Address to the Mid-Year Meeting of the National Association of Children's Hospitals and Related Institutions, Inc. (NACHRI),
In this address, Koop reviewed recent accomplishments and remaining objectives in the public health fields of disease prevention;
alcohol and drug abuse and mental health; primary health care, especially in community health centers; and, in greatest detail,
child and maternal health. In addition, he tried to assess how the economic recession of the early 1980s and President Ronald
Reagan's proposal to delegate certain federal health programs to the states in the form of block grants would affect services
in these four areas of public health.
Number of Image Pages:
19 (1,163,866 Bytes)
1982-03-08 (March 8, 1982)
Koop, C. Everett
This item is in the public domain. It may be used without permission.
Medical Subject Headings (MeSH):
Child Health Services
Maternal Health Services
Congenital Birth Defects and the Medical Rights of Children: The "Baby Doe" Controversy
"Address to the Mid-Year Meeting of the National Association of Children's Hospitals and Related Institutions, Inc.
(NACHRI), Alexandria, Virginia" [Reminiscence] (2003)
Deputy Assistant Secretary for Health and Surgeon General
U.S. Department of Health and Human Services
To the Mid-Year Meeting of the National Association of Children's Hospitals and Related Institutions, Inc.
Monday Morning, March 8, 1982
(Greetings to hosts, special guests, etc.)
I am delighted to join with so many friends this morning to talk about the needs of children and how, together, we might move
ahead and serve those needs.
I see many, many friends in the audience, so I will share something with you. I remember, down through the years sitting on
your side of the podium and trying to make some sense of what the person on this side the podium was saying. And why it was
important for children. So this morning I hope to bring you some ideas and information that would at least interest me, if
I were where you are. Needless to say, I dare not fail.
Bob Sweeney asked me to focus my attention on this administration's policy regarding child health. Before I discuss some
details of that policy, I think we ought to agree that this country simply does not change its fundamental child health policies.
By that I mean that the American people retain their basic commitment to child health -- regardless of the changing of the
guard every four years in Washington.
You and I both know that there's a very vocal and very powerful constituency for child health abroad in this land. It
is by no means monolithic. It is a constituency that is split (every now and then) by a loud, public fight. But the fact that
so many people care -- and care very deeply -- about the children of this country and of the world is a fact that ought to
make each of us feel good about our profession and what we do in our professional lives.
If I had to put into capsule form our national feelings about the welfare of children, I would say that we see them as our
real treasure, our real future, our most important renewable resource, and their welfare is the best measure of how well we
do as a civilized society.
There's nothing very partisan about that. It never has been a partisan issue, really, in this country -- for which we
ought to be profoundly thankful.
So let me emphasize that this administration remains as committed as any previous administration to enhancing the well-being
of all the children in this nation. Where we may differ is how we hope to carry out that fundamental, national commitment
Certainly one of the most widely discussed proposals by President Reagan last year was the block grant proposal. The President
believed that it was time to take a closer look at all the categorical grants-in-aid that had accumulated throughout the federal
government and see which ones were properly the responsibility primarily of the federal government and which ones were better
handled at the state and local levels.
By 1980 there were a bit more than 500 such programs at the federal level. Of those, 69 were health-related programs costing
some $8 billion annually. Last year, in response to the President's proposals, the Congress enacted legislation putting
into effect the block grant idea, thus making available to the states, territories, and the District of Columbia 22 health
services programs divided among four blocks:
- A prevention block
- A block for alcohol, drug abuse, and mental health programs
- A primary care block, of which the community health centers form the centerpiece
- And a maternal and child health block.
While all the blocks are vital to the health of our people, I want to turn in particular to the last one I mentioned, the
one that is devoted to programs that enhance the health and well-being of mothers, infants, and children in our society.
First of all, I share with each of you the concern that these many programs serving mothers and children, programs with which
we have become so familiar over the years, not be compromised. They are of fundamental importance to the health of America.
To the extent that they are not well conceived or well-managed, it is to that extent that our nation will suffer.
I am also aware, from many years' experience, that when those important health services are not given the attention they
deserve, effect is felt right in the very institutions that comprise NACHRI. The children injured in stressed births, born
of mothers who went part or all of their term without proper medical care, or victims in some other way of a less than caring
society . . . these are the children that eventually find their way into your institutions. I know that from what I myself
saw in more than three decades as surgeon-in-chief at the Children's Hospital of Philadelphia.
I also know that the health personnel in state and local government, for whom these programs were daily responsibilities,
did their jobs the kind of devotion and concern that we want and expect.
In 1980, my last full year as a working surgeon in Pennsylvania, that state invested over $61 million in maternal and child
programs. That was 45 percent of all public health expenditures by the Commonwealth of Pennsylvania. In addition, it was a
good deal more than the $53 million Pennsylvania received from the federal government that year for all its public health
programs . . . not just for maternal and child health, but for everything.
And Pennsylvania is not unique in that respect. Louisiana, Kansas, Tennessee, and others also put more state and local dollars
into those programs that federal dollars. As of today, 48 states, the District of Columbia, and 4 trust territories have applied
for and adopted the maternal and child health block grant. The remaining 2 states and 2 territories was adopted the block
by the fourth quarter of this fiscal year. The states believe in these programs. They have supported them in the past. They
will support them in the future -- not just with rhetoric but with their treasuries. And that is the acid test.
I might add that when the states do their annual accounting as to how much money they have put in and where they've put
it, they always include under the general heading of "Maternal and Child Health" the supplemental food program for
women, infants, and children, the so-called "WIC" program. Last month, the president included in his fiscal 1983 budget
plan the idea of putting the "WIC" program into this plot grant, also. It makes sense from a public health point of
view and, as I've indicated, it also reflects the way the states themselves account for this activity in their own planning
It is difficult for me to say that this or that element of policy is on the top of any list of priorities . . . especially
when we're talking about the health and welfare of mothers and babies. Frankly, I'm more comfortable talking in terms
of a constellation of policy elements that rank collectively as number one.
In that connection, I want to recall the promise made by Secretary Schweiker last year to "put prevention at the very
top of the federal medical agenda." And that's what we are doing, with strong support for President Reagan and the
White House staff.
The public health service generally -- and the MCH-related programs in particular -- follow the general roadmap, so to speak,
laid out in the Surgeon General's Report on Health Promotion and Disease Prevention, more commonly known by its short
title of Healthy People. That document is organized into 15 health areas requiring our best thinking and action, areas such
as "hypertension," "nutrition," "dental health," "smoking," and so on. To areas of particular
importance to this audience would be "immunization" and "pregnancy and infant health."
I think I ought to emphasize that, even in this period of very tight budgets, the President has proposed a modest increase
for the immunization program carried out by the Centers for Disease Control.
As you are very well aware, I'm sure, the child immunization program is one of the great public-health achievements in
this country. It has not only reduced the incidence of childhood diseases, but it has also reduced the chances of those diseases
reoccurring and regenerating.
When the program began, back in 1977, we had a "deficit" of some 25 million children who had not been reached. The
nation set a number of specific goals of coverage to overcome that deficit:
- 90 percent of all children under the age of 2 ought to have their complete, basic immunization series
- 95 percent of all school-age children should be fully immunized
- Fewer than 1,000 cases a year of mumps, rubella, and pertussis
- Fewer than 500 cases a year of measles
- Fewer than 50 cases a year of diphtheria and tetanus each, and
- Fewer than 10 cases a year of congenital rubella and polio.
If any of you have been following information in the weekly morbidity report, published by the Centers for Disease Control
of the US Public Health Service, you will have seen how far we have come toward reaching those important goals. In the measles
area alone, we ended 1981 with a total of 3,032 reported cases, which was a 77 percent decline from the total at the end of
December, 1980. In fact, we have every reason to believe that we may conquer indigenous measles . . . that is, reduce the
reported cases of indigenous strains to zero by autumn of this year, 1982.
So if we seem to be optimistic on the budgetary side, regarding support for the national childhood immunization program, is
because we have found and had immunized over 20 million of the estimated 25 million youngsters that had not been protected.
Also, while there has been a slight rise in the number of live infants born each year -- we're up around 3.6 million a
year now -- we do not see a sharp increase in the national birth rate for the foreseeable future.
Let me reinforce in your minds, as it has been reinforced in mine, that we could not achieve this historic accomplishment
for children, were it not for the commitment and professional dedication of thousands of public health officials in state
and local governments, many more thousands of concerned parents and educators working tirelessly through a variety of national
and local voluntary and professional associations, and were it not for the medical profession itself.
We estimate that nearly 50 million doses of vaccines are administered to children each year. About half of them are given
by public agencies -- clinics or schools -- and the other half are given by physicians or nurses in private practice.
While we feel good about this, is certainly no cause for complacency and I would not want this audience to believe for one
minute that our modest increase in funding has anything to do with our sense of what the priority should be for childhood
immunization. It is and it remains at the top of the list. And we have made substantial progress. The remaining 3 million
or so youngsters we have not yet reached, from that earlier estimated deficit, are, as you can imagine, the most difficult
to reach. They are, after all, only "alive" in our statistical databank. If we knew precisely who they were -- they
would have been inoculated by now.
In addition, we do not know how the cost of vaccines will rise in the coming year. We only know that, like everything else,
the cost of vaccines will indeed go up. We're just not sure by how much.
But Secretary Schweiker has been clear and consistent on this point:
If at any time he believes that the lack of funds may be jeopardizing the effectiveness of the immunization program, he would
not hesitate to go to the President and go to the Congress for the additional money he would need.
I'm comfortable with such a promise and I hope you are, also. I know the man means what he says.
I've spent time on this issue, since I know you feel as I do, that our commitment to such a program as immunization is
not only important by itself, but it also says something about how we feel about many other things as well. I think, for example,
that it demonstrates this administration's desire to carry on a national campaign to bring down infant mortality and morbidity
rates and to take proper care of those children who survive and live among us for seven, eight, or even nine decades.
In this connection, I'd like to put in a word here about a very important national public information and education campaign
called "Healthy Mothers, Healthy Babies." It's being carried out by a group called, appropriately enough, the
"Healthy Mothers, Healthy Babies Coalition," made up of over 40 professional, voluntary, and government organizations
with a common interest in prenatal and infant health. The six groups on the steering committee are the March of Dimes Birth
Defects Foundation, the American Academy of Pediatrics, the American Nurses Association, the American College of Obstetricians
and Gynecologists, the Parent Teachers Association, and our own U.S. Public Health Service. They represent a lot of energy
and expertise and devotion to mothers and children. I couldn't be more delighted to have them all working together on
such an important program.
The purposes of this program are simple enough to state, but so very complex to achieve:
- To provide information that promotes healthy behavior in pregnant women and women planning pregnancy . . .
- To increase understanding among these women a certain health risks and the importance of taking personal responsibility
for their health and the health of their babies . . .
- And to motivate women to take action to protect their own health, to obtain regular prenatal care, and to seek other kinds
of help when they need it.
This is certainly a statement of purpose worthy of the attention of everyone concerned about the health of mothers and babies.
We hope that this kind of all-out, national education campaign will not only contribute to the reduction of infant mortality
in this country, but also help reduce morbidity among infants and children as well. But whether these two phenomena go hand-in-hand
is another issue.
For example, between 1970 and 1981 the infant mortality rate dropped in this country from 20 infant deaths per 1,000 live
births to our most recent provisional figure of 11.8, as of last November. Theoretically we might assume that there would
be a rise in certain disease and disabling conditions among the newborn. But the relationship is not always precise. Parallel
with the decline in infant mortality has been the decline in the incidence of cerebral palsy. That is tenuous, of course,
since one of the constant problems we all share is the nature of our data collection in general. Nevertheless, we see these
But as you are all aware, the same kinds of new technologies that help lower the mortality rate -- infant intensive care and
much improved obstetric or practice -- have also help lower the incidence of cerebral palsy. The jury is still out, however.
It may well be that, as we begin to conquer the primary cause of infant mortality and morbidity -- that is, as we save more
low-birth weight newborns -- we may discover that the cerebral palsy curve will begin to turn upwards again from its present
point of about 9 percent among all live infants.
We have a somewhat similar situation regarding Down's Syndrome. During the past 20 years, while the infant mortality rate
was cut by more than half -- from 26 per 1,000 down to less than 12 per 1,000 -- the incidence of Down's Syndrome also
declined to about 25 percent. However, on closer examination, we see a slim relationship -- if any at all -- between the two
statistics. Rather, we see that, over the same period time, the number of women over age 35 who bore children declined by
half, as did the incidence of Down's Syndrome among children delivered of women over age 35. In other words, the drop
in the incidence of Down's syndrome was more closely tied to social and cultural patterns then to the decline in infant
This kind of information is generated by the Birth Defects Surveillance Program at CDC. That program, now almost 11 years
old, collects and tabulates mortality and morbidity data for some 150 known birth defects. From its periodic reports we are
beginning to learn a few things important to policy development. For example . . .
. . . Most defects have a low and fairly stable rate of incidents:
. . . The occurrence of these defects is not influenced very much by obstetrical practice, perinatal care, nutrition, diet,
or environmental toxins:
. . . If we hope to make any headway in reducing the incidence of birth defects, we will need a flexible strategy of research,
detection, and prevention. And I believe the administration has faced that idea and its response is reflected in the budget
increases for research and prevention and its strengthened partnership with the states to improve detection.
In my former life, my primary surgical interests were the congenital anomalies incompatible with life but amenable to surgical
correction. I know that, as we saved these young lives, my surgical colleagues and I joined with other medical neonatologists
in saddling you temporarily -- and I stress "temporarily" -- with a respirator-dependent infants and children.
I feel a sense of obligation to help solve this enormous economic problem. Before I left CHOP, I knew my colleagues had developed
home-care programs for respirator-dependent children in Pennsylvania and New Jersey. I want to assure you that I have not
forgotten this problem since coming to Washington. Here are some things I've been doing:
- I have been testing the sentiments in the private sector of health care to see the extent of its interest and potential
support for dealing with this problem . . .
- In the Department of Health and Human Services we are struggling with rewriting regulations so as to accommodate respirator-dependent
children at home instead of only in institutions . . .
- I have met with like-minded people representing a number of your member institutions to ascertain the boundaries of the
problem and the implications for the future . . .
- And finally, the planning and evaluation staff in our immediate office in the public health service is examining ways and
means of mounting some meaningful demonstrations that would point toward improving the quality of care and of life -- at considerably
reduced cost -- for these respirator-dependent children.
I would only add that the cooperation of the members of NACHRI and of many other members of the medical and health care professions
makes it possible for this administration to even hope for progress in this vital area of birth defects and their problems
During these past few minutes together, I've wanted to share with you some of the issues in child and maternal health
that I know concern you and to give you some idea of how they are perceived by the administration of President Reagan. I hope
you get a sense of our concern as well, of our strong desire to meet those issues had-on and sell them for the good of our
nation and its children. I don't doubt but that we will have differences of opinion along the way of how best to solve
them. But I feel secure in the fact that all of us -- in or out of government -- remain committed to the strengthening of
child health. It's a fundamental tenet of national health policy and has been since the beginning of the century.
I can't make many promises these days -- especially if those promises inflate the figures in our budget. But one I can
make: as long as I am here, you can be assured of my own personal advocacy and the moral suasion of my office on behalf of
children and institutions that care for them.