KEYNOTE

BY

C, EVERETT KOOP, MD

SURGEON GENERAL

       AND

DEPUTY ASSISTANT SECRETARY FOR HEALTH

PRESENTED TO THE REGION II CONFERENCE ON AGING

         NEWARK, NEW JERSEY

         SEPTEMBER 14, 1983


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(GREETINGS TO HOSTS, GUESTS)

  I WANT TO THANK EVERYONE OF YOU FOR BEING HERE TODAY AND
DEVOTING ALL OR AT LEAST A SUBSTANTIAL PART OF YOUR CAREERS TO THE
PROBLEMS ASSOCIATED WITH CARE FOR THE AGING IN OUR SOCIETY,

  IT'S PECULIAR, BUT THIS IS A SUBJECT THAT TOUCHES EVERYONE OF US
-- PERSONALLY -- IN THE COURSE OF OUR LIVES, YET IT IS ALSO A
SUBJECT TO WHICH TOO FEW OF US GIVE OUR VERY BEST ATTENTION,

  I THINK THIS CONFERENCE IS IMPORTANT BECAUSE IT MARKS ANOTHER
CHAPTER IN WHAT HAS BECOME KNOWN AS "CONSCIOUSNESS-RAISING"
REGARDING THE PROBLEMS OF PEOPLE WHO GROW OLD IN AMERICA. THIS IS
OUR PROBLEM, BECAUSE WE'RE IN PUBLIC HEALTH, BECAUSE WE ARE DEVOTED
TO PUBLIC SERVICE, AND BECAUSE WE'RE ALL GROWING OLDER DAY BY DAY,

  BUT GIVING THIS KEYNOTE ADDRESS IS NOT GOING TO BE EASY, I'VE
FOUND, FOR EXAMPLE, THAT IT'S JUST NOT POSSIBLE TO COME BEFORE A
GROUP SUCH AS THIS AND SAY, "LOOK HERE, THIS IS WHAT'S BEING DONE
AND THESE ARE THE THINGS YOU OUGHT TO TRY YOURSELF," IT'S NOT THAT
SIMPLE AT ALL, AND WE SHOULD BE VERY CAREFUL ABOUT PEOPLE WHO COME
UP WITH SIMPLE ANSWERS TO THE COMPLEX ISSUES SURROUNDING OUR COMMON
CONCERNS FOR AMERICA'S AGED.


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  1 VISITED WITH SOME P,H,S, INSTITUTE DIRECTORS, WITH THE PEOPLE

AT THE ALCOHOL, DRUG ABUSE, AND MENTAL HEALTH ADMINISTRATION, WHO

ALSO HAVE CONCERNS RELATED TO THE ELDERLY, AND I ALSO TALKED WITH A

NUMBER OF PEOPLE ELSEWHERE IN THE DEPARTMENT 0~ HEALTH AND HUMAN

SERVICES -- PEOPLE WHO WORK IN LEGISLATION, IN PLANNING AND

EVALUATION, AND IN SOCIAL SERVICES, TWO THINGS STRUCK ME:

FIRST, JUST ABOUT EVERYONE I TALKED WITH WHO WORKED IN SOME

ASPECT OF THE FIELD OF THE AGIIdG WAS GENUINELY CONCERNED FOR THE

1JELFARE OF AMERICA'S ELDERLY POPULATION. AND,,,

SECOND, JUST ABOUT EVERYONE I TALKED WITH CAME AT THE SUBJECT OF

AGII'~G FROM A DIFFERENT PERSPECTIVE, WITH DIFFERENT VALUE-LADEN

DATA, AND WITH A DIFFERENT CONCEPT OF WHAT THEY HOPED TO SEE

GOVERNMENT ACHIEVE,

  DRAWING UPON THOSE CONVERSATIONS AND UPON MY OWN READING, I

WOULD LIKE TO SUGGEST SOME COMMON GROUND FOR PEOPLE WHO WORK IN THE

AGITdG FIELD,  I CERTAINLY DO NOT MEAN TO BE PRESCRIPTIVE. BUT I DO
HOPE THAT THIS WON'T BE THE LAST WORD ON A COMMONLY ACCEPTED
PHILOSOPHY OF AGING FOR THOSE OF US IN HEALTH AND HUMAN SERVICES,

BUT RATHER 03E OF THE FIRST WORDS CONTRIBUTED TO THE BUILDING OF

THAT PHILOSOPHY IN -- AND FOR -- OUR HELPIriG PROFESSIONS.


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  FIRST, I THKNK WE NEED TO RECOGNIZE THAT A SERIOUS PROBLEM
ARISES IN THE FACT THAT, ALTHOUGH THE AGING PROCESS BEGINS IN YOUTH,

IT ENDS IN THE ULTIMATE, TERMINAL HUMAN EXPERIENCE. THEREFORE, I

WOULD SAY THAT MANY OF THE APPROACHES WE EMPLOY IN OTHER AREAS OF

PUBLIC HEALTH ARE NOT VERY APPROPRIATE WHEN DEALING WITH THE AGED,
OUR USUAL METHODS DON'T TRANSLATE WELL, SINCE THEY USUALLY LEAD TO

SOMETHING ELSE.  WE ARE TRAINED TO IDENTIFY OPPORTUNITIES FOR
"LINKAGE" AND "FOLLOW-THROUGH" AND "FOLLOW-UP" AND "COST-EFFECTIVE

THIS" AND "TECHNOLOGY-INTENSIVE THAT."

  BUT THE AGING EXPERIENCE LEADS TO A KNOWN END-POINT.. #NAMELY,

DEATH,  ANY FOLLOW-UP WOULD BE PURELY PRESUMPTIVE AND WOULD DEPEND

ON YOUR OWN PERSONAL THEOLOGY,  AND FOR THE MOST PART, WE HAVE TO

ADMIT THAT VERY LITTLE THAT'S DONE FOR THE AGED IS REALLY "COST-

EFFECTIVE?  I THINK WE OUGHT TO PUT THAT WAY D~\JN ore OUR LIST OF
CHECK-OFF POINTS' WITH THE AGED, WE BURY OUR SUCCESSES AS WELL AS

OUR FAILURES.  COST-EFFECTIVENESS IS REALLY BESIDE THE POINT.

  IF YOU LOOK AT THE AGING EXPERIENCE AS A TERMINAL BUT UNKNOWN
LENGTH OF TIME, YOU CAN THEN POSSIBLY MAKE SOME JUDGMENTS ABOUT THE

NATURE OF THAT TIME,  I THINK IF I WENT BACK TO MY FRIENDS WHO WORK
IN THE AGING FIELD AND ASKED THEM ~0 CHARACTERIZE THAT TIME PERIOD,


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THEY WOULD PROBABLY SAY THEY HOPED IT WOULD BE "GOOD" TIMEmTHAT IS,
IT WOULD BE MARKED AS A TIME IN WHICH THE AGING PERsoN MIGHT ENJOY...

REASONABLY GOOD HEALTH,,,

ENOUGH NOURISHMENT PREPARED AND PRESENTED WITH AT LEAST A TOUCH OF

INTEREST,. ,

A DEGREE OF COMFORT AS FAR AS CLOTHING AND SHELTER ARE CONCERNED,. ,

AND THEY MIGHT ALSO ENJOY, AT LONG LAST, A PERIOD OF PEACEFUL
HUMAN RELATIONSHIPS.

BUT A PART OF THAT TIME MAY NOT BE "GOOD," THIS IS THE TIME IN
WHICH THE PERSON 1s IN A REAL AND ACCELERATED DECLINE, HEALTH

DETERIORATES ,,,NOURISHMENT IS REDUCED TO JUST THAT, LACKING ANY REASON
FOR INTEREST.. ,DISCOMFORT BECOMES A ROUND-THE-CLOCK NORM. ..AND THE
HUMAN RELATIONSHIP THAT ABSORBS MOST OF THE DYIblG PERSON'S ATTENTION
IS THE RELATIONSHIP WITH OlE'S SELF.

THIS IS THE KIND OF TIME IN WHICH MOST OF US ARE PROFESSIONALLY

NEEDED,


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  I THINK IT'S CLEAR THAT GOOD MEDICAL AND HEALTH CARE IS NEEDED TO
INSURE TO THE FULLEST EXTENT THAT THERE ARE "GOOD" QUALITIES IN THAT
TERMINAL TIME IN THE AGING PROCESS, IT'S OUR JOB FREQUENTLY TO
COMPRESS THE DO1JNHILL SLIDE INTO AS SHORT AND PAINLESS A TIME AS

POSSIBLE a  OF COURSE, THE SHORTER THE TIME, THE STEEPER THE SLOPE,

  IN OUR AMERICAN CULTURE, THE AGE OF 65 IS CONSIDERED TO BE A
TURNING-POINT, THE PEAK OF LIFE, AS IT WERE. SOMEHOW OR OTHER, AFTER
65 HE OR SHE IS "OVER THE HILL,"  THE ROAD OF LIFE FROM THEN ON IS ALL

DOWNHILL,  THE ONLY VARIABLE, THEN, IS THE STEEPNESS OF THE DECLINE,

  BUT I WOULD SUGGEST THAT IT MIGHT BETTER BE OUR PREFERRED GOAL TO
KEEP THAT MAGIC AGE 65 AS A PLATEAU -- TO MAKE IT "GOOD" TIME FOR AS

LONG A PERIOD AS POSSIBLE.  THIS IS THE ASPECT OF A PHILOSOPHY OF

AGING THAT APPEALS TO ME MOST,

  BUT HOW DO WE -- PROFESSIONALS IN HEALTH, SOCIAL SERVICES, IN

PRIVATE AND PUBLIC AGENCIES -- HOW CAN WE PROLONG THAT "GOOD" TIME AND
HOlJ MIGHT WE TRY TO CONTROL THE ONSET OF THE PERIOD OF DECLINE?

  THE MORE WE THINK ABOUT THAT, THE MORE WE HAVE TO WRESTLE WITH A

COUPLE OF DIFFICULT PROBLEMS:


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FIRST, IF WE RECOGNIZE AGING AS BEING A "GOOD" TIME FOLLOWED BY A
DIFFICULT TIME, THEN WE MAY BEGIN TO SEE THE AGING PROCESS AS A
SERIES OF SELF-FULFILLING PROPHECIES -- WE PREDICT IT'S GOING TO
BE "BAD" AND SO IT THEREFORE BECOMES "BAD" -- AND THAT'S CERTAINLY

A PROBLEM FOR ANYONE I.11 HEALTH CARE,

SECOND, IF WE RECOGNIZE THAT THERE MAY BE TWO QUALITATIVELY

DIFFERENT PERIODS OF TIME -- A "GOOD" TIME AND A "BAD" TIME --

IT'S ONLY NATURAL THAT WE WOULD WANT TO MANIPULATE THEM IN SOME
WAY SO AS TO PROLONG A PERSON'S "GOOD" TIME AND SHORTEN THE TIME

OF DECLINE,  THE PERIOD OF DECLINE MIGHT BE HIS OR HER "DYING

TItlE," AS IT WERE, EXCEPT THAT WE KNOW IT IS STILL NOT REALLY
POSSIBLE TO ESTABLISH A NEAT DIVIDING LINE BETWEEN NORMAL LIVING

AND THE PERIOD OF DYING AND DEATH ITSELF,

  LET'S LOOK AGAIN AT THAT FIRST PROBLEM, THE PROBLEM OF SELF-FUL-

FILLING PROPHECIES,  WE'VE ALL EXPERIENCED THIS AT ONE TIME OR ANOTHER

OR WE KNOW THE WAY IT HAPPENS,  FOR EXAMPLE, A PHYSICIAN OR A COUNSELOR

WILL SAY, "you KNow, YOUR FATHER 1s GETTING 0N IN YEARS. you CAN
EXPECT THIS TO HAPPEN.  THEN THAT WILL HAPPEN,
                 AND YOU SHOULD PREPARE
YOUR FAMILY FOR THIS OTHER THING TO HAPPEN? AND SUPERFICIALLY THIS
SEQUENCE OF EVENTS MAY INDEED OCCUR MUCH AS IT IS DESCRIBED,


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  WE TEND TO ACCEPT THOSE PREDICTIONS, THEY ARE ORDERLY AND, THERE-

FORE, COMFORTING.  BUT WE KNOW FROM OUR OWN PERSONAL, HARD EXPERIENCE

THAT LIFE REALLY DOESN'T UNFOLD THAT NEATLY, EVENTS TUMBLE IN ONE UPON

THE OTHER a a CAUSE-AND-EFFECT IS VERY OFTEN A SHREWD GUESS AT BESTwAND

OTHER PEOPLE AND THE ENVIRONMENT ITSELF WILL TRIGGER SOME EVENTS TO

OCCUR EARLY AND DELAY OR PREVENT OTHERS FROM OCCURRING AT ALL.

  WHEN AN AGED PERSON CONTINUES TO LIVE NORMALLY -- THAT IS, HE OR

SHE MOVES AND IS MOVED BY EVENTS IN A RATHER RANDOM FASHION -- WE MAY

BECOME CONFUSED AND EVEN FEARFUL.  WE CONCLUDE THAT "SOMETHING IS

WRONG WITH DAD.  THIS IS HAPPENING WAY AHEAD OF SCHEDULE AND THAT

SHOWS NO SIGN OF EVER HAPPENING AT ALL." IN OTHER WORDS, DEVIATION

FROM THE ANTICIPATED NORM -- EVEN IF IT IS HEALTHFUL BEHAVIOR -- MAY

BE A CAUSE FOR OUR CONCERN'

  AND HERE'S LJHERE WE REALLY HAVE TO BE CAREFUL. THE AGED PERSON

CAN ACTUALLY BE THE VICTIM OF THIS KIND OF RESPONSE. IF WE EXPECT

DETERIORATION TO TAKE PLACE, WE MIGHT FEED AND MEDICATE THE AGING

PERSON AS IF DETERIORATION WERE IN FACT TAKING PLACE, AS A RESULT,

THE PERSON MAY BECOME MALNOURISHED AND THEN DETERIORATE, FULFILLING

THE PROPHECY.


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  OVER-MEDICATION IS ANOTHER DANGEROUS OUTCOME OF THIS KIND OF
BEHAVIOR TOWARD THE ELDERLY: WE ANTICIPATE THE AGING PERSON WILL
REQUIRE CERTAIN DRUGS AND MEDICINES' SO WE GO AHEAD AND ADMINISTER
THEM TOO SOON, AND THEN WE WITNESS THE VERY DECLINE WE THOUGHT WOULD

TAKE PLACE' RIGHT ON SCHEDULE.

  THE WHOLE PROBLEM OF AN AGED PERSON BEING ERRONEOUSLY JUDGED
`SENILE' IS YET ANOTHER ASPECT OF THE AGING PROCESS SEEN AS A SEQUENCE
OF ANTICIPATED EVENTS IN THE EYES OF THE FOREWARNED YOUNGER BEHOLDER,

  THE SECOND PROBLEM' HOWEVER, IS MORE DELICATE AND COMPLEX, THAT'S
THE PROBLEM OF OUR LACK OF ANY NEAT DEFINITIONS FOR THESE PERIODS OF

`GOOD' TIME AND 'BAD' TIME.  MEDICAL TECHNOLOGY CAN' TO A CERTAIN

LIMITED EXTENT, PROLONG LIFE.   WHEN TECHNOLOGY CAN EXTEND WHAT I HAVE

CALLED THE 'GOOD' TIME WITHIN THAT TERMINAL PERIOD OF AGING, I THINK
WE ALL AGREE IT SHOULD MOST PROBABLY BE USED. I'M THINKING OF

PACEMAKER IMPLANTS' COLOSTOMIES' CORONARY BYPASS SURGERY, OR MOTORIZED

EQUIPMENT FOR STROKE VICTIMS.


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  BUT WHAT DO WE DO ABOUT THAT FINAL PERIOD OF DECLINE? THIS IS THE

TIME WHEN PEOPLE SAY THAT THE DOCTOR IS "TAKING OF HEROIC MEASURES TO

SAVE MY MOTHER'S LIFE,"  IF WE ACCEPT THE PRINCIPLE THAT WE SHOULD TRY

TO MAKE THE "DYING" PERIOD AS BRIEF AND AS COMFORTABLE AS POSSIBLE,

THEN WE SHOULD BE ABLE TO FIND A RATIONAL COURSE LYING SOMEWHERE

BETWEEN "HEROIC MEASURES" 0~ THE ONE HAND AND "PULLING THE PLUG" 0N

THE OTHER."

  LET ME SAY RIGHT HERE THAT I NEVER USE THE TERMS "EXTRAORDINARY"

AND "HEROIC,"  WHAT WAS "EXTRAORDINARY" YESTERDAY IS "ORDINARY"

TODAY,  WHAT IS "EXTRAORDINARY" TODAY WILL BE "ORDINARY" TOMORROW, I

DON'T KNOW HOW TO DEFINE "HEROIC" IN THIS CONTEXT. NEVERTHELESS, EACH

OF US NEEDS TO DEVELOP SOME Ir4TUITIVE AND OPERATIONAL UNDERSTANDING OF

THESE TERMS SO THAT WE MAY DEAL OPENLY AND CANDIDLY WITH OUR PATIENTS,

  CJHEN WE COUNSEL WITH A PATIENT AND WITH THE PATIENT'S IMMEDIATE

FAMILY ABOUT A DEVELOPING CRISIS DURING THIS TIME OF DYING, WE NEED TO

CLARIFY WHAT OUR MEDICAL ALTERNATIVES ARE SUPPOSED TO ACCOMPLISH, WE

NEED TO ASK.'.


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  WILL THIS OR THAT PROCEDURE ENABLE THE PATIENT TO ENJOY SOME
ADDITIONAL "GOOD" TIME' OR WILL IT ONLY PROLONG THE PERIOD OF
DYING?

  WILL DOING NOTHING EFFECTIVELY SHORTEN THE PERIOD OF DYING?
AND DOES THE PATIENT CONSIDER THAT TO BE A DESIRABLE ALTERNATIVE?

  AT THIS POINT, LET US NOT CONFUSE THE WORDS "CURE" AND "CARE," WE
SELDOM CURE CHRONIC DISEASE IN THE ELDERLY. BUT WE ARE NEVER RELIEVED
OF THE OBLIGATION OF CARING FOR THEM,

  I HOPE I AM NOT MISUNDERSTOOD OR MISINTERPRETED, I AM COMMITTED
TO GIVING A PATIEIjT ALL THE LIFE TO WHICH HE OR SHE IS ENTITLED, YET,
I AM EQUALLY COMMITTED JiOJ TO PROLONG THE ACT OF DYING.


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AND HERE WE HAVE TO MOVE WITH GREAT CARE. WE NEED TO BE SURE WE
ARE UNDERSTOOD,  FOR EXAMPLE, THE PHRASE I JUST USED -- "ACT OF DYING"
-- HOW WOULD YOU DEFINE IT?

THE CO-AUTHOR OF MY MOST SUCCESSFUL BOOK HAS HAD LYMPHOSARCOMA FOR

7 YEARS,  HE HAS A TERMINAL ILLNESS.. *BUT HE Is m IN THE "ACT OF

DYING/'

  BUT SUPPOSE HE SHOULD DEVELOP A PLEURAL EFFUSION AND HIS LIVER
ENLARGES? WHERE Is HE THEN? IN THE "ACT 0F DYING?" PERHAPS,,, BUT
ON THE OTHER HAND, IF WE REMOVE THE FLUID FROM HIS CHEST AND GIVE HIM
DIGITALIS, HE MIGHT CONTINUE LIVING FOR A NUMBER OF YEARS MORE,
OBVIOUSLY, YOU HAVE TO KNOW QUITE A BIT ABOUT BOTH THE DISEASE AND THE
PATIENT WHO HAS IT.

  AND IT IS AT THIS POINT THAT WE HAVE TO DEAL WITH ALL THREE ASPECTS
OF THE HUMAN EXPERIENCE: THE STATE OF THE BODY, THE STATE OF MIND, AND
THE STRENGTH OF THE PATIENT'S SPIRIT, PHYSICIANS AND OTHER HEALTH
PROFESSIONALS WOULD RATHER STEER CLEAR OF THIS TRIANGLE. THEY SAY THEY
HAVE NO TRAINING TO DEAL 1iITH MATTERS OF SPIRIT, FOR EXAMPLE, AND, OF
COURSE, THAT'S PROBABLY TRUE.  BUT THEY STILL NEED TO RECOGNIZE THAT
SUCH MATTERS ARE A PROFOUND CONCERN OF THE PATIENT AND NEED TO BE
ADDRESSED SOMEHOW,


  I WOULD SUGGEST THAT THE WAY WE HANDLE PHYSICAL HEALTH, MENTAL
HEALTH, AND SPIRITUAL HEALTH WILL PROBABLY DETERMINE THE NATURE OF THE

MEDICAL CARE GIVEN TO THE ELDERLY PATIENT IN THE FINAL STAGE OF

APPROACHING DEATH,  HERE AGAIN, WE CANNOT EVEN ATTEMPT TO BE PRESCRIP-

TIVE TO EACH OTHER.  INSTEAD, WE MAY NEED TO SIMPLY ACCEPT, AS PART OF

OUR TREATMENT PHILOSOPHY, THAT WE WILL GIVE SUBSTANTIAL ATTENTION TO A

PATIENT'S SPIRITUAL HEALTH DURING THE FINAL PHASE OF THIS TERMINAL

PERIOD OF LIFE,

  LET ME SAY THAT, WHILE THIS MAY SOUND A LITTLE STRANGE, IT'S NOT

VERY REVOLUTIONARY TALK.  IT'S THE KIND OF THINKING THAT UNDERLIES THE

HOSPICE MOVEMENTS  WE KNOW THAT, AT SOME POINT DURING THEIR FINAL
PERIOD OF DECLINE, MANY PATIENTS ARE MORE CONCERNED ABOUT THE SPIRITUAL
QUALITY OF THEIR REMAINING TIME ON EARTH THAN ABOUT ANY FURTHER REPAIR

WORK ON THEIR BODIES OR MINDS,  ABOVE ALL THEY WANT PEACEFUL HUMAN

RELATIONSHIPS  THEY WANT DIGNITY.

  SOME ACT OF HEROISM -- EITHER BY THEIR PHYSICIANS OR BY THEMSELVES

-- MAY NOT BE VERY IMPRESSIVE OR VERY USEFUL, HOSPICE CARE IS
ORGANIZED TO PROVIDE THAT KIND OF PEACE-GIVING EXPERIENCE, WHETHER IN

AN INSTITUTION OR IN THE DYING PERSON'S OWN HOME,


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  I DON'T WANT TO DWELL UNNECESSARILY ON THE PERIOD OF DECLINE AND

THE EVENT OF DEATH. I THINK MANY OF US -- POSSIBLY MOST OF US IN THIS

ROOM -- HAVE DEALT WITH IT ALREADY AND SO I WILL ASSUME WE HAVE SOME

COMt~lON, UNDERSTOOD POINTS OF REFERENCE THAT DON'T NEED FURTHER

ELABORATION.  BUT HOW DOES THAT PERIOD BEGIN? WHEN DOES IT BEGIN?

LET ME RETURN TO THAT MAGIC NUMBER OF 65,

  AS I MENTIONED EARLIER, OUR CULTURE HAS MORE LESS DETERMINED THAT

THE BEGINNING POINT OF THE AGING PROCESS FOLLOWS ONE'S 65TH BIRTHDAY,

AT THAT POINT, YOU ARE "RETIRED", . . YOU ARE LITERALLY "WITHDRAWN" FROM

THE WORLD YOU'VE KNOWN FOR SIX AND A HALF DECADES, you ARE PAID OFF

IN SOME WAY -- A PENSION OR SOCIAL SECURITY OR A GOLD WATCH OR SOME

OTHER MEANS TO HELP YOU NEGOTIATE THIS LAST PERIOD OF YOUR LIFE,

  THE SOCIAL SECURITY RETIREMENT SYSTEM HAD SAID THAT MEN COULD BEGIN

RECEIVING THEIR FULL BENEFIT AT 65, BUT WOMEN COULD AT AGE 62, THE LAW

HAS SINCE BEEN CHANGED SO THAT BOTH MEN AND 'JOMEN CAN CLAIM AT AGE 62,

BUT FROM THAT POINT ON THEY kILL ONLY RECEIVE 80 PERCENT OF THEIR BENE-

FIT,  IF THEY WAIT UNTIL THEY'RE BOTH 65, THEY CAN THEN CLAIM THEIR

FULL RETIREMENT BENEFIT.  SO WE HAVE SOME ACKNOWLEDGEMENT THAT THE

AGING PROCESS MAY BEGIN A FEW YEARS EARLY FOR SOME PEOPLE,


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  THE LAW ALSO SAYS YOU CAN'T RECEIVE YOUR BENEFIT IF YOU EARN MORE
THAN A CERTAIN AMOUNT OF MONEY EACH YEAR FROM OTHER SOURCES WHILE
YOU'RE COLLECTING YOUR SOCIAL SECURITY BENEFIT, HOWEVER, IF YOU ARE
STILL ALIVE AT YOUR 72r~~ BIRTHDAY, YOU CAN THEREAFTER RECEIVE YOUR FULL
SOCIAL SECURITY BENEFIT AND EARN ALL THE MONEY YOU WANT WITH NO

PENALTY,  BUT EVEN THAT IS CHANGING. AS OF JANUARY 2, 1983, YOU CAN
COLLECT 100 PERCENT OF YOUR SOCIAL SECURITY BENEFIT AND ALSO EARN ALL
THE MONEY YOU WANT IF YOU'VE ONLY PASSED YOUR 70TH BIRTHDAY.

  SO THERE SEEM TO BE TWO INTERPRETATIONS OF WHEN THE "GOOD" TIME IN
THE AGING PROCESS MAY BEGIN -- AT AGE 65 AND AT AGE 70. THESE ARE, OF

COURSE, ECONOMIC INTERPRETATIONS,  THERE ARE A LOT OF THEM AROUND,
FOR EXAMPLE, SOME COMPANIES WANT TO "WITHDRAW" THE1 R MANAGERS WHEN

THEY REACH 55,  OTHERS HAVE A PRODUCTIVE ROLE FOR SENIOR MANAGERS WHO
ARE BETWEEN THE AGE OF 60 AND 70. THE MILITARY WILL ALLOW YOU TO
RETIRE AT 50 PERCENT OF YOUR PAY AFTER 20 YEARS OF SERVICE, SO IF VOU
JOIN AT AGE 18 AND STAY FOR TWO DECADES, YOU CAN RETURN TO CIVILIAN
LIFE AT AGE 38 AND RECEIVE HALF THE SALARY YOU RECEIVED WHEN LAST YOU

WERE IN UNIFORM,  IF YOU STAY 30 YEARS, YOU RECEIVE 75 PERCENT OF YOUR

PAY,


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GENERALS AND ADMIRALS ARE >ENT HOME WHEN THEY REACH THE MANDATORY
RETIREMENT AGE OF 62.  ONLY A PRESIDENTIAL APPOINTMENT CAN KEEP THEM
IN UNIFORM. AS YOU KNOW, THE OFFICE OF SURGEON GENERAL OF THE U.S.
PUBLIC HEALTH SERVICE CARRIES THE FLAG RANK OF ADMIRAL OF THE NAVY AND
THE INCUMBENT IS ALSO A PRESIDENTIAL APPOINTEE. HOWEVER, AT ALMOST 67
I A~I SURGEON GENERAL AND IN UNIFORM FIVE YEARS AFTER MosT OTHER
ADFIIRALS HAVE RETIRED. AND I MUST CONFESS THAT I THOROUGHLY ENJOY IT,

  SOME ORTHOPEDISTS TELL PATIENTS THAT THE AGING PROCESS BEGINS
AROUND AGE 30, WHEN THEIR SHOULDERS AND THEIR BACKS BEGIN TO STIFFEN
AND THE FIRST s1Gr4.s 0F ARTHRITIS ARE COMMON. SOME PSYCHIATRISTS
BELIEVE THAT THE AGING PROCESS BEGINS WHEN YOU FIRST CRY OUT IN THE
DELIVERY ROOM AND BECOME AN AIR-BREATHER,

  I THINK THERE Is rloRE POETRY IN ALL THIS THAN THERE 1s GOOD

SCIENCE.  I MENTIONED THE NATIONAL INSTITUTE ON AGING A FEW MOMENTS

AGO.  ONE OF THE QUESTIONS THEY KEEP RETURNING TO IS THIS: "WHEN DOES
THE AGING PROCESS REALLY BEGIN -- BIO~lEDICALLY~..BIOBEHAVIORALLY..,

NEUROPHYSIOLOGICALLY .,.CARDIORESPIRATORIALLYI..OR MUSCULOSKELETALLY?"
IV AFRAID WE ARE SOT,lE DISTANCE FROM A SCIEriTIFIC ANSWER,


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BUT THAT VERY LACK OF PRECISION MAY BE THE MOST IMPORTANT THING FOR
US TO KNOW RIGHT NOW,  IT MEANS WE HAVE TO TAKE INTO ACCOUNT A GREAT
DEAL OF BEHAVIORAL AND BIOMEDICAL INFORMATION BECAUSE WE DON'T DARE
LEAVE ANYTHING OUT. AND THAT'S GOOD, IT THROWS THE PUBLIC HEALTH
PROFESSIONAL IT4 AMONG MANY OTHER DISCPLINES FOR DEALING WITH THE AGING

PROCESS,  IT MEANS WE HAVE TO WORK WITH,. .

ELECTRONIC ENGINEERS,, ,    METALLURGISTS.,,   LAWYERS.. ,

ARCHITECTS,,,     INTERIOR DECORATORS,,,

EDUCATORS,..      LABOR LEADERS, a.   ECONOMISTS, AND OTHERS,

ULTIMATELY, OUR PHILOSOPHY OF AGING FOR PUBLIC HEALTH WILL BE
CONGRUENT WITH THE PHILOSOPHIES OF THESE OTHER PROFESSIONS AND

VOCATIONS AS WELL -- THAT IS, IF THEY ALSO CARE ENOUGH TO THINK IT

THROUGH,

  IF WE CAN INDEED ARRIVE, AS A PROFESSION, AT SOME CONSENSUS AS TO
WHAT OUR PHILOSOPHY OF AGING OUGHT TO BE, WHAT WOULD BE ITS SIGNIFI-

CANCE, a a ITS REAL IMPACT UPON THE PEOPLE WE SERVE?


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  I BELIEVE THAT, WITH THE HELP OF A COHERENT PHILOSOPHY, WE CAN

PROVIDE BETTER CARE TO ALL OLDER PEOPLE -- INCLUDING THOSE WHO ARE IN

THAT FINAL PERIOD OF DECLINE.  I ALSO THINK IT STIMULATES CLEARER

THINKING ABOUT THE AGING PROCESS AMONG THOSE VERY PEOPLE WE SERVE.

WITH THE HELP OF A STRONG PHILOSOPHIC APPROACH, WE CAN GAIN THE

MASTERY OF THAT BASIC INFORMATION ABOUT AGING THAT WOULD HELP US --

AND THROUGH US, HELP OTHERS -- MAKE INFORMED DECISIOW a.

ABOUT OUR 0wN AGING,, .

ABOUT THE AGING OF OUR FRIENDS AND MEMBERS OF OUR FAMILY,..

AND ABOUT THE AGING PROCESS IN SOCIETY ITSELF,

  I THINK WE NEED SUCH A PHILOSOPHY NOT ONLY FOR OUR OWN WORK IN

PUBLIC HEALTH BUT ALSO AS OUR CONTRIBUTION TO SOCIETY'S UNDERSTANDING

OF AGING IN GENERAL.

  BEFORE VERY LONG, YOUNG PEOPLE IN AMERICAN SOCIETY WILL HAVE TO

MAKE SOME DIFFICULT DECISIONS ABOUT THE ROLE OF OLDER PEOPLE IN

AMERICAN LIFE -- DECISIONS THAT COULD AFFECT PUBLIC POLICIES TOWARD

PENSIONS AND RETIREMENT, JOB SENIORITY AND SECURITY, HOME OWNERSHIP,

INSURANCE COVERAGE, MEDICAL BENEFITS, ArID SO ON.


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   0   THEY SHOULD BE MAKE THOSE DECISIONS, COMFORTABLE WITH THE

IDEA THAT, WHATEVER THEIR YOUTHFUL AGE, THEY MAY ALREADY BE PART OF

THE "AGING PROCESS,"

   0   THEY NEED TO UNDERSTAND AND ACCEPT -- IF AT ALL POSSIBLE --

THE EVENTUAL TERMINAL NATURE OF THE AGING PROCESS,. ,OF LIFE ITSELF,

   0   THEY NEED TO EVALUATE THE NATURE OF THE "GOOD" TIME FOR AN

ELDERLY PERSON.

   0   AND THEY NEED TO PARTICIPATE IN OR SOMEHOW INFLUENCE THE

DECISIONS MADE DURING THAT VERY DIFFICULT PERIOD OF FINAL DECLINE,

  AT ABOUT THE YEAR 2000, THE UNITED STATES IS PROBABLY GOING TO

HAVE SOME 50 MILLION PERSONS OVER THE AGE OF 65, OR ABOUT 20 PERCENT

OF THE AMERICAN POPULATION.  THAT'S TWICE THE NUMBER OF PEOPLE OVER

AGE 65 IN THE COUNTRY RIGHT NOW'  THE IMPACT UPON ALL OUR SERVICES --

BUT ESPECIALLY PUBLIC HEALTH SERVICES -- IS GOING TO BE OF CONSIDERABLE

MAGNITUDE'


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TODAY'S "MIDDLE-AGED" PERSONS ARE ALREADY AMBIVALENT ABOUT THE
EFFECTS OF THIS EVOLVING DEMOGRAPHY: THEY KNOW THAT DECISIONS ABOUT
CARE FOR THE AGED THAT ARE MADE AND RATIFIED TODAY MAY DETERMINE HOW
THEY THEMSELVES ARE CARED FOR NOT TOO MANY YEARS HENCE, YET, THEY ARE
SHY ABOUT PUTTING FORWARD ANY POSITION, HOWEVER REASONABLE, THAT MIGHT
RAISE THE HACKLES OF THEIR JUNIORS,

  THIS HAS ALREADY HAPPENED IN ORGANIZED LABOR, FOR EXAMPLE, OLDER
WORKERS HAVE WANTED CERTAIN BASIC RETIREMENT AND PENSION GUARANTEES
WRITTEN INTO NEW CONTRACTS AND HAVE BEEN WILLING TO DISCUSS LARGER
PAYROLL DEDUCTIONS OR EMPLOYER-EMPLOYEE CONTRIBUTIONS, BUT YOUNGER
WORKERS HAVE OFTEN VOTED THEM DOWN,  WITHOUT A GOOD BASIS OF COMMON
UNDERSTANDING BETWEEN YOUNG PEOPLE Ai'JD MIDDLE-AGED PEOPLE, OUR SOCIETY
MIGHT FACE SEVERAL MORE DECADES OF DEEP DIVISION OVER THE ISSUE OF
AGING AND THE POSITION OF THE AGED.

  CERTAINLY WE SHOULD LOOK TO PHILOSOPHY AS A WAY OF HEALING THOSE
DIVISIONS AND OVERCOMING BARRIERS, REAL OR IMAGINED. AT LEAST, THAT
IS MY INTENT IN PURSUING THIS IDEA OF A PHILOSOPHY OF AGING FOR PUBLIC

HEALTH.  NOR DO I SEE ANY CONFLICT IN THE VERY IDEA OF BUNDLING A WORD
LIKE "PHILOSOPHY" TOGETHER WITH A PHRASE LIKE "PUBLIC HEALTH,"


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  1 AM REMINDED OF THE LESSON TAUGHT BY THE LATE JAMES BRYANT

CONANT, WHO WROTE THAT "ANY ATTEMPT TO DRAW A SHARP LINE BETWEEEN

COMMON-SENSE IDEAS AND SCIENTIFIC CONCEPTS IS NOT ONLY IMPOSSIBLE BUT

UNWISE,"  I HOPE THAT, IN THESE FEW MINUTES TOGETHER, WE MAY HAVE MADE
SOME PROGRESS IN UNITING COMMON-SENSE WITH SCIENCE, WITH THE HELP OF

PHILOSOPHY.  IF SO, THEN I HOPE IT MIGHT COUNT AS ANOTHER SMALL

VICTORY FOR OLDER PEOPLE IN AMERICA.

THANK YOU.

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