The 'Community' in Community Health: Presented at the Dedication of the Headquarters of the Community Health Association,
This speech was presented on Koop's behalf by Deputy U.S. Surgeon General Faye G. Abdellah at the Dedication of the Headquarters
of the Community Health Association. In it Koop assessed the role both of the Public Health Service and of the nearly 100-year
old Community Health Association in addressing emerging health care challenges produced by demographic change and the aging
of the American population, namely, the prevention of heart disease, stroke, cancer, and other diseases more prevalent among
older people; smoking cessation; and ensuring proper exercise and nutrition.
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1982-05-14 (May 14, 1982)
Abdellah, Faye G.
Koop, C. Everett
This item is in the public domain. It may be used without permission.
Presented at the dedication of the headquarters of the Community Health Association
May 14, 1982
(Greetings to hosts, special guests)
I am delighted to be here at the dedication of your new quarters and to bring you greetings from Secretary Richard Schweiker,
from Assistant Secretary for Health Edward N. Brandt, Jr., And from a "favorite son" of Pennsylvania, Dr. C. Everett
Koop, Surgeon General of the US Public Health Service.
Of course, that's the right thing to say at the beginning of a keynote address. But in this case, it is more than that.
The three top civilian health officials of the federal government firmly believe that the essential American qualities of
decency, of community responsibility, and of professional capability are very much alive in our society. All those qualities
has certainly been part of the 96-year history of the Community Health Association. And you give every evidence of continuing
that record in the years ahead. It is vital that you do, for the sake of Ardmore and the surrounding communities and for the
nation's sake as well. That is the essential message I carry here today for my colleagues in Washington and, of course,
for myself as well.
In just four short years the Community Health Association will celebrate its centennial of community service in these handsome
new quarters. By then, I suppose, there will be lots of scuff marks on the floors and the door handles will all be shiny with
use. It will look the way it's supposed to look -- well used . . . friendly . . . capable . . . and concerned more with
what is happening to people outside the building walls than what's going on inside. This is my prediction, based on just
a quick reading of your history of service.
People in Washington do know about you, as we know about the many thousands of private professional and voluntary organizations
across America, all of them rooted deep within their own communities and all concerned, as you are, not only with strengthening
individual and family health but community health and well-being also.
There is so much discussion these days about the "changing nature" of health care, we tend to forget those services
and philosophies of community health that have not changed and, I would hope, never will. I'm speaking of the services
in the organizations that support both physical and mental health, single people and extended families, personal hygiene and
community-wide sanitation. And I am speaking of those philosophies of care that use categorical services but will never categorize
the people receiving them. If I'm not mistaken, that seems to be the general profile of the CHA and we honor you for it.
But life isn't that smooth and well-defined. There are still a few specific issues of contemporary health care that we
all face -- issues that will remain with us well into the next century. On this occasion of evaluation and renewal, I'd
like to explore some of them with you.
To begin with, the structure of our population is changing quite dramatically and, as a result, our communities will be changing
as well. This is a major challenge to anyone in health care. The old ways of doing things -- no matter how successful they've
been -- may not be adequate for the future.
We've all read popular magazine articles about the "Graying of America." And they're all true. The post-World
War II "Baby Boom" generation is now our adult work-force. It runs our factories and farms, dominate our political
life, and is at the core of our national vitality. During the 1980s this age group will expand by 40 percent.
They are living better will be living longer as the beneficiaries of about 30 years of research on the detection and treatment
of society's major killers:
First on anyone's list is heart disease . . . since 1950 we've been able to reduce the mortality rate from this disease
by over 30 percent, which means reducing the number of premature deaths among that "Baby Boom" generation.
Next is cancer . . . mankind's most persistent scourge, producing the second highest number of premature deaths in our
society. We haven't solved the puzzle of cancer, but we have nevertheless been able to drop the death rate from cancer
by 33 percent among persons under the age of 45 -- the "Baby Boom" generation again.
And then there is stroke . . . a complex disease that is so closely coupled to an individual's physical, mental, and emotional
health. But in the past 30 years, we were able to reduce the death rate from stroke by 49 percent. The first group of Americans
to benefit from this extraordinary advance in medicine has been that same "Baby Boom" generation.
One result of all this progress appears to be a few more years of life for the people of this generation. Shortly after the
turn-of-the-century -- around the year 2010 -- approximately one in every five Americans will be a senior citizen. There will
be something like 50 million persons over the age of 65, compared to about 25 million in that age group today. The median
age in America today is 28 years and 10 months. In the year 2010 the median age to be 35 years seven months.
I would guess that the CHA seen this kind of number-writing on the wall. You have adjusted your mix of services to accommodate
the growth in our aged population. He says the limitations of institutionalization for the elderly. And you have reinforced
your emphasis on home health care for individuals and families. Ardmore and surrounding communities have been the beneficiaries
of your foresight.
Would that I could stop there. But I can't, since this discussion of the "Graying of America" is really just half
This aging "Baby Boom" generation has had babies of its own. In fact, our society is experiencing what is called an
While the birth rate among "Baby Boom" women may not be high, there are so many more of them that the total number
of live births remains very impressive. For example, in 1957 the peak year of the "Baby Boom," there were 4.3 million
live births in a fertility rate of 3.5 children per woman. In 1980, there were 3.6 million live births but a fertility rate
of only 1.9, about half the rate of a generation ago. Just imagine if today's young women all wanted large families!
And more of their babies are surviving. The infant mortality rate in 1957 was just over 26. The latest estimate we have today
is 11.6 infant deaths for every 1,000 live births. So in just one generation, we reduced the infant mortality rate by more
than half. Equally significant, during this same period we cut the death rate for children ages 1 through 14 by nearly half.
There is only one conclusion to draw from all this: we may have another "Baby Boom" on the way.
But what does all this have to do with the Community Health Association of Ardmore or with many similar institutions around
the country? This would be my guess. Over the next 25 years or so we are going to have the unusual task of providing -- at
the same time -- quality geriatric and quality pediatric and young adult health and medical care.
I am sure we will. But I am not at all sure how we will. We have no experience for that kind of circumstance. No other country
has had such experience either. Let's face it: We're on our own.
As I say, I have no doubt that we will adjust and that society will benefit from the ability of professional personnel to
make those adjustments. We Americans do have an exceptional ability to change to make our nation stronger in the process.
In the past, of course, we've had many years to make those adjustments. But we may not have the luxury of time anymore.
We probably have a decade or two at most to prepare our physicians and nurses, our dentists and therapists, our technicians,
administrators, trustees, and social service workers to deal with the nation with many millions of elderly and many millions
of youngsters and a lot of the other people scattered in between.
What might this suggest as to the specifics of health care we should focus upon, particularly regarding her elderly? I think
one thing we will need to do is to adjust our traditional orientation of curative and reparative medicine. We will have to
pay more attention to the promotion of good health and the prevention of disease and disability. And let me offer three examples:
One of the great research achievements of the past 20 years has been the exhaustive work on the effects of smoking on health.
The causal relationship between smoking and cancer and cardiovascular and respiratory diseases has been well-documented. We
also know that, once a person stops smoking, he or she can slowly regain cardiorespiratory health. It may take 5, 10, or 20
years, depending on the individual and the degree of damage done. But we know that the body will respond and try to repair
But what of the person who is, say, 65 years old and is smoking the past 40 years? Should a physician advise that person to
stop smoking? I would hope so. But we have very little evidence that physicians and other health workers take that attitude
toward older patients. They don't seem aware that, by the end of this century, about 10 percent of our population will
be 75 years old or older. In other words, the simple preventive counsel -- "Stop Smoking" -- ought to be provided
to persons of all ages. We must eliminate any feelings that, for some older persons, a change of habit may be "too late."
For those elderly patients -- and for their friends and family -- the advice must be offered vigorously and repeatedly: Don't
My second example involves physical fitness and exercise. I think it's wonderful that so many young nurses and physicians
play handball and squash and jog and hike. Good for them. But I wonder if they advise her older patients to keep physically
fit, also. Of course, we can rule out handball and squash and even jogging, since so many older persons have orthopedic problems
of some kind. Nevertheless, elderly people need to maintain their muscle strength in order to live full and active lives.
There is a real danger that, through an activity, they will convert good muscle tissue to fat.
Good posture is also important for the maintenance of musculoskeletal health. There's an old saying . . . you've probably
heard it . . . "You don't stoop because you're old, you're old because you stoop." And how many younger
people have we seen -- persons in their thirties and forties -- who have bad posture and look so much older than they really
are. Well, the reverse is also true. Older people who have been counseled on ways to keep good posture will look younger and
act younger than their chronological age.
The President's Council on Physical Fitness and Sports, which is part of the Public Health Service, has developed several
excellent guides on exercise for persons age 65 and older. The Council had been originally called "President's Council
on Youth Fitness." But it soon dawned on people that such a title was too limiting . . . working adults and senior citizens
needed a lot of help in this area, too.
My third and last example is nutrition. We know that older people do not metabolize fat and carbohydrate as well as younger
people do. So they must adjust their diet to reduce the intake of fats, in order to maintain healthy body weight and avoid
obesity, for example. But good nutrition is also a preventive measure against heart disease and stroke . . . it can further
assure basic dental health . . . and it may even help prevent the occurrence of some cancers, such as colonic cancer.
I'm sure that nutrition counseling is an essential part of the home health service provided by the CHA. I encourage you
to strengthen this part of your program, if you can, and to share your understanding of this aspect of health promotion with
your colleagues throughout medicine and health care.
I may point out that the "Baby Boom" generation, as they begin to age at the turn-of-the-century, will be more knowledgeable
about health than yesterdays or today's seniors are. Today the members of that generation are in their prime. They are
living their most productive, active, and inquisitive years. And because they are a better educated generation, I think we
will see many changes in their health behavior -- the so-called "lifestyle" changes that can be an important defense
against disease, disability, and premature death. I sincerely hope those changes will also occur among nurses, physicians,
and other professionals in medicine and health care.
Of course, we must do better than operate on good instincts in this matter of health promotion and disease prevention. If
you want to be effective in keeping people out of institutions and in helping him adopt healthful lifestyles, we need to work
from a good knowledge base. Much information still needs to be generated by the health services community so that we may apply
it to patient care in the years ahead.
The Public Health Service has been supporting a number of research projects that ought to yield that kind of information.
Let me share some examples with you:
- There is so much discussion of the physician's role in prevention that we thought it worthwhile to get some baseline
data in two areas of prevention: smoking cessation and colorectal cancer screening. We hope to understand a little better
which kinds of physician interventions work with patients coming in for routine care.
- In another project, a review of health promotion and disease prevention activities in the workplace, we found that the most
common programs focus on nutrition and diet control, alcoholism counseling, smoking cessation, stress management, and physical
fitness. Again, please remember that the employees involved in these programs are tomorrow's senior citizens.
- Because hypertension is such a major health problem in the black community -- and because the patient can bring it under
control -- we are testing the long-term effectiveness of special packaging of anti-hypertension medications used by a middle-aged,
black, low-income population.
- The last one I want to mention is a project to research the ethical and social questions raised by a policy of health promotion
and disease prevention. One of the great strengths of our democracy is that no individual is fully at the mercy of people
who "know what's good for him." Granted, we do have certain laws regarding immunization, drunk driving, and the
use of helmets by motorcycle riders. But even they have been challenged and, in any case, there are really very few such laws
on the books. Will the government's health policy turn prevention into a form of benevolent despotism? I hardly think
so. But there are gradations of the issue and I think we have a responsibility to be sensitized to them. That, also, is a
fit subject for public health research.
These are just a few projects from among many in the works. They're not meant to indicate any rank-ordering. But I think
you can get it from them but there are several dimensions to the challenges facing people who provide health and medical care
- We must adjust our ways of practice so that we provide the best health and medical services for population with growth in
both ends of the age scale.
- We need to add the concept of prevention to the traditional modes of curative and reparative medical practice. The public
is ready for it. The professionals need to be, also.
- And finally, we need to do these things within the framework of family- and community-based medicine. That's where the
people are. That's where our national strength lies. That's where the job has to be done.
I have every confidence that these will remain the hallmarks of the care provided by the Community Health Association. Your
new headquarters will be put to excellent use, if it houses the philosophy and services that have made the CHA and honored
member of the health community for nearly a century.