Perspectives on Future Health Care: Presented to the Division of Health Psychology at the American Psychological Association
Annual Convention, Washington, DC
This speech reviewed the success and remaining challenges of federal public health initiatives in the areas of immunization,
infant mortality, blood pressure control, and smoking cessation during the three years since U.S. Surgeon General Julius Richmond,
Koop's predecessor, laid out numerical goals for improving the nation's health in his two reports, "Healthy People:
Disease Prevention and Health Promotion," and "Promoting Health and Preventing Disease: Objectives for the Nation."
Koop paid particular attention to the difficulty of convincing citizens of a democracy to change their behavior and lifestyle
for the sake of improving their health, in the absence of governmental authority to compel such changes.
Number of Image Pages:
24 (1,432,420 Bytes)
1982-08-24 (August 24, 1982)
Koop, C. Everett
This item is in the public domain. It may be used without permission.
Medical Subject Headings (MeSH):
"Perspectives on Future Health Care: Presented to the Division of Health Psychology at the American Psychological Association
Annual Convention, Washington, DC" [Reminiscence] (2003)
Deputy Assistant Secretary for Health and Surgeon General
US Department of Health and Human Services
Presented to the Division of Health Psychology at the American Psychological Association Annual Convention
August 24, 1982
(Greetings to hosts, guests, etc.)
I'm delighted to be your guest this morning, these annual APA conventions are awesome events. Considering the competition
all about town, your attendance for this session is very much appreciated. I honestly wouldn't begin to guess how you
choose the sessions you're hoping to attend. That in itself might be a fit subject for research, if it's not already
included in a "poster session" this very week.
So, to be honest with you, and I'm happy to be standing up here, rather than sitting down there. I haven't had to
suffer the agonies of choice.
But this may be one of the few times that choice is really out of my hands. The fact is that the public health field today
is confronted by a range of choices that have to be made. The people making those choices are in professional societies, such
as the APA, they are in our colleges and universities and our voluntary associations, they're in private business, and
they're in local, state, and federal government.
The presence of a range of difficult choices should tell us that health care holes a vital, central position in the public
mind. And in the involvement of so many diverse and knowledgeable interests should guarantee that we have serious debate and
each choice we make. Granted, this is not a particularly neat process of social growth -- but it's all ours. Theories
and practices come and go, yet we are conducting the public business now pretty much as Americans did nearly two centuries
ago, when de Tocqueville observed them and recorded his impressions. Our society remains open, our agenda is full to overflowing,
and full participation by everyone is our national goal.
But as we leave that lofty plateau of social theory and come closer to the particular health care issues of our own day --
the ones that require us to choose and choose now -- the debate becomes very complex. It's at this point that I am reminded
of the opinion of a more recent French writer that "Morality may consist solely in the courage of making a choice."
So this morning, I want to share with you a few of my thoughts on those public health issues that are beginning to test our
courage. In the course of my remarks, I hope you don't mind if I occasionally suggest what the psychologist's special
contribution might be.
Number of important issues fit together under the general heading of "Disease Prevention and Health Promotion." This
is an area that's already receiving a great deal of attention from both the behavioral and biomedical sciences. I think
that the most comprehensive guidance you can get for exploring this area lies in the pages of a benchmark publication called
Healthy People, put out by the public health service not too long ago. It is subtitled "The Surgeon General's Report
on Health Promotion and Disease Prevention."
Healthy People represents a consensus in prevention and health promotion. It is based upon contributions from some 2000 non-government
experts representing a broad spectrum of health and social service disciplines. A number of psychologists, several from division
38 itself, contributed to this report, for which we are all in your debt. The report shows how each of our major public health
issues affects Americans of different demographic, occupational, and socioeconomic backgrounds. It also indicates how we might
help resolve some of those issues during the decade of the 1980s.
I strongly recommend that you read Healthy People in the important follow-up document called Promoting Health and Preventing
Disease: Objectives for the Nation. The second publication is a bit different, in that it sets out specific, measurable goals
for this decade and the steps we might take to achieve them. This material includes the steps we ought to take in order to
bring about . . .
- Full immunization for at least 95 percent of all school-age children by the year 1990 . . .
- A decline in infant mortality rate from the present 11.5 deaths per 1,000 live births down to 9 deaths per 1,000 . . .
- Long-term blood pressure control for at least 60 percent of the population with definite hypertension, that is, with a reading
of 160 over 95 . . .
- A drop in adult cigarette smoking down to below 1 person in 4; it is now 1 in 3.
These are not all them. There are multiple objectives in 15 different health areas. But I hope you are stimulated by my few
remarks to read both reports, since they provide all of us with the kind of roadmap of where we're headed and how we hope
to get there.
One clear thread that runs through these reports is this: that our society will achieve its health goals primarily through
changes in behavior not only among the public in general but also among health professionals themselves. The clearest example
of this is cigarette smoking, this country's number one preventable cause of death.
Ever since the first Surgeon General's report on smoking and health back in 1964 there is been a 42 percent drop in the
number of smokers. But about 53 million Americans still smoke. Some groups -- adolescents and young adult women, for example
-- have had increases in smoking until very recently. As a result, smoking remains our top health hazard. It will cause an
estimated 340,000 premature deaths in this calendar year alone.
As we indicated in our annual report last February, about a third of these deaths are from smoking-related cancer. In the
report now in preparation, to be released early in 1983, we will lay out the data to illustrate the causal relationship between
smoking and cardiovascular disease. It is equally as convincing.
There is, however, no vaccine against the smoking habit. There is no discreet surgical procedure, no drug, no food, or no
magic therapy that is safe and effective for smoking cessation. Quitting the habit is entirely a personal decision by the
smoker. But getting a smoker to make that decision -- and to stick with it -- is a complex behavior problem.
Smokers who decide to break the habit prefer to do it on their own. A National Cancer Institute report indicated that as many
as 95 percent of those who quit smoking did so without the help of any organized smoking cessation program. They learn things
from books or magazine articles were encouraged by radio and TV public service announcements. Very few -- about 5 percent
-- sought the help of clinics, seminars, or group sessions.
Our understanding is still very crude, concerning which messages effectively turn smokers around. In addition, we have a mixed
picture on the ability of ex-smokers to stay away from cigarettes. We still don't know which reward systems are the most
reliable. And we're still experimenting with making changes in certain close environments -- non-smoking sections in restaurants,
for example, or smoking bans on public transportation. And should we emphasize self-management or should we encourage the
involvement of friends, families, coworkers and employers, and "concerned others?"
That kind of information can literally save lives. The United States cannot afford the hundreds of thousands of premature
smoking-related deaths every year nor can it afford the estimated $13 billion in health costs and $25 billion in lost production
and wages that can be traced to the effects of cigarette smoking.
Behavioral change among the smoking public is a major national public health priority. But those of us in the health professions
have a similar priority. In his "forward" to this year smoking report, Dr. Edward N. Brandt, Jr., the Assistant Secretary
for Health, directed a few remarks in our colleagues in medicine:
"As a physician," Dr. Brandt wrote, "I encourage all health care providers, particularly other physicians, to
counsel cigarette smokers to quit and to give them as much support as possible . . . a few minutes discussion with patients
about their smoking behavior can have a decisive impact on whether the quit smoking or continue to habit."
This is more than just a routine request. As most observers of the medical profession know, the education of physicians, dentists,
nurses, and other primary health care professionals is strong on curing and repairing and weak on preventing. There's
a lot of learning, re-learning, and un-learning to be done by physicians especially, if we hope to significantly reduce that
current group of 53 million smokers.
There are some subtleties to explore, also. For example, if we can convince family physicians to relay a strong anti-smoking
message to the patients, will they do this with their older patients as well? We have strong suspicions -- and some anecdotal
data -- that indicate physicians may suffer from "age prejudice" is much as the rest of the country does. Would a
physician try to convince a 65-year-old smoker to quit -- or would the physician think "It's too late to do any good."
It's my feeling that there may be too many physicians who can't bring themselves to practice good preventive medicine
with people who are 60 or 65 years old. Even though, depending on their sex and the general health status, no senior citizen
statistically may have as many as 15 to 18 years of life ahead of them.
How should we go about to change the smoking behavior of physicians, dentists, nurses, and other persons who provide health
care? This kind of thing comes up in other areas as well: getting physicians to advocate weight control, use of seatbelts,
and the control of drinking and drug use. Now were asking them to encourage patients to stop smoking -- even those patients
they consider to be "over the hill."
I think it is clear that the anti-smoking challenge -- one of the most serious challenges we now face -- can be met only if
there is a profound and permanent change in behavior among both the general public -- regardless of their sex or age or social
condition -- and also among the professionals who provide them with health care, preventive as well as curative.
This double challenge runs through most of our priority programs in health promotion and disease prevention. In the ones I
just mentioned, the behavioral factor -- or "lifestyle" -- is the single most important factor. But in other areas,
there is a complex relationship between behavioral and biomedical medicine in preventing disease and promoting health. Hypertension
offers a good example of this.
Having once identified a patient as hypertensive, a physician will tend to move immediately into diet control and drug therapy
to bring down the diastolic pressure. Equally impressed with the need for urgency, the patient will tend to follow both the
drug and the behavioral regimens. Early success with hypertension control is usually high. But that is by no means the end
The biomedical approach -- specifically, the use of drugs -- will bring down blood pressure but will not necessarily keep
it down without penalties for the patient. These would include the side effects of the medication -- dry mouth, for example,
or even impotence -- and the cost of the drugs. They aren't cheap. Therefore, the physician who relies almost entirely
on drug therapy will suffer a penalty, also: failure and frustration over the long term.
For most hypertensives, the therapy needs to be biobehavioral: early on, an emphasis on drugs and a start on changing lifestyles.
Then, as the blood pressure comes under control, the emphasis may begin to shift away from drug therapy and move toward long-term
behavioral change. At that point the patient has to get greater control over his or her behavior, change what has to be changed,
and -- again, as with smoking cessation -- maintain the new patterns of healthful behavior.
Unhappily, these long-term behavioral solutions are not always clearly transmitted to patients. Most physicians don't
have the teaching skills that might be most effective with hypertensive patients, nor have they been trained to monitor behavioral
change over the long run. Yet, it seems to me that that's precisely the kind of health care that would be fundamental
to successful, long-term therapy for hypertension.
Life, as APA members know quite well, it's not an either-or proposition. Nor is health. Nor is the promotion and maintenance
of health an either-or proposition. Medical practice, therefore, needs to understand the interdependence of the biomedical
and behavioral sciences and the practitioner -- especially the practitioner specializing in primary care -- must get used
to employing both, rather than rely either on one or on the other. Good practice is rarely that exclusive.
The biobehavioral experience with hypertension that I recounted earlier can we be repeated in many other areas as well --
in the detection and control of cardiovascular disease, in the treatment of certain diseases of the gastrointestinal tract,
and the management of stress, and in the relatively unexplored area of pain management.
But while I'm optimistic about this new development, I am also sensitive to some potential ethical problems it raises.
For instance, when testing the safety and efficacy of a hypothesized balance of drug and behavioral therapy, wouldn't
we at some point have to lower the approved drug dosage levels or even withdraw the drug altogether? And when we do that,
would we be stepping into that territory where we may be denying a patient standard treatment? This question has come up in
just a few instances in the past, as in the biobehavioral research into diabetes therapy. But it is still a very new area.
One major issue, of course, is that behavioral therapy is not covered by anything like the "Kefauver-Harris Drug Amendments."
Therefore, we do not measure behavioral research results against a standard analogous to the "safe and effective"
criteria and drug research. Few therapies used by psychologists would carry a "final printed label" listing all the
indications, contraindications, precautions, warnings, and adverse reactions. I seriously doubt that will ever develop such
labeling for psychotherapy. Nevertheless, the more deeply we penetrate this new biobehavioral area -- where measurable phenomena
become intertwined with indeterminate, unpredictable phenomena -- the more we're going to have to learn about providing
at least minimum guarantees for human research subjects.
This is an area, by the way, in which the American Psychological Association -- and division 38 in particular -- could be
of immense value. You can provide a much-needed forum for the development of professional standards for biobehavioral research.
In a recent editorial written for Science magazine, Dr. David Hamburg, the former president of the Institute of Medicine and
soon-to-be president of the Carnegie Foundation, wrote . . .
"Recent advances in molecular and cellular biology exceed what anyone could have imagined as recently as a few decades
ago. They link up with other fronts, such as neurobiology and human behavior. Nowhere are the needs and opportunities for
progress in the biobehavioral sciences clear," says Dr. Hamburg, "then in problems of health and human behavior."
He also refers to a recent report he co-edited for the Institute of Medicine titled Health and Behavior: Frontiers of Research
in the Biobehavioral Sciences. That report is very timely, considering the work to be done in prevention and health promotion
during the next several decades. Incidentally, much of the report's value rests on contributions by members of division
38, especially Dr. Judith Rodin, your incoming division president, who is also coeditor of that report. It's an excellent
document and not be in your library, along with Healthy People and Objectives for the Nation.
So far, I've had quite a lot to say about having people change the way they live. But even your surgeon general knows
that life doesn't work out quite that way. And I think that's a good thing for all of us. No one has a license to
impose preventive health policies and regimens on the general public, much less on physicians. There is in American society
an unwritten but nevertheless powerful rule that goes something like this:
People have the right to defend themselves from what other people think is good for them.
What, then, our society's options for handling people who don't like breakfast, hate exercise, and chew candy? Or
the people who drive too fast and smoke too much? In some cases, society can fashion laws to protect the majority from any
danger that might be caused by this feckless minority: we set speed limits and minimum drinking ages . . . we require vaccinations
and double the excise tax on cigarettes. That sort of thing.
But when you look over the 15 health areas catalogued in Healthy People, you have to conclude that laws and regulations probably
play a minor role in our national public health strategy. In most instances, coercion is simply not the procedure of choice
for social change.
That's nothing new. Almost 200 years ago James Madison wrote, in one of the later Federalist Papers . . .
". . . It is of great importance in a Republic not only to guard against the oppression of its rulers, but to guard one
part of society against the injustice of the other."
So we must be careful that, in our zeal to practice innovative preventive medicine, we do not impose an injustice upon her
neighbor. I believe that, in the future, we will be turning less often to the law for preventive medicine, even though, in
our frustration, we might want to take that path. However, I would counsel that we turn more often to the behavioral sciences
-- in particular, to the disciplines represented in health psychology -- which tend to be instructive and persuasive rather
And that brings me to the last subject I want to raise with you this morning. This also is the subject involving ethical standards
of behavior and of the choices now presented to the profession of psychology . . . indeed, to all professions involved in
health research. The subject is misconduct in research, something that has crept into the behavioral and biomedical fields
in the past several years.
First, it's important to recognize that American research -- carried out in the tradition of free inquiry and sheltered
within our great academic institutions -- still leads the world by any measure you may choose. Since becoming Surgeon General,
I have been privileged to represent the United States in meetings of the World Health Organization and to spend many long
hours with the leading health officials of other countries. And always the message is the same: the world looks to us to set
the standard by which mankind will make progress in health and medical care. I was impressed with the record before coming
to government. I'm even more impressed now.
So I am deeply troubled -- as we all should be -- when there are instances of misconduct in research. This is an especially
important problem for us right now. We are embarking on a long-term national commitment to preventive care and health promotion.
Most of our work so far has been carried by instinct, anecdotal reports, visceral responses, and double-blind cross-over guessing.
The base has to be solid.
In matters of personal and professional integrity, just as in the choice of more healthful behavior, I don't believe coercion
works either. I don't believe you can regulate honesty or legislate high ethical standards or mandate spotless professional
conduct. Rather, I believe this is a problem that lies at the doorstep of every professional organization and institution.
It is also the personal responsibility of everyone engaged in the behavioral and biomedical sciences. The profession itself
must put into place its own mechanisms for ensuring the integrity of research.
In this connection, I want to quote from a paragraph in the introduction to a new pamphlet published by the Association of
American Medical Colleges. It's titled The Maintenance of High Ethical Standards in the Conduct of Research. Rather than
paraphrase, I am going to quote directly from the "Introduction":
"The responsibility of the scientific community to the public is acknowledged," it says. "The maintenance of public
trust in this pursuit is vital to the continuing vigor of the biomedical research enterprise." And I would merely take
out the word "biomedical" and insert "total" instead. But to continue . . . "Loss of this trust because
of isolated instances of dishonest behavior on the part of a few researchers could cause great harm by calling into question
in the mind of the public the validity of all new knowledge and the integrity of the scientific community at large. In short,
is in the best interest of the public and of academic medicine to prevent misconduct in research and to deal effectively and
responsibly with instances where misconduct is suspected."
This is a call to action for everyone whose life is bound to the pursuit of new knowledge. For psychologists working on the
frontiers of human behavior, it has a special -- even an ironic -- significance. In a sense, it is behavioral research turned
in upon itself.
At a recent staff meeting in the Public Health Service headquarters we were discussing the issue of the reporting of fraudulent
data and other aspects of misconduct in research. In the course of the discussion it was noted that, between October 1, 1980,
and the end of June this year, there were only 45 cases of alleged misconduct in NIH-supported research. This was out of the
12,000 to 15,000 research projects they had been carried on during the same period of time.
The first response by some persons at that meeting was "Well, 45 out of 15,000 isn't so bad." Then one senior
staff member spoke up. He said, "We can't put too much weight on that figure. After all, in nearly every other sector
of society where we see examples of fraud and abuse, we say, 'Aha, I bet that's only the tip of the iceberg.'
We all do it -- with allegations of government corruption, business misconduct, welfare cheating, and so on. Why should the
public -- or why should we, for that matter -- view that number 45 with any less skepticism?"
I don't know whether he was being fair or not to the research community. But I think he was giving us the right message.
He was dealing head-on with the importance of appearances as well as of substance. Our research has to be excellent. That's
the unequivocal standard for substance. But it also has to look as if it will produce excellence. Public faith in the research
community rests upon both substance and appearance -- and I don't think there's anything wrong with that.
After a moment's reflection, I had to agree that 45 out of so many thousands of projects was no longer impressive. I had
to conclude that, with the second case of alleged misconduct, we actually hit critical mass. Two should have been our absolute
limit. The other 43 merely reinforce the dangers posed by the first two.
I tend to be an optimist about these matters, however. I believe that, somehow, the research and the academic communities
will put together a way of enforcing the highest standards of research, without endangering freedom of inquiry. And I sincerely
hope each person in the audience this morning will do whatever needs to be done to help justify my optimism.
I promised Dr. Mathews that I would devote my remarks to "Perspectives of Future Health Care." My perspectives this
morning may not be very exotic, but I submit them for your thoughtful attention. I think there is a great need for professionals
in every health discipline to grapple with . . .
- The growing importance of prevention and health promotion . . .
- The role of behavioral change within the prevention strategy . . .
- The ethical questions concerning this strategy and the persons affected by it . . .
- And finally the issue of misconduct in science, a very grave matter that must not be allowed to compromise the strength
of behavioral and biomedical research in this country.
I am confident we will attack these issues and resolve them in the years ahead with our society's characteristic energy.
Earlier I mentioned Alexis de Tocqueville's fascination with American behavior, so I would like to close my remarks this
morning with an observation he made in his book, Democracy in America, nearly 150 years ago:
"America is a land of wonders," he wrote, "in which everything is in constant motion and every change seems an
improvement." And as far as the average American is concerned, said de Tocqueville, "In his eyes, what is not yet
done is only what he has not yet attempted to do."
I think that we still are the nation of de Tocqueville's vision and that we will do those things "not yet done"
in public health.
Thank you again for your gracious invitation to have me join you. Please accept my best wishes for a successful annual meeting.