Public Health, Year 2000: Presented to the Alumni of Colby-Sawyer College, New London, New Hampshire
In this speech Koop projected how demographic change spurred by declining infant mortality, rising life expectancy, and the
aging of the American population would reshape medicine and health care in the United States by the year 2000.
Number of Image Pages:
16 (988,655 Bytes)
1982-06-05 (June 5, 1982)
Koop, C. Everett
This item is in the public domain. It may be used without permission.
Medical Subject Headings (MeSH):
Health Services for the Aged
Reproduction and Family Health
"Public Health, Year 2000: Presented to the Alumni of Colby-Sawyer College, New London, New Hampshire" [Reminiscence]
Deputy Assistant Secretary for Health and Surgeon General
US Department of Health and Human Services
Presented to the Alumni of Colby-Sawyer College
New London, New Hampshire
June 5, 1982
(Greetings to hosts, guests)
I'm delighted to be here to chat about the future. It is an appropriate topic for a college gathering. Colby-Sawyer is
devoted to preparing young people for the future. Some of our own individual futures may be limited in years. We don't
know how limited, although any friendly actuarian will gladly render an opinion. But I don't want to speculate on limits.
I'd rather spend these few moments with you speculating on potentials . . . on future hopes and possibilities . . . on
the things that whet one's appetite for more knowledge, more work, and -- of course -- more time.
In the public health area, we are heading into an exciting but very complex future. Complex because so many new relationships
are emerging -- social, economic, medical, demographic. And each new combination has implications for the future health of
our citizens. Time was when it was possible -- even in public health -- to have a "neighborhood vision," so to speak
. . . .to see those things that are known, familiar, and subject to long study . . . and not to see others. It may have been
a selective neighborhood vision, but it was sufficient.
Will Rogers once wrote that "everybody is ignorant, only on different subjects." And to a certain extent, society
was able to tolerate what Oscar Levant called "a smattering of ignorance." But that has changed. We are endangered
by "smatterings" both of ignorance and of knowledge. The need in public health, as in most of our professions, is
to know a great deal about many of the intersecting interests and influences of our society.
To illustrate this proposition, on this occasion of renewal here at Colby-Sawyer, I want to explore with you a few public
health issues that are with us today and which will accompany us through the remaining years the century -- and beyond. The
first issue is defined by demographics . . . who we are and who we will be.
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 way of doing things -- no matter how successful they've
been -- probably will 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, dominates our political
life, and is at the core of our national vitality. They are well-educated and make up the majority of the donors to college
alumni funds. I'm sure you'd agree with that. During the 1980s this age group will expand by 40 percent as its members
move up the population age pyramid.
This generation is living better and will be living longer as the beneficiary 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 in this generation. Therefore, we can
expect that shortly after the turn-of-the-century -- around the year 2010 -- approximately 1 in every 5 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 will be 35 years
and 7 months.
Many persons and organizations that deliver health and medical care has seen this kind of number-writing on the wall. They
are beginning to adjust their mix of services to accommodate the growth in our aged population. They also sense the futility
of planning for greater institutionalization for the elderly. Instead, they are emphasizing more health care services for
individuals and families.
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
"echo effect." While the birthrate among "Baby Boom" women may not be high, there are also so many more of
them 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 and 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! If the fertility rate were the same
today as it was 25 years ago, there would be something like 7 million babies born in America today.
And more of today's 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.
As Americans, we should be very proud of this record, particularly when compared with the data from other nations, as collected
by the World Health Organization . . . I, for example, with an estimated rate of 34.4 . . . or Italy, with a rate of 12.6.
Of special interest, I think, is the fact that, of all developed nations, only the Soviet Union is experiencing a rise in
their infant mortality rate . . . something about which they are not talking.
There's another interesting wrinkle in the American statistics. During the last 25 years we also cut the death rate for
children ages 1 through 14 by nearly half. There's 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 people in health and medical care? It's my best guess is that, over the next 25
years or so, we're 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 think we'll be able to do it. But I am not at all sure how we will do it. We have no experience for that kind of circumstance.
And 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 and to make our nation stronger in the process.
In the past, of course, we had many years to make those adjustments. But we may not have the luxury of time anymore. I suspect
we might 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 those other people scattered in between.
What might this suggest about the specifics of health care for our 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:
First, I would say that 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
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, 63 years old and has smoked for the past 40 years? Should a physician advise that person
to stop smoking, too? I would hope so. But I have to tell you that 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. They are today's 63-year-olds.
Let me put this in personal terms. I'm 65 years old and have never been in a nursing home. Statistically, I have about
12 more years of life. A woman my age, also with no nursing home experience, has about 15 years of life had. I don't think
we should be dismissed quite so easily.
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 Smoke.
I should point out that this advice is especially important for today's woman of any age who smokes. We are now seeing
among women, by the way, a repeat of the male experience with smoking-related lung cancer. In fact, we estimate that within
a year or so the lung cancer death rate will edge out the breast cancer rate is the leading cause of cancer related deaths
among women. And this can be traced directly to the recent -- that is, post-World War II -- rise in cigarette smoking among
women. I hope every student in the school gets this message.
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 advised older patients to keep physically fit,
also. Of course, we can rule out handball and squash and even jogging, since a great many older persons have orthopedic problems.
Nevertheless, elderly people need to maintain their muscle strength in order to live full and active lives. There is a real
danger that, through inactivity, 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 keep good posture will look younger and act younger than their chronological
It's also a fact that, of the 300,000 or so hip fractures a year in this country, about half could be eliminated if only
older people learn how to get up out of chairs or step out of automobiles or off buses. These are simple physical skills that
can be -- and ought to be -- learned because we know that, among older people, the fragile osteoporotic hip actually breaks
before a person falls, not after, as is commonly believed.
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 the "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 help in this area, too.
My third and last example is nutrition. We know that older people do not metabolize fats and carbohydrates as well as younger
people do. They need to reduce their intake of fats, in order to maintain healthy body weight and avoid obesity. This goes
right along with the comments I just made about exercise.
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 might point out that the "Baby Boom" generation -- as it begins to really show its age at the turn-of-the-century
-- will be more knowledgeable about health than yesterday's or even today's seniors are. As I mentioned a few moments
ago, the members of that generation are in their prime, 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 they can be an important defense against disease, disability, and premature death.
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 them adopt healthful lifestyles, we need to
work from a good knowledge base. Much information still needs to be generated and applied to patient care in the years ahead.
We hope to understand a little better which kinds of physician interventions work with patients coming in for routine care.
The physician seems to exercise a great deal of influence in convincing people to give up smoking. Of course, they do not
yet do this with older people to the extent that they should. But when they do offer that advice, people are inclined to follow.
Now we need to find out how to get more physicians to do this and we need to know why people seem to be influenced so painlessly
and for their own good. You have to admit, it's a rare enough phenomenon.
We also know that, among the health promotion and disease prevention activities sponsored by enlightened employers for the
benefit of their workers, the most common programs focus on nutrition and diet control, alcoholism counseling, smoking cessation,
stress management, and physical fitness. While there are many of these programs now going on, there could be a hundred times
as many. It would be good to understand how to reach the rest of American industry with this message. And please remember:
the employees involved in these programs are tomorrow's senior citizens.
The last research area I would mention has to do with the ethical and social questions raised by a policy of health promotion
and disease prevention. You see, 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 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 really aren't very
many such laws on the books.
So we need to ask if the government's preventive health policy could turn into a form of benevolent despotism? My guess
is that it probably would not. But there are gradations of the issue and I think we have a responsibility to be sensitized
These are just a few random thoughts, from a public health perspective, regarding the implications of the many changes to
be occurring in our society over the next two to three decades. They are in no particular rank order of importance. But I
hope they have served to illustrate the several dimensions to the challenges facing health and medical care in America:
Our first great challenge is to adjust our methods of practice so that we provide the best health and medical services for
population with growth at both ends of the age scale.
Our second great challenge would be 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 am optimistic about all of this, mainly because we are a nation with an unending sense of adventure and an almost childlike
inquisitiveness. I think we share the view of the world held by Albert Einstein, who wrote that "The eternal mystery of
the world is its comprehensibility." We are intrigued by the future and are impatient for it to arrive, positive that
we will understand it.
Americans may not all be as brilliant as Einstein, but I think we are as eternally optimistic as he was. Or else, why would
anyone here have bothered to come?