCOMFORT, DISEASE, AND DISABILITY. 4g AND IT'S YOUR BEST HEDGE AGAINST THE 4TH AND FINAL D: DEATH ITSELF. SO, YOU EACH HAVE AN INDIVIDUAL RESPONSIBILITY TO DO SOMETHING, TO DO MANY THINGS, TO MAINTAIN YOUR INDIVIDUAL HEALTH _— 44 Cc +) I'M SURE AIDS IS NOT A NEW TOPIC FOR ANYONE IN THIS ROOM. AFTER ALL I WROTE EACH OF YOU A LETTER ABOUT AIDS A YEAR AGO. AT LEAST I SENT THE AIDS MAILER TO 107 MILLION HOUSEHOLDS. 1 HOPE YOU RECEIVED YOURS. AND YET I'M SURE THERE ARE STILL MANY PEOPLE RIGHT HERE IN THIS AUDIENCE WHO ARE STILL UNCLEAR ABOUT THE NATURE OF THE DISEASE OF AIDS, 49 YOU MAY RECALL THAT, IN 1981, THE U.S. PUBLIC HEALTH SERVICE PUBLISHED THE FIRST REPORTS OF WHAT WAS TO BECOME THE AIDS EPIDEMIC. THEY CONCERNED 5 "PREVIOUSLY HEALTHY" HOMOSEXUALS WHO ae Cae ime ee Le UL MY SO VON OEY copes uve SRD cat Seve ime es se wre unter PNEUMONIA, A VERY RARE FORM OF PNEUMONIA. BY THE TIME THE REPORT HAD BEEN PUBLISHED, 2 OF THE MEN HAD DIED. THE OTHER 3 DIED SHORTLY THEREAFTER. 46 THEN, A MONTH LATER, THE PUBLIC HEALTH SERVICE PUBLISHED A REPORT THAT c& YOUNG MEN HAD BEEN RECENTLY DIAGNOSED AS HAVING KAPOSI'S SARCOMA, "AN UNCOMMONLY REPORTED" CANCEROUS CONDITION USUALLY FOUND IF AT ALL—AMONG ELDERLY MEN, FROM THAT SMALL BEGINNING THE CASES MUSHROOMED INTO THE EPIDEMIC GF THE LATE 1980S, 4? THE FIRST THING TO KNOW IS THAT THE AIDS VIRUS IS STILL Se a ee ne a Sane CO SR ED aD ee SS OER SAE ee Se SE ee ee THAT'S THE PREMISE FOR EVERYTHING WE DO. WE'VE GOT 4 KILLER DISEASE ON QUR HANDS AND IT'S REACHING FARTHER AND DEEPER INTO OUR SOCIETY EVERY DAY. QUR STATISTICIANS PREDICTED TWO YEARS AGO THAT THE AIDS EPIDEMIC WOULD CONTINUE TO GROW AND SPREAD WELL INTO THE 1990'S ... AND I'M AFRAID THEY WERE RIGHT. 48 AS OF LAST WEEK WE HAD /°9,00¢ CASES WITH 5°04 DEATHS, AND 1 t/c TO 3 MILLION CARRYING THE VIRUS. SOME OF THEM KNOW THEY HAVE IT AND SOME DON'T, BUT THEY ARE ALL INFECTIOUS TO OTHER PEOPLE THROUGH INTIMATE SEXUAL CONTACT OR SHARING PARAPHANAL IA WHEN THEY SHOOT DRUGS, Tears war ¢ PRefet_ Fa Sfewit alF pI SHEE CTION ~ NOI AOS - BEECHES E 17 (%WéePs Fetevs ev FHE Cnoemizy OIE WWE 1"hee Bee wt. ALMOST HALF THE NUMBER OF PEOPLE WHO WERE REPORTED WITH AIDS JUST 49 30, EVEN THOUGH WE DON'T KNOW EVERYTHING ABOUT THIS DISEASE, WE DO KNOW ONE THING FOR CERTAIN: IF YOU HAVE AIDS, YOUR CHANCES OF SURVIVING THE NEXT TWO OR THREE YEARS ARE NOT VERY GOOD. BUT YOUR CHANCES OF SURVIVING ANY LONGER THAN THAT ARE ALMOST NIL. 20 IN FEBRUARY 1984, PRESIDENT REAGAN ASKED THE SURGEON GENERAL TO PREPARE A REPORT 10 THE AMERICAN PEOPLE ON AIDS. THE REPORT HAD TO GIVE THE FACTS ABOUT AIDS AND TELL PEOPLE HOW TO PROTECT THEMSELVES FROM GETTING IT. AFTER 8 MONTHS OF LISTENING TO ALL SHADES OF OPINION -- LEFT, RIGHT, AND CENTER -- FROM A BROAD CROSS-SECTION OF QUR SOCIETY, I RELEASED MY REPORT DIRECTLY TO THE AMERICAN SEOPLE A AN OCTOBER 1986 PRESS CONFERENCE. ol AIDS IS TRANSMITTED IN FOUR WAYS ... AND IN ONLY FOUR MAYS: # THE FIRST WAY IS MOST COMMON ROUTE OF TRANSMISSION, i SEXUAL. INTERCOURSE ... MOSTLY BUT NOT EXCLUSIVELY ANAL INTERCOURSE , WHICH OCCURS MOST FREQUENTLY AMONG HOMOSEXUALS AND BISEXUAL MALES. THIS ACCOUNTS FOR ABOUT TWO-THIRDS OF ALL CASES OF AIDS. HOWEVER, AIDS IS TRANSMITTED THROUGH HETEROSEXUAL INTERCOURSE. AND EVEN THOUGH THE STATISTICAL INCIDENCE OF HETEROSEXUAL TRANSMISSION IS LOWER, IT IS JUST AS FATAL. DON'T FOOL AROUND. de # AIDS IS ALSO TRANSMITTED INTO THE BLOOD OF INTRAVENOUS DRUG INFECTED WITH AIDS VIRUS. # — THE VIRUS CAN ALSO BE TRANSMITTED FROM AN AIDS-INFECTED MOTHER TQ HER INFANT DURING PREGNANCY OR AT THE TIME OF DELIVERY, # AND FINALLY, AIDS CAN BE TRANSMITTED THROUGH TRANSFUSED BLOOD OR BLOOD PRODUCTS. BUT THIS DANGER IS NOW ALMOST STATISTICALLY INSIGNIFICANT. od AND, THERE ARE FOUR KEY ASPECTS OF THE DISEASE OF AIDS: ONE, THAT IT'S SPREADING ... TWO, THAT IT'S FATAL... THREE, THAT WE DON'T HAVE A CURE YET ... AND FOUR, THAT IT'S SPREAD MAINLY BY CERTAIN SPECIFIC “BEHAVIORS INVOLVING SEX AND/OR DRUGS. a4 THESE FOUR ASPECTS MAKE THE AMERICAN PEOPLE VERY EDGY ABOUT AIDS. AND THAT'S CERTAINLY UNDERSTANDABLE. BUT THE FACT REMAINS THAT YOU HAVE TO MAKE & CONSCIOUS: DECISION TO CARRY GUT A SPECIFIC FORM OF PERSONAL BEHAVIOR BEFORE you EXPOSE YOURSELF TO THE AIDS VIRUS. DON'T DO IT. THE ONLY WEAPON WE HAVE AGAINST THIS DISEASE IS EDUCATION, EDUCATION, AND MORE EDUCATION, 20 patie RATED: pps He AER nee jeu soe ut aati AIDS MAY BE THE MOST DEADLY DISEASE ON THE HORIZON, THE MOST UNIQUE CHALLENGE 70 US, BUT IT IS NOT THE GREATEST KILLER OR THE GREATEST BURDEN ON THE HEALTH CARE SYSTEM. THAT NOTORIETY GOES TO SMOKING-RELATED DISEASE. V6 THE EVIDENCE AGAINST SMOKING aulLns EVERY YEAR, AND THE AMERICAN PEOPLE ARE BELIEVING IT. AS YOUR SURGEON SENERAL I RELEASED 8 ANNUAL REPORTS ON SMOKING. THEY HAVE DEALT WITH CANCER, CARDIOVASCULAR DISEASE, CANCER IN WOMEN, SMOKING IN THE WORKPLACE, CHRONIC OBSTRUCTIVE LUNG DISEASE, INVOLUNTARY SMOKING OR WHAT IS SOMETIMES CALLED "PASSIVE SMOKING," AND THE ADDICTIVE QUALITIES OF NICOTINE. U 57 EACH ONE HAS ITS OWN SPECIFIC AND IMPRESSIVE DATA BASE. TODAY, THE SMOKING-AND-HEALTH RESEARCH BASE IS STILL GROWING. IT T5 COMPRISED OF MORE THAN 60,000 PUBLISHED ARTICLES. AGAIN, THE VAST MAJORITY QUITE CLEARLY REINFORCES THE FACT THAT CIGARETTE SMOKING IS THE SINGLE MOST IMPORTANT FACTOR BEHIND ACUTE AND CHRONIC MORBIDITY AND PREMATURE MORTALITY AMONG ADULTS. V5 AS THIS RESEARCH BASE EXPANDED, SO DID QUR EFFORTS TO EDUCATE THE PUBLIC ... TO GET THOSE WHO SMOKE, TO STOP ... AND THOSE WHO DON'T SMOKE, TO NEVER START. IN 1984, I WAS PERSONALLY SO CONVINCED BY THE DATA ACCUMULATED THUS FAR THAT I CALLED UPON MY FELLOW CITIZENS TO MAKE THE UNITED STATES A "SMOKE-FREE SOCIETY BY THE YEAR 2000." U 59 THaq SMUle-FREE SOcvETy WE'LL ACHIEVE THAT BECAUSE WE WILL GRADUATE A CLASS FROM HIGH SCHOOL IN 2000 THAT WILL HAVE HAD 12 YEARS OF ANTI-SMOKING HEALTH MESSAGES. IT STARTED THE YEAR BEFORE LAST, IN THE FIRST GRADE, TEACHING THAT YOUNG WILL WIN, FEW THINGS BRINGS ME AS MUCH SATISFACTION AS THE DRAMATIC DECREASE IN SMOKERS DURING THE LAST 8 YEARS, FROM 33 PERCENT 10 26 PERCENT. Y 40 BUT THERE 1S MORE TO DO. SMOKING IS STILL THE SINGLE MOST DEADLY "HABIT" ... WITH HIGHER MORTALITY AND MORBIDITY THAN DRUGS, AUTOMOBILES, AND AIDS ABOUT THE DISEASE, 8 YEARS, EQUALS THE SMOKING DEATHS OF ONLY MONTHS. VU él SMOKING IS THE ROOT CAUSE OR THE MOST SIGNIFICANT CAUSE FOR ABOUT LEADING KILLERS OF AMERICANS, SOME 30 MILLION AMERICANS STILL SMOKE, MAKING A MAJOR IMPACT ON HEALTH BUDGETS. J 42 BUT THE TOBACCO INDUSTRY HAS NOT GIVEN UP 1 DOUBT THAT YOU CAN FIND A MORE HEAVY-HANDED, OBTUSE, IMPOLITIC, AND UNTRUTHFUL GROUP OF CORPORATIONS ANYWHERE IN THE GREAT PANOPLY OF AMERICAN PRIVATE ENTERPRISE. 3 ALMOST FROM MY FIRST DAY IN OFFICE, THE INDUSTRY REMINDED ME AGAIN AND AGAIN -- AND NOT VERY SUBTLY EITHER -- THAT I OUGHT TO GET OFF MY ANTI~SMOKING "HOBBY-HORSE ," AS ONE TOBACCO LOBBYIST CALLED IT, AND PAY ATTENTION TO OTHER, ALLEGEDLY MORE IMPORTANT PUBLIC HEALTH MATTERS. ECHOES OF THEIR COMPLAINTS WERE RELAYED TO ME FROM THE WHITE HOUSE, THE CONGRESS, AND EVEN FROM MEMBERS OF THE PRESS, WHO HAVE OFTEN BEEN THE GULLIBLE CARRIERS OF THE INDUSTRY'S DISASTROUS MESSAGE . b4 T ALSO READ THEIR DECEPTIVE, FULL-PAGE ADVERTISEMENTS THAT LIFTED MENDACITY AND HALF-TRUTHS TO A NEW AND HIGHER LEVEL OF FAUSTIAN ART. TO BE PERFECTLY HONEST, I DID NOT ASSUME THE POSITION OF SURGEON GENERAL WITH THE CLEAR INTENTION OF BEING SO PRO-ACTIVE AN OPPONENT OF TOBACCO AS I HAVE BEEN. BUT THEN I BEGAN TO STUDY IN SOME DEPTH THE INCONTROVERTIBLE TRUTHS ABOUT THE HEALTH HAZARDS OF SMOKING. 69 AND I MUST TELL YOU THAT I WAS AT FIRST DUMBFOUNDED AND THEN PLAINLY FURIOUS AT THE TOBACCO INDUSTRY FOR ATTEMPTING TO OBFUSCATE AND TRIVIALIZE THIS EXTRAGRDINARILY IMPORTANT PUBLIC HEALTH INFORMATION. 66 HOW COULD THE TOBACCO INDUSTRY DARE TO DISMISS re UNFOUNDED AND UNPROVEN THE ABSOLUTELY CLEAR. CONNECTION BETWEEN SMOKING AND HEART DISEASE ... BETWEEN SMOKING AND DEATHS FROM STROKE ... BETWEEN SMOKING AND CANCER OF THE LUNG, THE MOUTH, THE ESOPHAGUS, AND OF THE STOMACH ... AND BETWEEN SMOKING AND A DOZEN OR MORE SERIOUS, DEBILITATING, EXHAUSTING, EXPENSIVE, AND HUMILIATING DISEASES? &7 HOW COULD THEY DARE TO DO THAT? I WONDERED. THE ANSHER WAS ... THEY JUST DID. AND THEY FLAUNTED THEIR ABILITY 10 BUY THEIR WAY INTO THE NARKETPLACE OF IDEAS AND POLLUTE IT WITH THEIR FALSE.AND DEADLY. INFORMATION, 90 QUR EDUCATION CAMPAIGNS, QUR SELF-HELP GROUPS MUST CONTINUE THETR GOOD WORK. WE MUST GUARD AGAINST COMPLACENCY, AND INTENSIFY QUR EFFORTS TO ELIMINATE THE GREATEST CAUSE OF PREVENTABLE DISEASE AND DEATH AFFLICTING OUR SOCIETY. $68 THERE IS ANOTHER ISSUE.CoWCFRviewe FeBsecu QUR SOCIETY IS NOT THE ONLY ONE AFFECTED, THE BATTLE AGAINST SMOKING WORLDWIDE 1S OUR BUSINESS TOO. IT 15 OUR CONCERN NOT ONLY BECAUSE OF & GENERAL INTEREST IN COMBATING DISEASE AND DEATH, BUT ALSO BECAUSE IT AFFECTS OUR ABILITY TO COUNTER THE PLOYS OF THE TOBACCO INDUSTRY, AND IT IS PART OF OUR WAR ON DRUGS. U 9 THE DECLINE IN TOBACCO COMPANY EARNINGS FROM THE SALE OF CIGARETTES 10 AMERICANS IS BEING OFFSET BECAUSE CIGARETTE COMPANIES ARE EXPLOITING MARKETS OVERSEAS. ——IN ONE OF THE MOST DISGRACEFUL EXAMPLES OF PRIVATE ENTERPRISE GONE AMOK, THE CIGARETTE INDUSTRY IS FOCUSING ITS HIGH-POWERED MARKETING ATTENTION ON THE UNPROTECTED CITIZENS OF THIRD-WORLD NATIONS IN ASIA, AFRICA, AND SOUTH AMERICA. 70 AS A RESULT, THOSE NATIONS ARE NOW BEGINNING TO EXPERIENCE THE SAME RISE IN SMOKING-RELATED DISEASES THAT WE EXPERIENCED A GENERATION AGO ... HEART DISEASE, STROKE, AND CANCER OF THE LUNG, MOUTH, ESOPHAGUS, AND STOMACH. AND AS AN AMERICAN CITIZEN, I AM APPALLED BY THIS CORPORATE BEHAVIOR OF AMERICAN COMPANIES AND, FURTHER, I AM SHOCKED BY THE QUR OWN GOVERNMENT'S SUPPORT OF SUCH BEHAVIOR. 71 IN 1987 IN TOKYO, REPRESENTATIVES OF 15 ASIAN COUNTRIES ATTENDED A WORLD HEALTH ORGANIZATION "REGIONAL WORKING GROUP ON TOBACCO OR HEALTH." HERE ARE SOME OF THE THINGS REPORTED AT THAT MEETING BY THE TOP HEALTH EXPERTS FROM THOSE 15 ASIAN COUNTRIES: SAYING SOMETHING IN ITSELF. 7e THE ALARMING THING ABOUT THIS HABIT IS THAT, WHEN IT INVADES A NEW MARKET, IT DOES SO WITH IMMENSE SPEED AND IMPACT. ACCORDING TO THE WORLD HEALTH ORGANIZATION, BETWEEN 1971 AND 1981 CIGARETTE CONSUMPTION INCREASED IN ASIA AND LATIN ANERICA AT A RATE 30 Se re te tees ee se ee ee ee ee oe nine ene eee Se ee ce re ere ee ee a 7d AND LISTEN CAREFULLY TO THIS: IN CHINA, WHERE COUPLES ARE SUPPOSED TQ HAVE ONLY 1 CHILD PER FAMILY, THERE ARE AT THIS MOMENT AN ESTIMATED 50,000,000 CHILDREN RUNNING AROUND TODAY WHO WILL EVENTUALLY DIE PREMATURELY FROM SMOKING. SECOND -~- AND HERE'S WHERE WE DESERVE TO SQUIRM IN SHAME -- IN 10 OF THOSE 13 ASIAN COUNTRIES, AMERICAN CIGARETTES WERE THE MOST COMMON KIND IMPORTED. 74 BUT THOSE AMERICAN CIGARETTES ARE A LITTLE DIFFERENT OVERSEAS: FOR ONE THING, THEY DON'T CARRY THE SURGEON GENERAL'S WARNING. AND FOR ANOTHER, MANY AMERICAN CIGARETTES MANUFACTURED FOR EXPORT HAVE 4 HIGHER TAR CONTENT AND ARE, THEREFORE, EVEN MORE DANGEROUS THAN THE LOWER-TAR, FULLY-LABELLED PRODUCTS SOLD HERE IN THE UNITED STATES. 79 AND NOT SURPRISINGLY, THESE SAME 15 COUNTRIES REPORTED THAT COMMUNICABLE DISEASE WAS NO LONGER THE NUMBER ONE PUBLIC HEALTH MENACE IN ASIA. TODAY, THE TOP THREE CAUSES OF DEATH IN ASIA ARE ~~ CAN YOU GUESS? -- THE SAME THREE SMOKING-RELATED CAUSES OF DEATH THAT PREVAIL HERE IN THE UNITED STATES: HEART DISEASE, CANCER, AND STROKE. 76 [ SHOULD ADD THAT MR. J.T. BUNN, THE TOBACCO EXPORTER, WARNED ME LAST FEBRUARY THAT IF I CONTINUE TO PROMOTE ANTI-SNOKING CAMPAIGNS WORLDWIDE -- WHICH I HAVE SURELY DONE -- I WOULD BE “TELLING QUR FOREIGN FRIENDS HOW TO CONDUCT TRADE AND HOW TO CHANGE THEIR HABITS. IT PROJECTS FOR THE U.S. AN IMAGE OF 'THE UGLY AMERICAN, '" SAID MR. BUNN IN ONE OF THE BEST DEMONSTRATIONS UF BARE-FACED CYNICISM I HAVE HAD THE PRIVILEGE TO ENCOUNTER. 77 TAIWAN REDUCED SMOKING IN '85 AND '84 BY 5% AND 4% RESPECTIVELY. BUT WHEN THE AMERICAN THREAT TO IMPOSE TRADE SANCTIONS FORCED THEM TO OPEN THEIR DOORS TO AMERICAN CIGARETTE ADVERTISING, SMOKING INCREASED BY 10 PERCENT, THE COSTS OF THE RESULTING DISABILITY AND DEATH WILL EXCEED THE ABILITY OF TAIWAN TO PAY, 78 I DO NOT BELIEVE THE UNITED STATES WILL EVER AGAIN BE A GOOD MARKET FOR TOBACCO PRODUCTS. THE CURVE IS GOING DOWN AND ACCELERATING. AND [ FEEL QUITE GOOD ABOUT THE ROLE I BELIEVE I PLAYED IN BRINGING ABQUT THIS MARKET CHANGE. J 79 WE HAVE BEATEN THE CIGARETTE INDUSTRY ON ITS OWN HOME TURF ... BUT WE'VE DRIVEN THEM TO SCOUR THE REST OF THE EARTH FOR NEW VICTIMS. | IT 1S THE HEIGHT OF HYPOCRISY FOR THE UNITED STATES, IN QUR WAR AGAINST DRUGS, TO DEMAND THAT FOREIGN NATIONS TAKE STEPS TO STOP THE EXPORT OF COCAINE TO OUR COUNTRY WHILE AT THE SAME TIME WE EXPORT NICOTINE, A DRUG JUST AS ADDICTIVE AS COCAINE, TQ THE REST OF THE WORLD. 80 I MUST CONFESS THAT, WHILE I RECEIVE MUCH PUBLIC PRAISE FOR MY INVOLVEMENT WITH SMOKING AND WITH AIDS, I COUNT AS ONE OF MY MAJOR ACHIEVEMENTS OF THESE PAST 9 YEARS THES EVOLUTION OF A MORE WIDESPREAD, MORE EFFECTIVE, AND MORE COMPASSIONATE APPROACH TO CHILDREN WHO ARE BORN WITH A NON-FATAL HANDICAP. Gi FOLLOWING THE YEAR-LONG "BABY DOE" DIALOGUE IN 1982, I CONVENED A SERTES OF "SURGEON GENERAL'S WORKSHOPS" THAT FOCUSED ON THE NEEDS OF THE HANDICAPPED CHILD AND HIS OR HER FAMILY. I INVITED PHYSICIANS, NURSES, SOCTAL WORKERS, HOSPITAL PERSONNEL , COMMUNITY ACTIVISTS, CHILD ADVOCATES, AND OTHERS. 82 GRADUALLY, WITH THE HELP OF THE NEW LAW AND THESE WORKSHOPS, THE COUNTRY HAS BEEN ABLE NOT ONLY TO DEFEND THE LIVES OF ITS NEWBORN CITIZENS, BUT ALSO TO DEAL MORE DIRECTLY AND MORE HELPFULLY WITH THE PROBLEMS THAT ARISE AS A RESULT OF THE SAVING OF THOSE LIVES. WHAT HAS EVOLVED IS "FAMILY-CENTERED, COMMUNITY-BASED, COMPREHENSIVE CARE FOR CHILDREN WITH SPECIAL NEEDS." IT'S A NEW CONCEPT. IT WORKS. AND IT'S BEING ADOPTED MORE AND MORE ALL ACROSS THE COUNTRY, 83 THE PROBLEM OF DRUGS IN AMERICA IS SO LARGE AND SO OFTEN DISCUSSED THAT 1 DON'T NEED TO ADD MY VOICE TO ALL THOSE WHO POINT OUT. THE URGENCY ABOUT DOING SOMETHING ABOUT THE DRUG CRISIS. IT IS A COMPLICATED PROBLEM, TOUCHING NOT ONLY UPON PUBLIC HEALTH, BUT ALSO INVOLVING LAW, POLITICS, AND EVEN THE MILITARY. % MY ONE COMMENT ON THIS ISSUE WILL MAKE A MEDICAL COMPARISON. NOT TOO LONG AGO THE MEDICAL COMMUNITY SPENT A GOOD DEAL OF TIME AND EFFORT TRYING TO DECIDE WHICH WAS THE BEST TREATMENT FOR CANCER: SURGERY, RADIATION, CHEMOTHERAPY, ETC. PEOPLE DIVIDED THEMSELVES INTO CAMPS, EACH PLUGGING ITS OWN SOLUTION. 97 EVENTUALLY IT BECAME CLEAR THAT THE SMARTEST STRATEGY WAS A MULTIPLE STRATEGY, EMPLOYING ALL OF THEM, EMPHASIZING ONE OR THE OTHER FOR CERTAIN PROBLEMS, IN THE SAME WAY, PERHAPS TO MUCH TIME HAS BEEN SPENT TRYING TO FIND THE BEST WAY TO FIGHT DRUGS: ELIMINATE THE SUPPLY, REDUCE THE DEMAND, INTERDICTION, INCARCERATION, SOLVING BASIC SOCIAL PROBLEMS. WE NEED ALL THESE, IN A MULTIPLE STRATEGY, AND THE WISDON TO DECIDE WHICH TO EMPHASIZE WHEN, 98 MY FINAL APPEARANCE BEFORE CONGRESS AS SURGEON GENERAL FOCUSED ON A DRUG TOPIC THAT FIGURED LARGELY IN MY FINAL YEAR IN OFFICE, ONE THAT. 1S HIGH ON THE AMERICAN LIST OF CONCERNS: ALCOHOL ABUSE, ESPECIALLY ALCOHOL-IMPATRED DRIVING. AN ESTIMATED 18 MILLION ADULT AMERICANS HAVE MEDICAL, SOCIAL AND PERSONAL PROBLEMS RELATED TO THE USE OF ALCOHOL, AS DO SEVERAL MILLION ADOLESCENTS FOR WHOM ALCOHOL IS AN ILLEGAL DRUG. eee EN, 99 MILLIONS OF OTHER ADULTS AND YOUTHS ARE AFFECTED BY THE ALCOHOL PROBLEMS OF FAMILY MEMBERS, FRIENDS, AND WORK ASSOCIATES. BY 1990 ALCOHOL ABUSE AND ALCOHOLISM ARE EXPECTED TO COST THE AMERICAN SOCIETY $196 BILLION A YEAR, INCLUDING BETWEEN $10 TO ~ $19 BILLION FOR ALCOHOL RELATED CRASHES. THESE FIGURES DO NOT INCLUDE THE COSTS OF GRIEF AND HUMAN SUFFERING. HOW MANY DEFICITS OF THIS KIND CAN THE COUNTRY AFFORD? I WAS LED 10 TACKLE THE ISSUE OF DRUNK DRIVING BECAUSE OF THE URGENCY OF THE CRISIS. T COULD SEE THE URGENCY IN THE MANY LETTERS THAT CAME IN TO MY OFFICE FROM STATE AND LOCAL OFFICIALS OF EVERY AREA OF THE COUNTRY. I ALSO RECEIVED THOUSANDS OF CARDS, LETTERS, AND TELE- GRAMS FROM SURVIVING FAMILY MEMBERS GRIEVING OVER THE LOSS OF A LOVED ONE ... SOMEONE KILLED BY A DRUNK DRIVER. 101 THE URGENCY WAS CLEAR FROM THE SENTIMENT EXPRESSED BY 99 UNITED STATES SENATORS AND FROM A UNANIMOUS HOUSE OF REPRESENTATIVES, WHO ASKED ME TO TAKE ON THIS ISSUE AND DO WHATEVER I COULD TO BRING IT UNDER CONTROL. TIME [5 NOT ON OUR SIDE. 102 HENCE, WE CAN EXPECT THAT 1990 -- LIKE 1989 AND 1988 BEFORE IT -- WILL BE A YEAR IN WHICH 24,000 MORE AMERICANS WILL HAVE DIED ON QUR HIGHWAYS IN ALCOHOL-RELATED ACCIDENTS. AND MANY THOUSANDS MORE WILL HAVE BEEN KILLED IN ACCIDENTS THAT ARE DRUG-RELATED. 103 DURING MY TIME AT THIS MICROPHONE THREE OF OUR CITIZENS WILL BE KILLED BY A DRUNK DRIVER. 934,000 PEOPLE ARE INJURED IN ALCOHOL- RELATED TRAFFIC CRASHES EACH YEAR. LEFT BEHIND -- THE PERMANENT BRAIN DAMAGE, THE SPINAL CORD INJURIES, THE LOST OR PERMANENTLY DEFORMED LIMBS, THE BLINDNESS AND THE IMPOTENCE ... THE LIFETIMES CRIPPLED WITH DISABILITY AND HAUNTED BY RECURRENT NIGHTMARES OF HOW IT ALL HAPPENED. 104 TENS OF THOUSANDS OF DEATHS ... HUNDREDS OF THOUSANDS OF INJURIES .+» THOSE ARE NUMBING STATISTICS. BUT THEY ARE ALSO MORE THAN JUST STATISTICS. THEY ARE REAL PEOPLE ... REAL HUMAN LIVES. THIS [5 A TOPIC THAT AFFECTS EACH OF YOU. IT TS A PROBLEM ALL TOO COMMON AMONG UNIVERSITY STUDENTS. 105 UNFORTUNATELY, A DISPROPORTIONATE NUMBER OF HIGHWAY VICTIMS ARE c4. NO OTHER COMPARABLE AGE COHORT HAS SUCH A RECORD OF DEATH AND INJURY ON THE HIGHWAY. AND THIS AGE GROUP, BY ITSELF, ACCOUNTS FOR OVER 8,000 ALCOHOL- RELATED FATALITIES, OR ABOUT A THIRD OF ALL FATALITIES EACH YEAR IN WHICH ALCOHOL IS IMPLICATED. 106 WITH ALCOHOL-IMPAIRED DRIVING, AS WITH SMOKING, THE ISSUES ARE MANY AND COMPLICATED, AND EVEN SMALL STEPS TOWARD ALLEVIATING THE PROBLEM TRIGGER STRONG EMOTIONS AND VEHEMENT CONTROVERSY, FOR EXAMPLE, LAST DECEMBER I INVITED TO A WORKSHOP ON DRUNK DRIVING, REPRESENTATIVES FROM THE NATIONAL ASSOCIATION OF BROADCASTERS, THE AMERICAN ASSOCIATION OF ADVERTISING AGENCIES, AND THE ASSOCIATION OF NATIONAL ADVERTISERS. THEY ALL DECLINED, VET CRITICIZED STRONGLY THE WORKSHOP AND ITS RECOMMENDATIONS. THE NATIONAL BEER AHOLESALERS ASSOCIATION WENT SO FAR AS TO FILE A LAWSUIT FOR A RESTRAINING ORDER FOR THE WORKSHOP, 107 ALCOHOL-IMPATRED DRIVING MUST BE SEEN AS A PUBLIC HEALTH AND OAFETY PROBLEM, RATHER THAN AS AN ECONOMIC AND MORAL ISSUE, AND QUR PRIMARY CONCERN MUST BE WITH PRESERVING HUMAN LIVES, AFTER THE WORKSHOP I INFORMED CONGRESS, MANUFACTURERS, THE VOLUNTARY AGENCIES, ADVERTISERS, AND LAW ENFORCEMENT AGENCIES WHAT EACH COULD DO TO STOP THE CARNAGE. LET ME HIGHLIGHT ONE MESSAGE 108 Te Pay - WE NEED SPECIAL ATTENTION TO THE PERNICIOUS MESSAGES OF ALCOHOL ADVERTISING. CURRENT ALCOHOLIC BEVERAGE ADVERTISING IS INCREASINGLY TARGETED AT YOUNG PEOPLE AND MINORITIES, AND OFTEN DEPICTS ALCOHOL CONSUMPTION AS A NORMAL AND GLAMOROUS ACTIVITY WITHOUT NEGATIVE CONSEQUENCES. DRINKING IS FREQUENTLY SHOWN IN ASSOCIATION WITH HIGH-RISK ACTIVITIES AND LINKED TO ATHLETIC, SOCIAL, AND SEXUAL SUCCESS. THAT'S THE WRONG MESSAGE. 109 QUR GOAL MUST BE THE NATIONAL TOTAL UNACCEPTABILITY OF DRIVING EF Re ee re ee Se ee cet i i ee me et ee ce ee nis AFTER USING ALCOHOL OR OTHER DRUGS. THE VERY ENORMITY OF OUR LOSSES DEMANDS NO LESS OF A RESPONSE. 110 Cc) YOU KNOW, THERE ARE RESPONSIBILITIES THAT COME WITH YOUR EDUCATION. YOU WILL BE THE NEXT GENERATION OF MOVERS AND SHAKERS OF AMERICA. AND ONE OF THOSE RESPONSIBILITIES IS TO BE ae en ee ce eee meee ene ee me eae et ome ee ee ee ee ee mee see ome ~~ REGARDING THE DELIVERY OF HEALTH CARE IN THIS COUNTRY. 126 THAT'S THE ISSUE I WANT TO CLOSE WITH. AND IT'S A BIG ONE. TO BEGIN WITH, THIS IS A TIME IN WHICH WE HAVE VERY HIGH EXPECTATIONS FOR MEDICINE AND HEALTH. WE'VE PUT A GREAT DEAL OF FAITH INTO NEW TECHNOLOGIES, NEW PHARMACEUTICALS, NEW SURGICAL OF MEDICINE. 127 WE ROUTINELY EXPECT MIRACLES TO HAPPEN -- EVEN THOUGH THE REAL WORLD OF MEDICINE ISN'T ALWAYS ABLE TO DELIVER. WE HAVE THAT OITUATION RIGHT NOW WITH AIDS. FOR THE PAST 7 YEARS, SCIENTISTS AND CLINICIANS HAVE BEEN WORKING AROUND THE-CLOCK TO UNDERSTAND AND CONQUER THE DISEASE OF AIDS. BUT IT STILL REMAINS A MYSTERY. I'M SORRY TO SAY THIS, BUT I DOUBT THAT WE'LL GET FULL CONTROL OVER THE ning VIRUS BEFORE THE TURN OF THE CENTURY, 128 BUT, AS FAR AS THE GENERAL PUBLIC IS CONCERNED, THE AIDS SITUATION IS THE EXCEPTION AND NOT THE RULE. THE AMERICAN PEOPLE STILL MAINTAIN HIGH HOPES FOR WHAT MEDICINE AND HEALTH CARE CAN DO FOR THEM, BUT I THINK IT'S ALSO BECOMING CLEAR THAT THOSE HIGH EXPECTATIONS ARE FAST QUT-RUNNING QUR ABILITY TO PAY FOR THEM. IN OTHER WORDS, WE HAVE A CLEAR GAP IN OUR SOCIETY TODAY BETWEEN WHAT WE WOULD LIKE TQ SEE HAPPEN IN HEALTH CARE ... AND WHAT CAN 129 AND SQ THE AMERICAN PEOPLE ARE ENGAGED IN A DEBATE IN RESPECT TO ASPIRATIONS VERSUS RESOURCES. 17'S A DEBATE THAT TOUCHES ON MANY ASPECTS OF AMERICAN LIFE ... BUT I'LL FOCUS JUST ON HEALTH CARE, WHICH IS PROFQUNDLY AFFECTED BY THAT GROWING TENSION BETWEEN ASPIRATIONS AND RESOURCES, 130 SOME CRITICS WILL SAY THAT THE CHIEF CAUSE IS THE BUDGET DEFICIT. ONCE WE GET RID OF THE DEFICIT, SAY THESE CRITICS, WE WILL ALSO GET RID OF THAT GAP BETWEEN ASPIRATIONS AND RESOURCES ... BETWEEN DREAMS AND REALITY. a ee ee ome ee ee ee oe ee re INFLATION RATE FOR THE REST OF THE AMERICAN ECONOMY. 131 BUT WE DIDN'T SEE IT ... OR, IF WE DID SEE IT, WE PREFERRED NOT TO WORRY ABOUT IT, TODAY, WE STILL HAVE AN INFLATED HEALTH CARE ECONOMY ... BUT WE ALSO HAVE INFLATED HEALTH CARE ASPIRATIONS. AND WE SIMPLY CAN'T AFFORD ANY INFLATION AT ALL. 132 WHEN I OR OTHER PEOPLE TALK LIKE THIS, OUR CRITICS COME BACK AT US AND SAY THAT THINGS REALLY AREN'T THAT BAD ... THAT ALL WE NEED TO DO 1S PUT A REIMBURSEMENT CAP ON THIS ... OR CHANGE THE ELIGIBILITY REGULATIONS FOR THAT ... OR CUT BACK A LITTLE HERE »++ OR PRUNE BACK A LITTLE THERE. eee ee ee oe 133 DURING 8 YEARS AS YOUR SURGEON GENERAL, I'VE LISTENED TO THESE DEBATES AND I'VE THOUGHT ABOUT THE TRUE HUMAN COSTS ASSOCIATED WITH THAT KIND OF A PATCHWORK APPROACH. AND TODAY I'M MORE CONVINCED THAN EVER THAT QUR WHOLE HEALTH CARE SYSTEM NEEDS TO BE STUDIED WITH AN EYE TO MAKING A NUMBER OF VERY MAJOR CORRECTIONS. NOW, I CAN ALREADY HEAR THE CRITICS SAYING, "WAIT A MINUTE, DR. KOOP. THE SYSTEM AIN'T BROKE, SO DON'T FIX IT." 134 TO WHICH IT WOULD REPLY, "YOU'RE WRONG. THE SYSTEM IS BROKE ... UNIFORMLY GOING UP AS WELL. 195 IN ONE OF HIS PLAYS, GEORGE BERNARD SHAW ASKED WHY WE PAY DOCTORS TO TAKE A LEG OFF BUT WE DON'T PAY THEM TO KEEP A LEG ON. NOW, ALMOST 80 YEARS HAVE PASSED AND WE STILL HAVEN'T COME UP WITH A GOOD ANSWER. OUR TECHNOLOGY-DRIVEN REIMBURSEMENT SYSTEM -- WHETHER BY GOVERNMENT OR OUT-OF-POCKET -- 15 STILL PREDICATED ON TAKING THE LEG OFF. 136 WORSE STILL, AS THE COST OF HOSPITAL -BASED CARE INCREASES, THE HOSPITALS THEMSELVES ARE TRYING TO NARROW THEIR PATIENT POOL ... FOR EXAMPLE, ELIMINATING THE NEED TO PROVIDE IN-PATIENT MEDICAL CARE FOR POOR AND DISADVANTAGED AMERICANS. T SAY THERE'S SOMETHING TERRIBLY WRONG WITH A SYSTEM OF HEALTH CARE THAT SPENDS MORE AND MORE MONEY TO SERVE FEWER AND FEWER PEOPLE. 137 AND WE HAVE MUCH THE SAME PROBLEM IN RESPECT TO PHYSICIAN SERVICES AND FEES. 1 COULD MAKE THE SAME CASE AS I DID FOR HOSPITAL CARE. BUT PHYSICIANS ARGUE THAT THEY HAVE LITTLE OR NO CONTROL OVER SOME OF THE INFLATIONARY THINGS THEY DO. THAT'S SO. I'VE BEEN THERE. 138 LET ME SAY THAT IN GENERAL I SUPPORT THE CONCEPT OF A LAISSEz- FAIRE MARKETPLACE AND I BELIEVE IN A FREELY COMPETITIVE ECONOMY, T THINK A LAISSEZ-FAIRE ECONOMY WORKS BEST FOR ALL OUR CITIZENS AND I'M THRILLED -- AS I'M SURE ALL AMERICANS ARE THRILLED -- TO SEE SO MANY COUNTRIES WITH STATE-CONTROLLED ECONOMIES COMING AROUND TO QUR POINT OF VIEW. 139 NOW, HAVING SAID THAT, LET ME GO ON TO SAY THAT THE HEALTH CARE MARKETPLACE IS LAISSEZ-FAIRE ... BUT IT'S NOT FREELY COMPETITIVE AND, HENCE, IT HAS VIRTUALLY NO MODERATING CONTROLS WORKING ON BEHALF OF THE CONSUMER, OR THE PATIENT. IN HEALTH CARE, RIGHT ACROSS THE BOARD, PRICES HAVE GONE UP OTHER MARKETPLACE CONTROL. 140 TRY AS THEY MIGHT, I DON'T SEE THE MEDICAL PROFESSION ACHIEVING MUCH SUCCESS IN SELF-REGULATION. GRANTED, IT'S NO SIMPLE TASK, PHYSICIANS CAN HELP PUT THE BRAKES ON SOME GENERAL EXPENDITURES, INDIVIDUAL PATIENT AT THE BEDSIDE. 141 WE SEEM 10 HAVE, THEREFORE, A SYSTEM OF HEALTH CARE THAT'S DISTINGUISHED BY A VIRTUAL ABSENCE OF SELF-REGULATION ON THE PART OF THE PROVIDERS OF THAT HEALTH CARE -- THAT IS, HOSPITALS AND PHYSICIANS -- AND DISTINGUISHED AS WELL BY THE ABSENCE QF SUCH NATURAL MARKETPLACE CONTROLS AS COMPETITION IN REGARD TO PRICE, QUALITY, OR SERVICE. 142 WHAT IS THE EFFECT OF SUCH A SYSTEM ANYWAY? ONE VERY SERIOUS EFFECT HAS BEEN THE EMERGENCE OF A THREE-TIER FRAMEWORK OF HEALTH CARE. WE'VE ALWAYS SAID WE NEVER WANTED EVEN 143 IN THE FIRST TIER ... THE BOTTOM TIER ... ARE UPWARDS OF 30 MILLION AMERICANS -- ABOUT 15 PERCENT OF THE POPULATION -- WHO FALL THROUGH THE CRACKS AND HAVE NO HEALTH INSURANCE COVERAGE ... NO HIGH OPTIONS ... NO LOW OPTIONS ... NO OPTIONS AT ALL. THEY'RE NOT OLD ENOUGH FOR MEDICARE AND NOT POOR ENOUGH FOR MEDICAID. WHAT, THEN, DOES THIS “HEALTH CARE SYSTEM" OF OURS DO FOR THE UNINSURED? IN THE VAST MAJORITY OF CASES THE ANSWER IS oe» VERY LITTLE ... OR NOTHING. 144 THEN WE HAVE A SECOND TIER, THIS TIER RECEIVES A NARROW RANGE OF BASIC MEDICAL AND HEALTH SERVICES WITH MORE OR LESS FIXED LEVELS OF REIMBURSEMENT. THIS IS LOW-OPTION COVERAGE ... MEDICARE AND MEDICAID COVERAGE ... WITH THE PATIENT PAYING MANY COSTS QUT-OF- POCKET OR WITH THE HELP OF SOME FORM OF SUPPLEMENTAL INSURANCE , WHICH 15 -- IN MY BOOK -- JUST ANOTHER KIND OF OUT-OF-POCKET EXPENSE. 149 FINALLY, WE HAVE THE THIRD TIER, THE TOP TIER. THE PEOPLE IN THIS TIER RECEIVE A FULL RANGE OF MEDICAL AND HEALTH SERVICES, THEY ARE COVERED BY HIGH-OPTION HEALTH INSURANCE AND ALSO HAVE A FEW DOLLARS LEFT OVER TO PAY THE 15 OR 20 PERCENT DIFFERENCE BETWEEN THE ACTUAL BILL FROM THE DOCTOR AND THE CHECK FROM THE INSURANCE COMPANY. 146 MANY QF QUR LARGEST BUSINESS AND INDUSTRIAL ORGANIZATIONS ARE IN THIS TOP TIER. YEARS OF TOUGH COLLECTIVE BARGAINING MADE IT POSSIBLE FOR MILLIONS OF THEIR UNIONIZED EMPLOYEES AND THEIR FAMILIES TO BE IN THAT TOP THIRD TIER. BUT NOW IT'S NO SECRET THAT HEALTH CARE INFLATION HAS BECOME 147 BUT HOW DOES THE BARGAINING END? THAT'S EASY: MORE MONEY IS PROMISED FOR EMPLOYEE HEALTH BENEFITS wee AND THE INCREASED HEALTH COSTS TRANSLATE INTO HIGHER PRICES FOR THE CUSTOMER OR THE UTILITY RATE-PAYER. THAT WHAT THE TELEPHONE STRIKE WAS ABOUT: NOT WAGES, NOT WORKING CONDITIONS, -- BUT HEALTH INSURANCE, 148 BUSINESS ITSELF IS FINALLY COMING AROUND TO UNDERSTAND THAT IT CANNOT CONTINUE TO BURY INFLATED COSTS OF HEALTH CARE IN THE PRICE-TAGS OF THEIR GOODS AND SERVICES. YOU CAN'T DO THIS AND ALSO EXPECT TO BE COMPETITIVE, 149 IT DOESN'T MAKE SENSE TO BE TOUGH WITH THE JAPANESE, FOR EXAMPLE, BUT THEN MEEKLY GIVE YOUR HEALTH PLAN THE 10 PERCENT ... 12 PERCENT ... OR 13 PERCENT ANNUAL INCREASE IT DEMANDS. AND AMERICAN BUSINESS AND LABOR LEADERS ARE FINALLY COMING TO UNDERSTAND THAT FACT OF LIFE. 190 A SURPRISING AND VERY SIGNIFICANT EVENT TOOK PLACE AT THE BEGINNING OF LAST SUMMER, TWO GROUPS, UNLIKELY PARTNERS IN THIS SORT OF ISSUE, EACH CALLED FOR A NATIONAL HEALTH SERVICE, THE FIRST WAS ONE OF THE MAJOR AUTOMOBILE MANUFACTURERS , BODY. 151 NEVER BEFORE HAVE THERE BEEN SO MANY VOICES CLAMORING FOR RADICAL REFORM OF THE AMERICAN HEALTHCARE SYSTEM, IN CONGRESS, IN LABOR, IN BUSINESS, IN PHYSICIANS’ OFFICES PEOPLE AGREE: SOMETHING MUST BE DONE. 13e RECENTLY I'VE NOTICED A STRANGE INTEREST IN THE CANADIAN SYSTEM, EVERVWHERE I GO PEOPLE SAY TO NE, “VE NEED THE CANADIAN SYSTEN, sol say, "TELL NE, WHAT IS IT YOU LIKE ABOUT THE CANADIAN SYSTEM, 2" THEY ALWAYS ANSWER, "I DON'T REALLY KNOW, BUT IT'S A GOOD SYSTEM, " 133 THE GROWING INFATUATION WITH FOREIGN NATIONAL HEALTH SERVICES IS BASED MORE UPON DISSATISFACTION WITH OUR SYSTEM THAN UPON UNDERSTANDING OF ANOTHER ONE. MOST AMERICANS DO NOT REALIZE THAT A NATIONAL HEALTH SERVICE, ee ree at ee ces nee oe 154 EXPERIENCE THE WORLD OVER HAS SHOWN THAT WHEN GOVERNMENT ECONOMIC CONTROLS ARE APPLIED TO HEALTH, THEY PROVE --IN TIME-- TO BE DETRIMENTAL. EVENTUALLY THERE IS AN EROSION OF QUALITY, PRODUCTIVITY, INNOVATION, AND CREATIVITY. THEN, LACK OF RESPONSIVENESS TO PATIENTS (THE CANADIAN SYSTEM IS NOT CONTROLLED BY PHYSICIANS). FINALLY, RATIONING AND WAITING IN LINES, 199 AMERICANS DO NOT PATIENTLY QUE UP FOR ANYTHING, ESPECIALLY FOR MEDICAL CARE, THE HEALTH CARE SYSTEM IN AMERICA TODAY IS A TERRIBLE MORAL ee Oe te eee co ne a inte eS eee) ae see eee eae EVERY OTHER SECTOR OF AMERICAN SOCIETY. 194 WE NEED TO CHANGE THAT SYSTEM. NOT JUST A LITTLE CHANGE HERE AND A LITTLE CHANGE THERE. WE NEED TQ BRING ABOUT A PROFOUND CHANGE ACROSS-THE-BOARD IN THE WAY WE MAKE MEDICAL AND HEALTH CARE AVAILABLE TO ALL OUR CITIZENS, BUT CAN WE DO IT? T'D LIKE TO THINK WE CAN ... BECAUSE WE HAVE TO... AND ESPECIALLY BECAUSE WE'VE DONE IT BEFORE. 157 OUME 30 YEARS AGO, FOR EXAMPLE, WE AMERICANS KNEW THAT IT WAS MORALLY WRONG FOR QUR SOCIETY TO ALLOW ITS OLD PEOPLE TO DRIFT INTO POVERTY AND STARVATION. WE KNEW THAT WE COULD NO LONGER STAND BY HELPLESS IN THE FACE OF SUCH HUMAN MISERY, oe ee ee oe ee WE WERE BETTER THAN THAT ... WE HAD TO BE BETTER THAN THAT ... BECAUSE OUR SOCIETY COULD NOT CARRY SUCH A BURDEN OF UNFAIRNESS ° AND SQ WE ENACTED A SOCIAL SECURITY LAW TO MAKE SURE THAT EVERY AMERICAN WOULD BE ASSURED OF A MEASURE OF HUMAN DIGNITY AND RESPECT IN HIS OR HER TWILIGHT YEARS. IT WAS AN ACT OF FUNDAMENTAL DECENCY, WE KNEW WE HAD TO DO IT. AND WE DID IT. WE MET A SIMILAR CHALLENGE MORE RECENTLY THAN THAT. BACK IN THE 17905 AND EARLY 1960S, THE PEOPLE OF THIS COUNTRY BECAME PAINFULLY AWARE OF THE TERRIBLE UNFAIRNESS OF "SEPARATE BUT EQUAL" EDUCATION. 159 AND SQ, THROUGH OUR COURTS AND QUR LEGISLATURES, WE RELEASED Ae cee ca en ee es eee sc een ee ee ee eee ee Se cae Cores ee ee SCHOOLS. THAT'S OVER. AND THANK GOODNESS IT IS. DID We GET RID OF THOSE BURDENS ONCE AND FOR ALL? WELL, NOT EXACTLY: 140 WE HAVEN'T YET SOLVED EVERY PROBLEM ASSOCIATED WITH "GROWING OLD IN AMERICA." WE KNOW THAT, AND WE HAVEN'T YET PRODUCED THE PERFECT, EGALITARTAN SCHOOL SYSTEM. WE KNOW THAT, TOO. 161 BUT AT LEAST WE'VE LIFTED FROM THE SHOULDERS OF OUR PEOPLE A LARGE MEASURE OF THE BURDEN OF SHAME AND GUILT THAT CAME WITH DOING NOTHING. WE DID WHAT WAS MORALLY RIGHT FOR THIS COUNTRY. AND I BELIEVE WE CAN -- AND MUST -- DO THAT AGAIN. LET'S FINALLY SAY WHAT WE'VE HESITATED TO SAY FOR TOO MANY YEARS, AND THAT IS ... QUR CURRENT SYSTEM OF HEALTH CARE IS NOT FAIR vee IT'S NOT JUST ... AND, THEREFORE, IT IS NOT THE MORALLY STRONG SYSTEM THAT OUR SOCIETY NEEDS. WE ARE IN A PERIOD OF TIGHT FINANCIAL CONSTRAINTS, AND IF YOU READ THE LIPS OF THE PRESIDENT -- NO NEW TAXES. 13 IF THAT WERE NOT SO, I THINK WE'D HAVE A GOVERNMENT-CONTROLLED NATIONAL HEALTH SERVICE ALMOST IMMEDIATELY. THAT WOULD SEEM MARVELOUS AT THE BEGINNING, BUT DISSATISFACTION WOULD COME UNTIL YOU COULDN'T WAIT TO CHANGE IT AGAIN. THAT MEANS THE PRIVATE SECTOR HAS A CHANCE -- IN A SMALL WINDOW -- TO COME UP WITH A SOLUTION. WE'LL SEE. 14 PUTTING TOGETHER SUCH A MORALLY STRONG AND FAIR SYSTEM OF HEALTH CARE WILL BE A MAJOR TASK FOR THIS COUNTRY. T HAVE NO ILLUSIONS ABOUT THAT. BUT WE MUST NOT LET SUCH CONSIDERATIONS STOP US FROM DOING WHAT WE KNOW IS RIGHT, 145 IT 1S A CHALLENGE TO ALL OF US ... BUT IT IS ESPECIALLY IMPORTANT TO YOU, AS YOU BEGIN TO PARTICIPATE FULLY IN AMERICAN LIFE. WE CAN -- AND WE MUST -- FIND A WAY TO HAVE BOTH EXCELLENCE ee ane ae are aie ee ey ee a ee ee, .» TO WORK TOGETHER TO ACHIEVE SUCH A SYSTEM. 146 DO YOU REMEMBER THE WORDS OF THE PROPHET? "IF I AM NOT FOR MYSELF, WHO AM I FOR? BUT IF I AM ONLY FOR MYSELF, WHAT AM 1? AND IF NOT NOW ... WHEN?" THANK YOU., tH # # # 167 a) IN 1870 THE UNITED STATES CONGRESS PASSED A LAW CREATING AN ORGANIZATION TQ PREVENT CRUELTY TO ANIMALS. VERY QUICKLY, EVEN IN RELATIVELY SMALL TOWNS, ORGANIZATIONS BEGAN TO PROTECT ALL MANNER OF FURRY OR FEATHERED CREATURES. IT 15 A SAD COMMENTARY ON OUR SOCIETY TO ADMIT THAT IT TOOK AN ADDITIONAL 100 YEARS TO CREATE OUR FIRST SHELTER FOR BATTERED WOMEN. 84 VIOLENCE IS NOT ONLY A PROBLEM FOR AMERICAN SOCIETY, PROBLEM. MY INTEREST IN THIS ISSUE BEGAN IN A CURIOUS WAY. IN 1984, I WAS ASKED TO ADDRESS A MEETING ON TELEVISION VIOLENCE. THE GOVERNMENT HAD BEEN FUNDING RESEARCH IN T.V. VIOLENCE FOR THE PAST 20 YEARS AND SPEECHES ON THE SUBJECT BY THE SURGEON GENERAL WERE RATHER ROUTINE ... G5 BUT I BEGAN TO WONDER IF SOMEHOW OUR PREOCCUPATION WITH T.V. VIOLENCE MIGHT ACTUALLY BE PREVENTING US FROM SEEING THE LARGER AND MUCH MORE SERIOUS PROBLEM OF REAL VIOLENCE IN OUR SOCIETY. EVEN A QUICK GLANCE AT THE PROBLEM REVEALED ITS STAGGER ING DIMENSIONS. 86 REPORTS FROM AROUND THE NATION INDICATED THAT AS MANY AS 4 MILLION CHILDREN WERE VICTIMS OF ABUSE AND NEGLECT. TO QUR SHAME WE HAD HIDDEN THIS NATIONAL TRAGEDY. MANY OF THOSE YOUNG VICTIMS HAVE BEEN PUNCHED ... SLAPPED ... THROWN ... AND BEATEN WITH FISTS, CLUBS, AND OTHER WEAPONS. ADULTS DO THAT TO CHILDREN. 87 FOR CENTURIES ADULTS HAVE INJURED CHILDREN ... AND HAVE LIED ABOUT IT... AND OTHER ADULTS HAVE HEARD THOSE LIES AND THEN MERELY TURNED AWAY. THE STATISTICS FOR WOMEN ARE EQUALLY ALARMING. ESTIMATES VARY, BUT WE KNOW THAT FROM 1 TO 3 MILLION WOMEN IN THE UNITED STATES ARE BATTERED AND ASSAULTED EACH YEAR BY THEIR HUSBANDS OR PARTNERS. MANY ARE RAPED, 88 THESE WOMEN VICTIMS OF ASSAULT ARE PERMANENTLY INJURED -- NOT JUST PHYSICALLY BUT ALSO MENTALLY --~ WHILE SOME OF THEM LOSE THEIR LIVES. BATTERY IS THE SINGLE MOST SIGNIFICANT CAUSE OF INJURY TO WOMEN IN THIS COUNTRY. 89 ONE IN EVERY FIVE WOMEN SEEN IN HOSPITAL EMERGENCY ROOMS 15 A VICTIM OF PERSONAL INJURY CAUSED BY SPOUSE ABUSE. REMEMBER, BEHIND THESE COLD NUMBERS, PERCENTAGES, AND STATISTICS ARE REAL PEOPLE, OUR NEIGHBORS, OUR FAMILY MEMBERS, OUR FELLOW CITIZENS. - 10 THE CONSEQUENCES ARE ENORMOUS: LOSS OF SELF-ESTEEM, INABILITY TO WORK PRODUCTIVELY AND TO CARE FOR CHILDREN, PSYCHIATRIC PROBLEMS, ALCOHOL AND DRUG DEPENDENCE. STUDIES HAVE SHOWN THAT BATTERED WOMEN ARE FOUR TO FIVE TIMES MORE LIKELY THAN NON-BATTERED WOMEN TO REQUIRE PSYCHIATRIC TREATMENT. 91 MANY SUFFER FROM ANXIETY, INCREASED LEVELS OF HOSTILITY, OBSESSIVE-COMPULSIVE SYMPTOMS, AND AGORAPHOBIA - FEAR OF OPEN SPACES. SOME COMMIT SUICIDE. MOREOVER, STUDIES HAVE SHOWN THAT WOMEN WHO ARE ABUSED ARE EIGHT TIMES MORE LIKELY TO ABUSE THEIR CHILDREN THAN WOMEN WHO ARE NOT ABUSED. THESE ABUSED CHILDREN THEN OFTEN BECOME ABUSERS THEMSELVES. 92 WE REALIZE THAT WE DON'T HAVE GOOD STATISTICS IN THIS DIFFICULT AREA. BUT, IF ANYTHING, THESE NUMBERS ARE MUCH TOO LOW. WE ESTIMATE, FOR EXAMPLE, THAT FOR EVERY ADULT VICTIM OF VIOLENCE ADULT VICTIMS PASS THROUGH HOSPITAL EMERGENCY ROOMS OR COMMUNITY CLINICS AND ARE MISSED BY THE POLICE ALTOGETHER. 93 INTERPERSONAL FAMILY VIOLENCE 1S AN OVERWHELMING MORAL, ECONOMIC, AND PUBLIC HEALTH BURDEN THAT OUR SOCIETY CAN NO LONGER BEAR. IN THIS COUNTRY, NO MAN HAS A LICENSE TO BEAT A WOMAN ... AND GET AWAY WITH IT. AND NO WOMAN IS OBLIGED TO ACCEPT A BEATING ... AND SUFFER BECAUSE OF IT. 94 T WON'T GO INTO ALL THE DETAILS OF HOW WE FACED THIS PROBLEM, BUT MUCH HAS BEEN ACCOMPLISHED. NOT ENOUGH. THERE [5 STILL MUCH TO DO. WE SAY WE ARE A CIVILIZED SOCIETY. ALL RIGHT, LET'S ACT LIKE ONE. 99 WE AMERICANS CAN GET SLIGHTLY ZANY ABOUT FOOD -- THE TEACHERS"--AND FOR THE STUDENTS, HOUSEWIVES PITCHED QUT JARS OF APPLESAUCE, AND THEN THERE WAS THAT FRANTIC MOTHER IN UPSTATE NEW YORK WHO INSISTED THAT THE STATE POLICE INTERCEPT HER DAUGHTER'S SCHOOL BUS, BECAUSE SHE HAD PACKED AN APPLE IN THE LITTLE GIRL'S | LUNCH BOX BEFORE HEARING NEWS REPORTS ABOUT ALAR. 111 SUME PEOPLE THINK THAT ALL MAN-MADE SUBSTANCES SHOULD BE REMOVED FROM OUR FOOD SUPPLY, AND THAT EVERYTHING OCCURRING IN NATURE IN BENEFICIAL. THEY INSIST ON BANNING ALL PESTICIDES. FORTUNATELY THE LARGE CHAIN STORES HAVE NOT JUMPED ON THIS BANDWAGON, ALTHOUGH SOME SMALL STORES HAVE PLEDGED Td SELL NOTHING EXCEPT | FOODS UNTREATED BY PESTICIDES. NOT ONLY WILL THIS LEAVE THEN WITH ROTTEN FOOD, BUT ALSO THEY WILL FAIL TO PROTECT THE CONSUMER AF FLA FUN, AGAINST MOLD SUCH AS ATF WHICH IS LETHAL, AND OCCURS, FOR EXAMPLE, ON CORN. Ile PEOPLE WHO ARE SOQ WORRIED ABOUT PESTICIDES FAIL TO REALIZE THAT THE CANCER RATES HAVE DROPPED OVER THE LAST 40 YEARS: STOMACH CANCER HAS DROPPED MORE THAN 75%, WHILE RECTAL CANCER DROPPED MORE THAN 454. THE ONLY CANCER RATE THAT IS GOING UP IS AN ENVIRONMENTAL CANCER, CIGARETTE- INDUCED LUNG CANCER. MUCH OF THE PUBLIC CONCERN ABOUT CARCINOGENS IN PESTICIDES IS MISPLACED. 11d THE CHAIRMAN OF THE DEPARTMENT OF BIOCHEMISTRY AT BERKELEY, AND AUTHOR OF IMPORTANT ADVANCES IN ONCOLOGY BELIEVES THAT THE FDA IS CORRECT IN SAYING THAT AVERAGE AMERICAN CONSUMES 45 NICROGRAMS OF POSSIBLE CARCINOGENIC MAN-MADE PESTICIDE RESIDUES EVERY DAY. BUT HE POINTS OUT THAT THERE ARE 500 MICROGRAMS OF NATURALLY OCCURRING CARCINOGENS IN 1 CUP OF COFFEE, 185 MICROGRAMS OF NATURAL CARCINOGENS IN A SLICE OF BREAD, 2000 MICROGRAMS OF NATURE'S CARCINOGENS IN COCA-COLA, 114 UNTIL RECENTLY, AMERICANS THOUGHT ABOUT FOOD IN TERMS OF TASTE AND COST. NOW THETR CHIEF CONCERNS ARE HEALTH AND SAFETY. AMERICANS ENJOY THE SAFEST FOOD SUPPLY IN THE WORLD, BUT IT TAKES ONLY AN ISOLATED INCIDENT OR RUMOR TO MAKE THIS NATION PANIC ABOUT THE SAFETY OF OUR ENTIRE FOOD SUPPLY. 115 THE AMERICAN PEOPLE WANT ASSURANCE THAT EVERYTHING THEY EAT IS "SAFE". THE BUESTION ABOUT THE FOOD SUPPLY IS NOT "IS IT SAFE?" ~-FEW THINGS IN LIFE CAN BE GUARANTEED "SAFE" -- BUT "IS IT SAFE ENOUGH?" 114 IN THE FOOD SUPPLY --AS IN ALL OTHER PUBLIC HEALTH QUESTIONS-- WE NEED BETTER UNDERSTANDING OF RISK AND HAZARD --AND THE DIFFERENCE BETWEEN RISK AND HAZARD. THERE IS RISK IN ALMOST EVERYTHING WE DO, SQ WE NEED TO CONCENTRATE ON THE DIFFERENCE BETWEEN EXPOSURE TO A HAZARD AND TRUE RISK, 117 SOME INSIST THAT NO AMOUNT OF CHEMICALS OR PESTICIDE RESIDUE IN FOOD 1S ACCEPTABLE. PUBLIC HEALTH OFFICIALS, HOWEVER, OPERATE ON THE PRINCIPLE THAT MERE EXPOSURE TO A SUBSTANCE DOES NOT NECESSARILY CREATE A HAZARD. IT IS THE COMBINATION OF TOXICITY AND EXPOSURE THAT CREATES THE ee ane ete cee one one ene aoe ae ae ee ene eae coe RISK. WE STILL HAVE A LONG WAY TO GO IN EDUCATING THE AMERICAN PEOPLE ABOUT THIS DIFFERENCE BETWEEN EXPOSURE AND RISK. 118 A NUMBER OF RECENT SCARES SHOWED US HOW QUICKLY CONCERN TURNS TO AS A PUBLIC HEALTH OFFICIAL, I APPLAUD THE AMERICAN CONCERN FOR A HEALTHFUL DIET. SUSTAINED PUBLIC INTEREST IN DIET AND HEALTH IS BOUND TO MAKE A DIFFERENCE, BECAUSE DIET 1S FUNDAMENTAL TO THE HEALTH OF THE AMERICAN PEOPLE. 119 INDEED, THE AMERICAN COUNCIL ON SCIENCE AND HEALTH INDICATES THAT TWO-THIRDS OF ALL DEATHS IN AMERICA ARE DIRECTLY OR INDIRECTLY RELATED TO DIET. BUT PUBLIC HEALTH OFFICIALS BECOME FRUSTRATED WHEN CONCERN ABOUT DIET LEADS TO CONFUSION ABOUT THE SAFETY OF THE FOOD SUPPLY. 120 SOMETIMES BEING TOO CONCERNED ABOUT DIET CAN BE COUNTER- PRODUCTIVE. WORRYING ABOUT TRACES OF CHEMICALS IN A FEW FOODS MAY BE KEEPING MANY AMERICANS FROM EATING THE WELL-ROUNDED AND NUTRITIONAL DIETS THEY NEED, 121 WHILE WE ARE TALKING ABOUT FOOD, A FEW WORDS ABOUT THE CHOLESTEROL ISSUE. THE CHOLESTEROL BALLOON HAS BEEN PRICKED AND IS DEFLATING. LET'S BE VERY CLEAR ABOUT CHOLESTEROL. IT IS A RISK FACTOR FOR CORONARY HEART DISEASE. i2e2 IT 15 HOWEVER, ONLY ONE OF SEVERAL RISK FACTORS, AND MOST SCIENTISTS THINK THE OTHERS, SUCH AS SMOKING AND HIGH BLOOD PRESSURE ARE MORE IMPORTANT AND EASIER TO CONTROL. BECAUSE CHOLESTEROL IS MANUFACTURED IN THE BODY NATURALLY, DIET DOES NOT HAVE THE DIRECT RELATIONSHIP TO BLOOD LEVELS THAT MANY MISLED LAYMEN ASSUME. 123 THEN TOO, THE STATED RELATIONSHIP BETWEEN CORONARY HEART DISEASE AND CHOLESTEROL BLOOD LEVELS FALLS OFF FOR WOMEN WHEN THEY GET OVER 35 AND MEN WHEN THEY GET OVER 40. HEREDITY IS A PROMINENT FACTOR. IN SUMMARY IT SEEMS THAT ADVICE CONCERNING CHOLESTEROL DIET IN RELATIONSHIP TO CORONARY HEART DISEASE HAS BEEN GIVEN TO MORE PEOPLE THAN THOSE TO WHOM THE INFORMATION 15 PERTINENT. A SEGMENT OF THE POPULATION MAY HAVE BEEN MISLED INTO THINKING DIETARY CHANGES CAN ACCOMPLISH MORE THAN IS POSSIBLE. 124 THE NUMBERS ARE INTERESTING. WHILE MANY STUDIES SHOW THAT THERE TS A REDUCTION IN THE NUMBER OF HEART ATTACKS ASSOCIATED WITH THE LOWERING OF CHOLESTEROL, THERE 15 NO EVIDENCE THAT THERE IS AN ACCOMPANYING REDUCTION IN THE DEATH RATE FROM CORONARY EAR DISEASE. SQ, ALTHOUGH THE QUALITY OF LIFE MIGHT BE IMPROVED, THE DEATH RATE IS STILL THE SAME. THERE IS NO DOUBT THAT SOME HAVE BENEFITTED FROM THE CHOLESTEROL HEALTH INITIATIVE, BUT GREATER NUMBERS HAVE BEEN TREATED THAN NECESSARY OR PRUDENT. 125