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WE’D FEEL GOOD ABOUT OURSELVES AND OUR HEALTH CARE
SYSTEM.

NO LONGER.

IN A WORD --WE HAVE BIG PROBLEMS.

SOMETIMES I USED TO WONDER IF THERE SHOULD NOT HAVE
BEEN ANOTHER SURGEON GENERAL’S WARNING:

"WARNING! THE AMERICAN HEALTH CARE SYSTEM CAN BE

HAZARDOUS TO YOUR HEALTH!

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 PROCEDURES, AND SO
ON, AND WE CONTINUE TO HAVE FAITH IN WHAT I LIKE TO CALL

THE MAGIC OF MEDICINE.

WE ROUTINELY EXPECT MIRACLES TO HAPPEN -- EVEN THOUGH

THE REAL WORLD OF MEDICINE ISN’T ALWAYS ABLE TO DELIVER.

WE HAVE THAT SITUATION RIGHT NOW WITH AIDS.
FOR THE PAST 8 YEARS, SCIENTISTS AND CLINICIANS HAVE BEEN
WORKING AROUND-THE-CLOCK TO UNDERSTAND AND CONQUER
THE DISEASE OF AIDS. BUT IT STILL REMAINS SOMEWHAT OF A
MYSTERY AND I DOUBT THAT WE’LL GET FULL CONTROL OVER
THE AIDS VIRUS BEFORE THE TURN OF THE CENTURY.

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 OUT-RUNNING OUR ABILITY TO PAY
FOR THEM.

IN OTHER WORDS, WE HAVE A CLEAR GAP IN OUR SOCIETY
TODAY BETWEEN WHAT WE WOULD LIKE TO SEE HAPPEN IN
HEALTH CARE ... AND WHAT CAN REALISTICALLY HAPPEN IN

HEALTH CARE.
AND SO THE AMERICAN PEOPLE ARE ENGAGED IN A DEBATE IN
RESPECT TO ASPIRATIONS VERSUS RESOURCES.

THIS IS A DEBATE THAT TOUCHES ON MANY ASPECTS OF
AMERICAN LIFE... BUT PLL FOCUS JUST ON HEALTH CARE, WHICH
IS PROFOUNDLY AFFECTED BY THAT GROWING TENSION

BETWEEN ASPIRATIONS AND RESOURCES.
MANY OF OUR GREAT EXPECTATIONS COME FROM OUR ABIDING
FAITH IN EVER-IMPROVING MEDICAL TECHNOLOGY.
BUT NOW, I BELIEVE THE PUBLIC WONDERS IF MEDICAL

TECHNOLOGY MIGHT BE A MIXED BLESSING.

THANKS TO AN EXPLOSION OF NEW KNOWLEDGE IN SCIENCE
AND TECHNOLOGY OVER THE PAST SEVERAL DECADES, WE KNOW

HOW TO DO MANY NEW AND FASCINATING THINGS:
BUT KNOWING HOW TO DO SOMETHING HAS NEVER BEEN
ENOUGH.

PEOPLE ALSO WANT TO KNOW WHY ... OR WHY NOT?

AND TODAY, AS THE COST OF OUR MAGIC TECHNOLOGY SOARS,

WE’RE ASKING "WHY?" MORE OFTEN AND MORE INSISTENTLY.

IN REGARDS TO PROLONGING LIFE, FOR EXAMPLE, BOTH
THE LAY PUBLIC AND THE MEDICAL PROFESSION ARE EVEN NOW
DEBATING THE WISDOM OF USING SO-CALLED "EXTRAORDINARY"
MEASURES TO SAVE OR PROLONG THE LIVES OF PERSONS

PROFOUNDLY TRAUMATIZED OR TERMINALLY ILL.
FOR MANY PEOPLE WHO MUST DECIDE THE FATE OF LOVED
ONES, HIGH-TECH MEDICINE SOMETIMES ACTS LIKE A FRIEND ...

AND SOMETIMES IT ACTS LIKE AN ENEMY.

HENCE, SOME PEOPLE ARE TURNING TO LEGAL INSTRUMENTS
LIKE THE SO-CALLED "LIVING WILL" AND THE "DURABLE POWER
OF ATTORNEY" TO PROTECT THEMSELVES FROM RUNAWAY
MEDICAL TECHNOLOGY, IN THE EVENT THEY ONE DAY HAVE A

TERMINAL ILLNESS OR INJURY.
HENCE, IN MANY REAL-LIFE SITUATIONS, TECHNOLOGY IS A
MIXED BLESSING ... AT BEST ... AND CAN BE A CURSE, AT THE

WORST.

IS OUR SOCIETY STILL READY AND WILLING TO DELIVER HIGH-
QUALITY, TECHNOLOGY-INTENSIVE MEDICAL CARE TO
EVERYONE, REGARDLESS OF COST?

TP’D HAVE TO SAY THE ANSWER I GET AS I TRAVEL AROUND THE

COUNTRY IS, "PROBABLY NOT."

10
WHAT WE HAVE, THEN, IS A RISE IN THE NEW TECHNOLOGIES
AVAILABLE TO PHYSICIANS ...
BUT, AT THE SAME TIME, A DECLINE IN THEIR SIGNIFICANCE FOR

A SUBSTANTIAL NUMBER OF PATIENTS.

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.

11
OUR TECHNOLOGY-DRIVEN REIMBURSEMENT SYSTEM --
WHETHER BY GOVERNMENT OR OUT-OF-POCKET -- IS STILL

PREDICATED ON TAKING THE LEG OFF.

AND TO FURTHER COMPLICATE THE ISSUE, THE STRUGGLE
BETWEEN OUR ASPIRATIONS AND OUR RESOURCES HAS ALSO
COME AT THE WORST POSSIBLE TIME,

A TIME WHEN DEMOGRAPHIC TRENDS ARE RUNNING AGAINST US.

12
TODAY, FOR EXAMPLE, FOR EACH PERSON WHO IS OVER THE AGE
OF 65, THERE ARE 5 YOUNGER, TAX-PAYING WAGE-EARNERS TO

PAY FOR THAT ONE PERSON’S MEDICARE COVERAGE.

IN ANOTHER 20 YEARS, HOWEVER, FOR EACH PERSON OVER THE

AGE OF 65, THERE WILL BE ONLY 3 YOUNGER, TAX-PAYING WAGE-

EARNERS CONTRIBUTING TO MEDICARE.

13
THAT MEANS THAT IN A CLIMATE OF SCARCITY, AMERICANS WILL
HAVE TO WORK OUT AN EQUITABLE SHARING OF NEEDED
MEDICAL RESOURCES BETWEEN ONE POPULATION GROUP THAT
IS GROWING -- THAT IS, THE ELDERLY, PEOPLE OVER THE AGE OF
65 -- AND THE POPULATION GROUP THAT IS COMPARATIVELY

SHRINKING -- THAT Is, CHILDREN UNDER THE AGE OF 18.

14
OVER THE PAST 8 YEARS I’VE DEALT WITH ADVOCATES FOR
CHILDREN AND I’VE DEALT WITH ADVOCATES FOR THE ELDERLY.
THEY ARE BOTH VERY DEDICATED AND VERY PERSUASIVE
GROUPS. AND BOTH WILL BE QUITE RIGHTLY COMPETING FORA

LARGER PIECE OF A SMALLER PIE.

THIS HAS CHILLING ETHICAL IMPLICATIONS, AND WE MUST
GUARD AGAINST LETTING OUR ETHICS BE DETERMINED BY OUR
ECONOMICS,

AND NOT THE OTHER WAY AROUND.

15
I’M SURE YOU PEOPLE WHO DEAL WITH THE EVERYDAY ISSUES
OF HEALTHCARE PROVISION LOOK DOWN THE ROAD AS I DO AND

SEE THE PROBLEMS ON THE HORIZON.

SOME CRITICS WILL SAY THAT THE CHIEF CAUSE FOR THE |
CRUNCH 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.

MAYBE ... BUT I DON’T THINK SO.

- 16
WELL BEFORE WE TALKED ABOUT A BUDGET PROBLEM, WE
ALREADY HAD A HEALTH CARE ECONOMY THAT CONSISTENTLY
RAN AT AN ANNUAL INFLATION RATE THAT WAS 2 TO 3 TIMES THE
INFLATION RATE FOR THE REST OF THE AMERICAN ECONOMY.
BUT WE DIDN’T SEE IT ... OR, IF WE DID SEE IT, WE PREFERRED

NOT TO WORRY ABOUT IT.

17
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.

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 IS 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.

18
NOW, I CAN ALREADY HEAR THE CRITICS SAYING, "WAIT A

MINUTE, DR. KOOP. THE SYSTEM AIN’T BROKE, SO DON’T FIX IT."

TO WHICH I WOULD REPLY, "YOU’RE WRONG. THE SYSTEM IS

BROKEN ... AND IT MUST BE FIXED." BAND-AIDS WON’T DO.
HOSPITAL COSTS ARE STILL CLIMBING ... AND NO ONE CAN

PROVE TO THE AMERICAN PEOPLE THAT THE QUALITY OF

HOSPITAL-BASED CARE IS UNIFORMLY GOING UP AS WELL.

20
ON THE CONTRARY, OUR PEOPLE COMPLAIN THAT THEY ARE
PAYING MORE AND MORE FOR MEDICAL CARE, AND ARE GETTING

LESS AND LESS.

WORSE STILL, AS THE COST OF HOSPITAL-BASED CARE
INCREASES, SOME 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.

21
I SAY THERE’S SOMETHING TERRIBLY WRONG WITH A SYSTEM OF
HEALTH CARE THAT SPENDS MORE AND MORE MONEY TO SERVE

FEWER AND FEWER PEOPLE.

AND WE HAVE MUCH THE SAME PROBLEM IN RESPECT TO

PHYSICIAN SERVICES AND FEES.

22
I CAN TELL YOU THAT MANY OF MY FRIENDS AND COLLEAGUES
IN MEDICAL PRACTICE ARE TRYING TO DO WHAT THEY CAN TO
INCREASE THE QUALITY OF CARE THEY DELIVER WITHOUT
INCREASING THEIR COSTS.

BUT THEY ARGUE THAT THEY HAVE LITTLE OR NO CONTROL

OVER SOME OF HE INFLATIONARY THINGS THEY DO.

AND THAT’S TRUE.

23
PVE BEEN THERE -- SO IT’S NOT JUST GIVING THEM THE BENEFIT
OF THE DOUBT.

BUT THE FACT STILL REMAINS THAT PHYSICIAN FEES ARE GOING
UP, AND THEY DO ADD TO A BURDEN ON THE PUBLIC THAT IS

BECOMING INSUPPORTABLE.

24
AND, AGAIN -- AS WITH HOSPITAL-BASED CARE -- THE AMERICAN
PEOPLE HAVE NOT BEEN ASSURED, IN ANY RATIONAL AND
MEASURABLE WAY,

THAT THE HIGHER COSTS OF A PHYSICIAN’S CARE WILL IN FACT
BUY THEM A PROPORTIONATELY HIGHER QUALITY OF SUCH

CARE.

25
BEFORE I GO ANY FURTHER, LET ME SAY THAT IN GENERAL I
SUPPORT THE CONCEPT OF A LAISSEZ-FAIRE MARKETPLACE AND
I BELIEVE IN A FREELY COMPETITIVE ECONOMY, . —>

I 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 OUR POINT OF

VIEW.

26
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, THAT I STILL PREFER TO CALL, THE PATIENT.

27
IN MOST OTHER AREAS OF OUR ECONOMY, THE MARKETPLACE
DOES EXERCISE SOME CONTROL OVER ARBITRARY RISES IN
CHARGES TO THE CONSUMER. THERE REALLY IS COMPETITION.
HERE AND THERE IT MIGHT BE RATHER THIN ... BUT IT DOES
EXIST AND IT DOES PROVIDE SOME ASSURANCE THAT
INEFFECTIVE, UNCOMPETITIVE, HIGH-COST, LOW-QUALITY

ENTERPRISES WILL FAIL.

28
BUT IN HEALTH CARE, RIGHT ACROSS THE BOARD, PRICES HAVE
GONE UP IRRESPECTIVE OF THE QUALITY OF CARE BEING

DELIVERED OR OF ANY OTHER MARKETPLACE CONTROL.

TRY AS THEY MIGHT, I DON’T SEE THE MEDICAL PROFESSION

ACHIEVING MUCH SUCCESS IN SELF-REGULATION.

29
GRANTED, IT’S NO SIMPLE TASK. BUT, UNTIL THE PURCHASING
PUBLIC "BUYS RIGHT’-- AS WALTER MCCLURE PUTS IT-- THE

MARKET CANNOT CHANGE.

PHYSICIANS CAN HELP PUT THE BRAKES ON SOME GENERAL
EXPENDITURES, BUT THERE ARE VERY FEW PHYSICIANS WHO CAN
HONESTLY AND EFFECTIVELY CONTROL EVEN THE DELIVERY OF
SERVICE -- MUCH LESS CONTROL THE COSTS OF THAT SERVICE --
WHILE CARING FOR A SPECIFIC, INDIVIDUAL PATIENT AT THE

BEDSIDE.

30
WE SEEM TO 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 OF SUCH NATURAL
MARKETPLACE CONTROLS AS COMPETITION IN REGARD TO

PRICE, QUALITY, OR SERVICE.

31
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.

Lo
“WE’VE ALWAYS SAID WE NEVER WANTED EVEN A TWO-TIER

SYSTEM. |

BUT WE HAVE IT ... AND A THIRD TIER, ALSO.

32
IN THE FIRST TIER ... THE BOTTOM TIER ... ARE UPWARDS OF

PERHAPS 30 MILLION AMERICANS -- ABOUT 12 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.

33
WHAT, THEN, DOES THIS "HEALTH CARE SYSTEM" OF OURS DO
FOR THE UNINSURED?

AS YOU KNOW, IN THE VAST MAJORITY OF CASES THE ANSWER IS
.. VERY LITTLE ... OR NOTHING. AND THEY ARE SUFFERING THE
CONSEQUENCES.

STUDY AFTER STUDY INDICATES THE CORRELATION BETWEEN NO

MEDICAL INSURANCE AND INCREASING HEALTH PROBLEMS.

THE HEALTH PROBLEMS OF THE LOWEST TIER, IF IGNORED BY

SOCIETY NOW, WILL BE BORNE BY SOCIETY LATER.

34
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 OUT-OF-
POCKET OR WITH THE HELP OF SOME FORM OF SUPPLEMENTAL
INSURANCE, WHICH IS -- IN MY BOOK -- JUST ANOTHER KIND OF

OUT-OF-POCKET EXPENSE.

35
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.

36
MANY OF OUR 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 THE MAJOR STICKING-POINT IN THEIR COLLECTIVE

BARGAINING, ALSO.

37
BUT HOW DOES THE BARGAINING END?

THAT’S EASY: MORE MONEY IS PROMISED FOR EMPLOYEE
HEALTH BENEFITS ... AND THE INCREASED HEALTH costs
TRANSLATE INTO HIGHER PRICES FOR THE CUSTOMER OR THE

UTILITY RATE-PAYER.

IN OTHER WORDS, EMPLOYEE HEALTH PLANS HAVE REALLY
BECOME "PASS-ALONG" MECHANISMS THROUGH WHICH
DOLLARS, ARE PASSED ALONG AND INTO THE HEALTH CARE

SYSTEM.

38
IT’S BEEN WORKING THAT WAY FOR THE PAST 20 YEARS OR SO.
BUT I DON’T THINK AMERICANS CAN KEEP FEEDING THE HEALTH
CARE SYSTEM QUITE THAT WAY ANY MORE. WE’VE GOT TO MAKE

SOME CHANGES.

AND BUSINESS ITSELF IS FINALLY COMING AROUND TO
UNDERSTAND THIS. IT CANNOT CONTINUE TO BURY INFLATED
COSTS OF HEALTH CARE IN THE PRICE-TAGS OF THEIR GOODS

AND SERVICES.

39
SINCE 1984 THE AVERAGE PREMIUMS FOR EMPLOYER-PROVIDED

HEALTH INSURANCE HAVE APPROXIMATELY DOUBLED... TO $3,117

PER YEAR,

AND HAVE RISEN FROM 8 PERCENT OF BUSINESS PAYROLL COSTS

TO 13.6 PERCENT LAST YEAR.

BUSINESSES CAN’T ABSORB THESE COSTS AND ALSO EXPECT TO

BE COMPETITIVE.

40
AMERICAN BUSINESSMEN AND LABOR LEADERS ARE FINALLY
COMING TO UNDERSTAND WHAT THIS MEANS. THERE IS A
"HEALTH BENEFITS SURCHARGE’, IF YOU WILL,ON EVERY
MANUFACTURED PRODUCT. FOR EXAMPLE, ON EVERY CAR THAT
GENERAL MOTORS MANUFACTURES IN THIS COUNTRY, IT
AMOUNTS TO WELL OVER $600 PER CAR. IN CONTRAST, CARS
MADE AT THE NEW NISSAN PLANT IN TENNESSEE , THE "HEALTH

BENEFITS SURCHARGE" IS ONLY SIXTY DOLLARS PER CAR.

41
THE GENERAL MOTORS HEALTH PLAN IS A GENEROUS ONE, AND
IT COVERS RETIRED EMPLOYEES AS WELL AS ACTIVE WORKERS.
NISSAN, ON THE OTHER HAND, OFFERS A LIMITED PLAN THAT
DOES NOT EVEN PROVIDE MATERNITY BENEFITS OR PEDIATRIC

CARE FOR ITS ACTIVE EMPLOYEES.
BUT, WHILE ECONOMIC PRESSURES MAKE BUSINESS CONSIDER

CUTTING BACK ON THE HEALTH-CARE BENEFITS THEY PROVIDE,

SOCIAL PRESSURE COMPELS PROVIDING EVEN MORE.

42
WE HAVE SEEN CURRENT LABOR DISPUTES FOCUS NOT ON
WAGES OR HOURS BUT ON HEALTH BENEFIT PACKAGES.

C~)
r™M REMINDED, OF THE RECENT REPORT OF THE "NATIONAL
COMMISSION TO PREVENT INFANT MORTALITY."
AMONG OTHER THINGS, THE COMMISSION RECOMMENDED THAT
THE AMERICAN PEOPLE MUST ... "PROVIDE UNIVERSAL ACCESS TO
EARLY MATERNITY AND PEDIATRIC CARE FOR ALL MOTHERS AND

INFANTS."

43
IN OTHER WORDS, LET’S GET RID OF ANY AND ALL BARRIERS TO
HEALTH CARE FOR EACH AND EVERY MOTHER AND CHILD IN

AMERICA.

OF ALL INDUSTRIALIZED NATIONS, ONLY THE UNITED STATES

DOES NOT GUARANTEE ACCESS TO BASIC HEALTH CARE.

44
BUT THIS RECOMMENDATION AMPLIFIES THE CONCEPT OF
"ACCESS" IN A NEW AND VERY IMPORTANT WAY. IT SAYS THAT ...
"EMPLOYERS MUST MAKE AVAILABLE HEALTH INSURANCE

COVERAGE THAT INCLUDES MATERNITY AND WELL-BABY CARE."

THE COMMISSION WAS EVENLY BALANCED WITH PHYSICIANS
AND NON-PHYSICIANS ... REPUBLICANS AND DEMOCRATS ...
FEDERAL AND STATE OFFICIALS ... AND SO ON. HARDLY A
RADICAL BUNCH BY ANYONE’S

STANDARD.

45
YET, THE MEMBERS CAME OUT FOR A MUCH GREATER ROLE FOR

PRIVATE EMPLOYERS.

WHY DID THEY DO THAT?

BECAUSE TODAY, OF THE MORE THAN 56 MILLION AMERICAN
WOMEN OF CHILD-BEARING AGE, ROUGHLY 16 TO 44, ALMOST 28
MILLION OF THEM ARE EMPLOYED FULL-TIME IN THE AMERICAN

WORK-FORCE.

46
THAT’S 50 PERCENT OF ALL WOMEN IN THAT CRUCIAL CHILD-
BEARING AGE GROUP.

IN ADDITION, WELL OVER HALF OF ALL MOTHERS OF SMALL
CHILDREN = KIDS THREE YEARS OLD OR YOUNGER -- ARE

WORKING FULL-TIME.

ON A DAY-TO-DAY BASIS, IT IS NOW CLEARLY THE MANAGEMENTS
OF BUSINESS AND INDUSTRY WHO EXERCISE THE MOST CRITICAL
INFLUENCE UPON THE HEALTH OF AMERICA’S MOTHERS AND

CHILDREN.

47
THE HEALTH CARE SYSTEM IN AMERICA TODAY IS A TERRIBLE
MORAL BURDEN FOR SOCIETY TO BEAR, IN THAT THE SYSTEM

DOES NOT RESPOND AT ALL TO SOME 12 TO AS HIGH AS 15

 

PERCENT OF OUR POPULATION.

AND IT IS A TERRIBLE ECONOMIC BURDEN FOR SOCIETY TO
BEAR, IN THAT THE SYSTEM SATISFIES ITS OWN UNCONTROLLED
NEEDS AT THE EXPENSE OF EVERY OTHER SECTOR OF AMERICAN

SOCIETY.

48
WE NEED TO CHANGE THAT SYSTEM.

NOT JUST A LITTLE CHANGE HERE AND A LITTLE CHANGE THERE.

 

 

WE NEED TO 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?

49
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WE ARE AT A CROSSROADS. WE CANNOT AFFORD TO DO
NOTHING,

TO CONTINUE BUSINESS AS USUAL.

THE PRESSURE FOR RADICAL CHANGE IS COMING FROM ALL
DIRECTIONS:

FROM MEMBERS OF CONGRESS, FROM BUSINESS, FROM LABOR,
AND FROM THE GENERAL PUBLIC.

INCREASINGLY WE HEAR THE DEMAND FOR RESTRUCTURING THE
FINANCING AND DELIVERY OF HEALTHCARE IN THE UNITED

STATES.

50
EVEN SOME BUSINESS LEADERS WHO NORMALLY CRINGE AT THE

_ THOUGHT OF GOVERNMENT INTERVENTION OR REGULATION

FIND THEMSELVES CALLING FOR A SYSTEM OF NATIONAL

HEALTH CARE AS A SOLUTION TO RISING INSURANCE COSTS.
oD

A SURPRISING AND VERY SIGNIFICANT EVENT TOOK PLACE AT

THE BEGINNING OF LAST SUMMER.

51
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,

AND THE OTHER WAS THE HERITAGE FOUNDATION, A MOST

CONSERVATIVE BODY.

52
RECENTLY PVE NOTICED A STRANGE INTEREST IN THE CANADIAN
SYSTEM.

EVERYWHERE I GO PEOPLE SAY TO ME, "WE NEED THE CANADIAN
SYSTEM." SO I SAY, "TELL ME, WHAT IS IT YOU LIKE ABOUT THE
CANADIAN SYSTEM.?"

THEY ALWAYS ANSWER, "I DON’T REALLY KNOW, BUT IT’S A GOOD

SYSTEM."

53
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 ANY NATIONAL

HEALTH SERVICE, IS BASED UPON PLANNED SCARCITY.

54
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. THIS IS ESPECIALLY TRUE OF RESEARCH.
THEN, LACK OF RESPONSIVENESS TO PATIENTS. FINALLY,

RATIONING AND WAITING IN LINES.

55
AMERICANS DO NOT PATIENTLY QUE UP FOR ANYTHING,
ESPECIALLY FOR MEDICAL CARE.
THE MAJORITY HAS BECOME ACCUSTOMED TO AVAILABLE CARE,
IF NOT ACCESSIBLE CARE.

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AND WE DESIRE PERSONAL CARE.
NOW, IT MAY NOT BE POSSIBLE TO HAVE THE SAME PERSONAL
RELATIONSHIP BETWEEN DOCTORS AND PATIENTS THAT OUR

GRANDPARENTS HAD.

56
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TODAY, URBAN PEOPLE, ESPECIALLY, RELY UPON EMERGENCY
ROOM CARE AND GROUP PRACTICES, AND THE EFFICIENCY THEY
BRING HAVE COME AT THE COST OF THAT PERSONAL

RELATIONSHIP.
BUT, WE CAN DO A LOT TO RESTORE THE DOCTOR-PATIENT

RELATIONSHIP, A RELATIONSHIP THAT IS UNFORTUNATELY

BECOMING CHANGED TO A PROVIDER-CONSUMER RELATIONSHIP.

57
I REALIZE THAT THERE ARE SOME BUILT-IN PROBLEMS. PEOPLE
AREN’T HAPPY ABOUT BEING ILL, NEEDING TO GO TO A
PHYSICIAN.

HAVING TO PAY A HIGH PRICE FOR IT MAKES IT EVEN MORE
UNPLEASANT.

BUT WE NEED TO SUBORDINATE THE ECONOMIC ASPECT OF THE
RELATIONSHIP TO THE CLIMATE OF TRUST BETWEEN THE

DOCTOR AND THE PATIENT.

58
IF THE PATIENT THINKS OF HIMSELF PRIMARILY AS A
CONSUMER, GETTING THE MOST FOR HIS MONEY, SHOPPING
AROUND FOR A DOCTOR WHO CHARGES $5 LESS FOR AN OFFICE
VISIT, HE AUTOMATICALLY PUTS THE DOCTOR IN THE ROLE OF

THE SELLER, GETTING THE MOST FOR HIS SERVICES.

IF THE DOCTOR IS PRIMARILY CONCERNED ABOUT COLLECTING
HIS FEE, HE AUTOMATICALLY AROUSES THE CONSUMER
MENTALITY IN HIS PATIENT. WE CAN’T HAVE PATIENTS
WONDERING IF THEIR TREATMENT IS DETERMINED BY THE

DOCTORS FINANCES.

59
WE ALSO NEED TO REFORM THE MALPRACTICE MESS, THE

TORTURED TORT SYSTEM THAT FORCES DOCTORS AND PATIENTS
TO VIEW EACH OTHER AS LEGAL ADVERSARIES. WE CAN’T HAVE
DOCTORS WONDERING IF THEY’LL NEXT SEE THEIR PATIENTS IN

COURT, FLANKED BY THEIR LAWYERS.

WE NEED TO GET PAST THE STAND-OFF BETWEEN DOCTORS AND

LAWYERS.

60
I’M SURE THAT BOTH THE DOCTOR AND THE PATIENT WOULD

PREFER TO HAVE THAT OLD RELATIONSHIP OF TRUST THEY USED

TO HAVE.

IT CAN BE RESTORED.

BUT IT WILL TAKE COMMITMENT BY PEOPLE ON BOTH SIDES OF

THE STETHOSCOPE.

61
BUT IF WE DON’T OFFER SOMETHING BETTER, WE WILL GET A
GOVERNMENT CONTROLLED MEDICAL SYSTEM, AND LOSE
FOREVER THE PRESENT POTENTIAL FOR THE BEST SYSTEM

POSSIBLE.

THE FALLACY OF ECONOMIC CONTROLS IS THAT THEY ATTEMPT
TO FORCE CHANGE AND REORGANIZATION AGAINST THE WILL OF
THOSE PROVIDING HEALTH CARE. IT IS NOT IN THEIR INTEREST,
AS THEY SEE IT, BECAUSE THE MORE INEFFICIENT PROVIDER,
THE MORE REVENUE, REGARDLESS OF HEALTH PRODUCED, OR

NOT PRODUCED.

62
WE ARE IN A PERIOD OF TIGHT FINANCIAL CONSTRAINTS, AND IF

YOU READ THE LIPS OF THE PRESIDENT -- NO NEW TAXES.

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.

THERE IS A BETTER WAY, AND IT PREVENTS THE FURTHER
INTRUSION OF THE GOVERNMENT INTO THE DELIVERY OF

HEALTH CARE.

63
A MARKET-BASED STRATEGY MUST ADDRESS THE FORCES
DRIVING COSTS UPWARD WHILE AT THE SAME TIME ATTACKING

BARRIERS TO ACCESS.

WE HAVE THE PARADOX OF TOO MUCH CARE AND TOO LITTLE
CARE FOR DIFFERENT SEGMENTS OF SOCIETY AT THE SAME
TIME. AS HIGH-TECH MEDICINE GROWS OUT OF CONTROL,
UNBRIDLED BY INFORMED PURCHASERS, MANY PEOPLE ARE

DENIED BASIC PREVENTIVE AND PRIMARY CARE.
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TWO THIRDS OF OUR POPULATION - ABOUT 160 MILLION
AMERICANS ARE COVERED BY EMPLOYER-PURCHASED HEALTH
INSURANCE. EMPLOYERS AND WORKERS TOGETHER MUST
IDENTIFY THE LEADERSHIP TO BRING HEALTHCARE COST UNDER

CONTROL.

SUCH A NATIONAL ALLIANCE HAS BEEN FORMED AND IS
GROWING. AS THIS REFORM IN THE PRIVATE SECTOR IS TAKING
PLACE THERE MUST BE FURTHER JOINING OF FORCES WITH
GOVERNMENT - AT FEDERAL AND STATE LEVELS - WHERE
MEDICARE AND MEDICAID ARE ADMINISTERED, IF WE ARE TO
RESTRUCTURE THE ENTIRE SYSTEM OF PURCHASING AND

PROVIDING HEALTHCARE.

<

65
NOT LONG AGO A COALITION OF BIG BUSINESS AND LABOR
UNIONS FORMED TO ADDRESS THIS PROBLEM.

I THINK THAT THIS IS THE WRONG COALITION.

THAT IS HOW WE GOT TO OUR CURRENT PROBLEMS OF
PROFLIGACY AND POOR CARE.

WORKERS WANT QUALITY HEALTH CARE, NOT A NATIONAL
HEALTH SERVICE.

EMPLOYERS WANT TO FURTHER ESCALATION OF HEALTH COSTS,

NOT A NATIONAL HEALTH SERVICE.

66
THE COALITION THAT NEEDS TO BE FORMED COMBINES
BUSINESS AND ORGANIZED HEALTH CARE. TOGETHER THEY CAN
FORGE THE ALLIANCE THAT REWARDS HIGH QUALITY AND HIGH
EFFICIENCY WITH MORE PATIENTS, RATHER THAN REWARDING
POOR QUALITY CARE WITH DOLLARS AS WE DO NOW.

BUSINESS AND MEDICINE HAVE THE MOST TO LOSE: POOR

QUALITY MARRIED TO GOVERNMENT CONTROL.

67
WE NEED TO COMMUNICATE BETTER ABOUT HIGH-QUALITY AND
EFFICIENT CARE. THEN THE PATIENTS WILL COME FROM THE
POOR QUALITY, INEFFICIENT SYSTEMS WHICH WILL HAVE TO

IMPROVE OR PERISH.

WE WILL NEED - AND THEY ARE BEING DEVELOPED - TOOLS TO
MEASURE MEDICAL NECESSITY, APPROPRIATENESS,
EFFECTIVENESS AND OF COURSE OUTCOMES. QUALITY, AND
EFFICIENCY ARE DIFFICULT IF NOT IMPOSSIBLE TO MEASURE.

BUT THEY ARE MORE IMPORTANT THAN MERE QUANTITY.

68
FOR THOSE WITHOUT ACCESS, THE GOAL IS UNIVERSAL
COVERAGE TO BE ACHIEVED THROUGH COMPREHENSIVE
REFORMS OF GOVERNMENT PROGRAMS FOR THE POOR AND
UNINSURED COMBINED WITH RISK POOLING. MEANWHILE
INTERIM STEPS INCLUDE MEDICAID EXPANSION, UNDER
EXISTING LAW, AND TAX INCENTIVES TO ENCOURAGE SMALL
BUSINESS INSURANCE COVERAGE. THESE LATTER ELEMENTS

ARE THE ONLY ONES THAT REQUIRE PUBLIC POLICY REFORMS.

69
ONE WAY TO GET THINGS MOVING IN THE RIGHT DIRECTION IS
THROUGH A PRESIDENTIAL COMMISSION.

I URGED THIS IN A PRIVATE CONVERSATION WITH THE
PRESIDENT IN AUGUST 1988, SEVERAL MONTHS BEFORE HIS
ELECTION,

AND I’VE MADE THE SAME SUGGESTION IN EDITORIALS IN
NEWSWEEK AND FROM MANY PLATFORMS AROUND THE
COUNTRY.

THIS IS THE BEST WAY TO GET ACTION, BECAUSE THE
CONGRESSIONAL MEMBERS OF A PRESIDENTIAL COMMISSION
WILL TAKE THE PLANS BACK TO CONGRESS FOR DISCUSSION, A

VOTE, AND THEN IMPLEMENTATION.

70
THE OPPORTUNITY IS NOW.

THE TIME IS SHORT.

THE STAKES ARE HIGH.

THE ALTERNATIVES UNDESIRABLE.

IT REMAINS TO BE SEEN WHETHER OR NOT THE PRIVATE SECTOR

SEIZES THIS ONE AND ONLY OPPORTUNITY, WE’LL SEE.

71
WE ALL NEED TO BE A PART OF THE EFFORT.

BUT THERE IS NO QUICK FIX.

FROM HERE TO THERE COULD TAKE A DECADE, BUT WE’D

IMPROVE YEAR BY YEAR ALONG THE WAY.

72
choose: prevention ending, or international health ending, or both

73
IN THE MEANTIME, EVERYDAY, ALL OF US WHO ARE PART OF THE
HEALTHCARE SYSTEM, ALL OF US WHO ARE PART OF AMERICAN
SOCIETY FIND OURSELVES IN THE MIDST OF A GREAT

REVOLUTION.
THIS REVOLUTION IS MORE IMPORTANT THAN THE NEEDED
REVOLUTION IN THE STRUCTURE OF HEALTH CARE OR IN THE

FINANCING OF HEALTH CARE.

THIS REVOLUTION CHANGES EVERYDAY INDIVIDUAL BEHAVIOR.

74
YOU ARE A PART OF THAT REVOLUTION, AND YOU’LL IMPROVE
THE HEALTH OF THE AMERICAN PEOPLE --AS WELL AS YOUR

OWN HEALTH-- IF YOU PLAY YOUR PART.

TWO CONCEPTS FORM THE BASIS FOR THIS REVOLUTION.

FIRST, YOUR HEALTH AND THE HEALTH OF THOSE WHO COME TO

YOU PROFESSIONALLY WILL DEPEND MOSTLY UPON THE

PREVENTION OF DISEASE AND DISABILITY AND THE PROMOTION

OF GOOD HEALTH.

75
SOME ANALYSTS EVEN SAY THAT PREVENTION AND HEALTH
PROMOTION CAN POSTPONE UP TO 70 PERCENT OF ALL
PREMATURE DEATHS, WHEREAS THE TRADITIONAL CURATIVE
AND REPARATIVE APPROACH OF MEDICINE CAN POSTPONE NO
MORE THAN 10 TO 15 PERCENT OF SUCH DEATHS. EVEN IF
THEY’RE ONLY HALF RIGHT, THAT’S QUITE A DIFFERENCE IN

SOCIAL PAY-OFEFS.

76
SECOND WE HAVE COME TO REALIZE THAT THESE TWO
APPROACHES TO HEALTH -- THAT IS, DISEASE PREVENTION AND
HEALTH PROMOTION -- ARE THE PRIMARY RESPONSIBILITIES OF
EACH INDIVIDUAL.

PHYSICIANS AND THERAPISTS AND PHARMACISTS AND NURSES
MUST PROVIDE AMERICANS WITH INFORMATION, SERVICE, AND
EXAMPLES. BUT THE CRITICAL CHOICES REST WITH EACH
INDIVIDUAL. AND THEY ARE FREE CHOICES IN NEARLY EVERY

CASE, NOT MANDATED BY LAW -- AT LEAST NOT YET.

77
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.

78
NEVERTHELESS, I THINK THE OVERALL PERCEPTION AMONG THE
AMERICAN PEOPLE IS STILL AN OLD-FASHIONED ONE: THAT IS,
THAT PUBLIC HEALTH AND MEDICAL AND NURSING PERSONNEL
ARE REALLY ON THE JOB TO PATCH YOU UP IF YOU GET HURT OR

TO CURE YOU IF YOU GET SICK. IN OTHER WORDS, THE PATIENT

IS PASSIVE AND THE HEALTH SYSTEM IS THE ONLY ACTIVE

PARTY.

79
I THINK THE PUBLIC STILL ADHERES TO THE IDEA THAT THE
PATIENT IS SUPPOSED TO "FOLLOW THE DOCTOR’S ORDERS," OR

"FOLLOW THE DRUGGIST’S ORDERS".

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.

80
WE IN THE PUBLIC HEALTH PROFESSIONS HAVE BEEN
DILIGENTLY TRYING TO TURN THAT CONVENTIONAL WISDOM

AROUND. AND I THINK WE ARE!

1 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.

YOU CAN ASSUME A POSITION IN THE FRONT LINES, BY

WORKING, FOR INSTANCE, TO REMOVE TOBACCO PRODUCTS

FROM VENDING MACHINES AND FROM PHARMACIES.

$1
THERE’S ALSO BEEN A DROP IN THE CONSUMPTION OF HARD
LIQUOR, WITH A SHIFT TO BEER AND WINE -- OR SIMPLY WATER.
AS A RESULT, THERE’S BEEN A DRAMATIC DROP IN CHRONIC

LIVER DISEASE AND CIRRHOSIS MORTALITY IN GENERAL.

PEOPLE SEEM TO 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 TO 15 YEARS AS WELL. THERE’S NO DOUBT ABOUT THAT.

82
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.

83
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.

84
WHEN WE SAY THAT THE BEST WAY TO BEAT HEART DISEASE IS
THROUGH ROUTINE EXERCISE, NO SMOKING, AND A
HEALTHFUL DIET,

THAT’S JU ST ANOTHER WAY OF TELLING PEOPLE,

"DON’T RELY COMPLETELY ON HIGH-COST HIGH-TECH MEDICINE

TO SAVE YOUR LIFE.
YOU CAN AFFORD PREVENTION ... YOU CANNOT AFFORD A

QUADRUPLE

BY-PASS."

85
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.

86
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.

87
AND IT’S YOUR BEST HEDGE AGAINST THE 4TH AND FINAL D:
DEATH ITSELF.

HEALTHCARE WORKERS AND THEIR FELLOW CITIZENS ALIKE
CAN EMBRACE A LARGER VISION OF HEALTH PROMOTION AND
DISEASE PREVENTION. WE ARE ALLIES AS WE ASSUME LEADING
ROLES IN THIS NEW HEALTH REVOLUTION IN AMERICA AS WE

PREPARE FOR THE 21ST CENTURY.

THANK YOU

HHHEHH F

88
89
NOW, I'D LIKE TO TAKE A FEW MINUTES TO TALK ABOUT

INTERNATIONAL HEALTH.

FOR MOST OF MY SURGICAL CAREER, I WAS INVOLVED IN
INTERNATIONAL HEALTH WORK. BUT IT WAS ONLY DURING MY
TENURE AS SURGEON GENERAL OF THE U.S. PUBLIC HEALTH
SERVICE, THAT I HAD THE OPPORTUNITY TO WORK CLOSELY
WITH THE LEADERSHIP AND STAFF OF THE WORLD HEALTH

ORGANIZATION.

90
THE EXPERIENCE HAS REINFORCED MANY TIMES OVER MY
BELIEF THAT

W.H.O. IS NOT ONLY AN AGENCY WHOSE EXISTENCE IS ESSENTIAL
TO WORLD HEALTH, BUT IS ALSO AN ORGANIZATION WHOSE
ACCOMPLISHMENTS OVER THE PAST 40 YEARS HAVE EVEN
EXCEEDED THE GREAT HOPES THAT ATTENDED ITS BIRTH.

AND IT HAS BEEN DRIVEN BY A POWERFUL CONCEPT ... "THAT
HEALTH, GOOD OR ILL, COULD NEVER AGAIN BE PURELY A

NATIONAL PHENOMENON."

91
THE HEALTH STATUS OF ALL THE PEOPLE OF THE WORLD --

WHETHER THEY LIVE IN DEVELOPED OR DEVELOPING

COUNTRIES -- AFFECTS ALL OTHERS. IT WAS THEREFORE IN THE

INTEREST OF ALL NATIONS TO WORK TOGETHER TO ADDRESS

THE TOTALITY OF WORLD HEALTH PROBLEMS.

92
AS WE LOOK AT OUR WORLD TODAY, WE SEE THAT ENORMOUS
PROGRESS HAS BEEN MADE IN THE FOUR DECADES DURING
WHICH W.H.O. EVOLVED FROM A TECHNICAL ASSISTANCE
AGENCY, PRIMARILY CONCERNED WITH COMMUNICABLE
DISEASES CONTROL, TO A PARTNER OF ALL NATIONS IN THE

SUPPORT OF NATIONAL GOALS FOR HEALTH FOR ALL.

93
0 WE HAVE IMPROVED OUR HEALTH CARE SYSTEMS AND
MADE HEALTH SERVICES AVAILABLE TO A DEGREE

UNKNOWN 40 YEARS AGO.

o TODAY, THANKS TO A VERY ACTIVE AND SUCCESSFUL W.H.O.
EXPANDED PROGRAM ON IMMUNIZATION, THERE IS

EXCELLENT VACCINATION COVERAGE AGAINST POLIOMYELITIS,

DIPHTHERIA, TETANUS, WHOOPING COUGH, MEASLES, AND

TUBERCULOSIS.

94
LIFE EXPECTANCY HAS RISEN FROM A WORLDWIDE

AVERAGE OF 41 YEARS IN 1950 TO 61 YEARS TODAY.

AND, WHILE FAR TOO MANY CHILDREN STILL DIE BEFORE
THE AGE OF FIVE, THE WORLD IS CERTAINLY A SAFER PLACE
FOR CHILDREN. THE NUMBER OF INFANTS AND CHILDREN
WHO DIE BEFORE THE AGE OF FIVE IS MANY MILLIONS LESS
TODAY THAN THE NUMBER WHO DIED DURING THE 1950’S,
EVEN THOUGH THE TOTAL CHILD POPULATION IN THE

WORLD HAS SUBSTANTIALLY INCREASED.

95
AND, AT THE REQUEST OF MEMBER NATIONS, W.H.O. HAS NOW
LAUNCHED A SPECIAL EFFORT TO ELIMINATE POLIO
EVERYWHERE. POLIO MAY WELL BECOME THE SECOND DISEASE
TO BE ERADICATED THROUGH THE EFFORTS OF MANKIND,

FOLLOWING SMALLPOX ON THE ROAD TO EXTINCTION.

ORAL REHYDRATION THERAPY IS WELL ON ITS WAY TO
BECOMING ANOTHER SUCCESS STORY. IT IS BECOMING SO
EFFECTIVE THAT THE LIVES OF COUNTLESS INFANTS AND
CHILDREN ARE BEING SPARED. THE THERAPY, OF COURSE, IS
BASED ON A SIMPLE SOLUTION OF WATER, SUGAR, AND SALTS ...

A FORMULA DEVISED BY W.H.O. SCIENTISTS.

96
THE WORK ON MALARIA ALSO CONTINUES TO HOLD PROMISE
THAT THIS DISEASE, TOO, WILL ONE DAY BE CONQUERED. FROM
ITS CREATION, W.H.O. HAS TARGETED THIS DISEASE. AND
DESPITE THE DIFFICULTIES OF MALARIA CONTROL, WE CAN

REMAIN OPTIMISTIC ABOUT THE FUTURE.

THESE SUCCESS STORIES ARE IMPRESSIVE. BUT IF ANYTHING,
THEY SHOULD SERVE AS A STIMULUS TO US TO DO BETTER.

THEY MUST NOT BE AN EXCUSE FOR COMPLACENCY.

97
WE KNOW ALL TOO WELL THAT VICTORY OVER DISEASE IS OFTEN
COUNTER-BALANCED BY THE APPEARANCE OF NEW THREATS AND

NEW DISEASES.

WE ARE NOW EXPERIENCING THIS WITH AIDS AS A WORLDWIDE

EPIDEMIC.

AIDS THREATENS EVERY NATION AND PRESENTS AN
UNPRECEDENTED CHALLENGE TO INTERNATIONAL PUBLIC
HEALTH. EACH COUNTRY AFFECTED THAT CONFRONTS THIS NEW
HEALTH PROBLEM MAY DISCOVER IT MAY NEED TO RESPOND
WITH RESOURCES OF SO GREAT A MAGNITUDE THAT IT CAN
DEVASTATE THE VERY HEALTH SYSTEM IT IS TRYING TO

STRENGTHEN.

98
IN DEVELOPING NATIONS, AIDS TENDS TO IMPACT MOST OFTEN
ON THE MOST PRODUCTIVE MEMBERS OF SOCIETY: THE
BREADWINNERS IN THE PRIME OF THEIR LIVES HENCE,
DEVELOPING NATIONS HIT BY AIDS COULD LOSE AN
IRREPLACEABLE GENERATION OF ENGINEERS, HEALTH
WORKERS, TEACHERS, AND GOVERNMENT OFFICIALS, AS WELL AS

WORKERS IN AGRICULTURE, INDUSTRY, AND TRADE.

AIDS HAS THE POTENTIAL TO DEVASTATE A DEVELOPING

COUNTRY’S PLANS FOR DEVELOPMENT.

99
A TOP PRIORITY FOR W.H.O. AND THE NATIONS OF THE WORLD IS

TO MAKE THE WORLD’S BLOOD SUPPLY SAFE FOR TRANSFUSION.

THE GLOBAL FIGHT AGAINST AIDS WILL TAKE MANY YEARS, AND
IT WILL REQUIRE POLITICAL AND HEALTH LEADERS ALIKE TO
HAVE THE STRENGTH OF COMMITMENT NECESSARY TO MAKE
DIFFICULT DECISIONS, TO STAND FIRM AGAINST UNREASONABLE
FEAR, AND TO MAINTAIN THE CONSISTENCY AND UNITY OF
ACTION THAT ARE ABSOLUTELY VITAL FOR A GLOBAL FIGHT

AGAINST THIS GLOBAL THREAT.

100
LIKE AIDS, THE HEALTH CONSEQUENCES OF SMOKING HAVE
BECOME AN INTERNATIONAL PROBLEM. AND, I’M SORRY TO
ADMIT, THE UNITED STATES HAS PLAYED A SINISTER ROLE IN

THIS TRAGEDY.

THE FACT OF THE MATTER IS THAT THE CIGARETTE COMPANIES -
- AMERICAN COMPANIES AND THEIR EUROPEAN COUNTERPARTS -
- ARE EXPLOITING THE UNPROTECTED MARKETS OF THE THIRD
WORLD: ASIA, SOUTHEAST ASIA, AFRICA, AND CENTRAL AND

SOUTH AMERICA.

101
AND THEY ARE VERY EFFECTIVE, I MIGHT ADD. THEY HAVE
INUNDATED THOSE UNDEVELOPED AND DEVELOPING COUNTRIES
WITH CIGARETTE ADVERTISING AND PROMOTION TO SUCH AN
EXTENT THAT CIGARETTE CONSUMPTION IN THOSE COUNTRIES

IS ON THE RISE.

AND ALSO ON THE RISE ARE THE MORBIDITY AND MORTALITY
RATES FOR SUCH SMOKING-RELATED DISEASES AS STROKE,
HEART DISEASE, AND CANCERS OF THE LUNG, MOUTH,

ESOPHAGUS, AND STOMACH.

102
AND I MUST ADD THAT THIS EXPORT OF DEATH AND DISEASE HAS
BEEN CARRIED OUT WITH THE SUPPORT OF THE UNITED STATES
GOVERNMENT -- OUR TRADE REPRESENTATIVES, OUR STATE
DEPARTMENT, OUR COMMERCE DEPARTMENT, AND OUR
AGRICULTURE DEPARTMENT.

IT’S NOT A VERY PRETTY STORY. BUT THERE IT IS.

103
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 AMERICA AT A RATE 30 PERCENT AHEAD OF
THE RATE OF POPULATION INCREASE ... IN AFRICA, IT ROSE 77

PERCENT AHEAD OF THE RISE IN POPULATION.

104
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 A HIGHER TAR
CONTENT AND ARE, THEREFORE, EVEN MORE DANGEROUS THAN
THE LOWER-TAR, FULLY-LABELLED PRODUCTS SOLD HERE IN

THE UNITED STATES.

105
NOW, LET ME MAKE SURE YOU UNDERSTAND WHAT I JUST SAID.
I SAID THAT SOME AMERICAN CIGARETTE MANUFACTURERS -- AS
KNOWLEDGEABLE AS I AM, CONCERNING THE HEALTH RISKS OF
SMOKING -- KNOWINGLY PRODUCE A MORE HARMFUL
CIGARETTE FOR EXPORT THAN THEY PRODUCE FOR DOMESTIC

CONSUMPTION.

106
JUST A LITTLE MORE THAN A YEAR AGO, 15 ASIAN 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.

107
IN OTHER WORDS, THE TOBACCO EPIDEMIC AND ITS LETHAL
CONSEQUENCES HAVE HIT ASIA ... AND -- THANKS TO OUR OWN
CIGARETTE INDUSTRY AND THAT OF THE UNITED KINGDOM.--

HAVE HIT ASIA HARD.

108
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 I FEEL QUITE GOOD ABOUT THE
ROLE I BELIEVE I PLAYED IN BRINGING ABOUT THIS MARKET

CHANGE.

I THINK THAT 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.

109
IT IS A TERRIBLE BURDEN FOR THE CONSCIENCE OF THE UNITED
STATES. BUT WE WILL HAVE TO BEAR IT UNTIL WE FIND A WAY
TO END, ONCE AND FOR ALL, THE PUBLIC HEALTH HAVOC

CREATED BY TOBACCO EVERYWHERE IN THE WORLD.

MY ONE REGRET IS THAT I LEFT OFFICE JUST AS THE FIGHT IS
BEGINNING TO RID THE REST OF THE WORLD OF THE SCOURGE
OF TOBACCO AS WELL. IT’S A SHAME, BECAUSE I REALLY FEEL

UP TO IT.

110
OUR EFFORTS TO HELP THE ENTIRE WORLD ABOUT THE THREATS
POSED BY AIDS AND SMOKING DEPEND ONLY ON EDUCATION

AND PREVENTION.

THAT’S THE NEW --AND OLD-- HEALTH MESSAGE OF THE 1990S.

THANK YOU

HHHH HF

111