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