This speech was delivered to the American Academy of Pediatrics, New York, New York.
During his two terms as U.S. Surgeon General, Koop applied public health methods and approaches, namely epidemiological study,
disease prevention strategies, and information on health promotion, to several issues that had not previously been regarded
as matters of public health. Violence, especially domestic violence, was one such issue, as this speech--one of his first
on the issue--demonstrated. Long treated as the domain of law, law enforcement, and criminology, the "epidemic of violence"
in the United States, as Koop called it, produced a range of physical and psychological health consequences that he explored
in speeches, workshops, and reports. He also thought that violence, particularly domestic and sexual violence, could be prevented
through appropriate health messages, health education, and psychological screening and counseling.
Number of Image Pages:
16 (1,001,437 Bytes)
1982-10-26 (October 26, 1982)
Koop, C. Everett
This item is in the public domain. It may be used without permission.
Medical Subject Headings (MeSH):
Reproduction and Family Health
Violence and Public Health: Delivered to the American Academy of Pediatrics, New York City, New York (October 26, 1982)
Surgeon General and Deputy Assistant Secretary for Health
Delivered to the American Academy of Pediatrics
New York, New York
October 26, 1982
(Greetings to hosts, guests)
I appreciate this opportunity to speak to this group on a subject that is an uncomfortable one to raise: violence done to
children. It is uncomfortable because, in the raising of the issue, we are admitting that the human race hasn't come quite
that far after all. There is still streak of violence that seeks out the most vulnerable members of society -- our children
-- and does them permanent damage.
We feel much shame and much anger, when this subject is raised. It's difficult to discuss child-abuse without becoming
somewhat emotional. That may be one reason for the late start we are making in trying to understand violence against children.
We wish we didn't have to. We wish it would go away . . . that it would become a chapter of mankind's history that
is closing, rather than one just opening up for us to explore and try to understand.
There is another reason, also, that we are getting a really late start in this field. For several centuries medicine -- and
its predecessor, magic -- have been concerned with the infectious diseases of childhood. Outbreaks of those diseases have
raced through whole societies, wiping out almost an entire generation, pushing children -- and the future -- deep into the
ground. But gradually those diseases have been brought under control. And that's a rather recent story. In 1913, after
all, Dr. Bela Schick discovered how to test children for diphtheria immunity. Dr. Schick died only 15 years ago. The great
battle to overcome the infectious diseases of childhood began and has been waged in our lifetimes.
The Public Health Service had started a vigorous immunization program just 5 years ago. It set October 1982 as the deadline
for eliminating indigenous measles from this country. It would go the way of smallpox . . . become extinct here and then,
country by country, it would disappear from Mankind's environment altogether.
Indigenous measles has not been wiped out as of this month, but we are down to the last stratum of effort. Better than 95
percent of children entering school for the first time have been immunized. And as of the week of September 18 of this year,
we had an historic low of only 1,230 cases. Just two years, as of the same date we had 10 times as many cases: 12,843. In
addition, we are now down to three known strains of indigenous measles. And we know where they are. If we interrupt those
three strains of transmission, and all future cases of measles in this country will, by definition, have been imported.
Dr. Schick would have been pleased to note that as of the beginning of October there are only 2 reported cases of diphtheria
so far this year. There have been only 3 cases of polio. As for the other infectious diseases of childhood -- mumps, pertussis,
German measles -- the record shows hard going, but progress nevertheless and truly significant changes in just the past five
We have the same record so far in infant mortality. In our own lifetimes we have seen the birth event itself become among
the safest for both mother and child. When I was awarded my degree from the Cornell Medical School in 1941, the infant mortality
rate was 45.3 per 1,000 live births. Since then we've cut that rate by three-fourths. Our latest provisional estimate
for the 12 months ending in July is 11.3 infant deaths per 1,000 live births.
As many of you know, the Public Health Service has set as a goal for 1990 the reduction of that infant mortality rate to 9
per 1,000. I believe we have a good chance to make it.
Of course, we are now entering the most difficult area to make progress. Here, medical technology is still helpful -- infant
intensive care, emergency airlifts -- and we can use even more exotic technologies for more precise and reliable antenatal
diagnosis. But this is really the area where medicine and behavior have equal significance. In fact, it may be that the behavioral
factors have the edge.
For example, there is no question but that current infant mortality statistics are skewed by the comparatively large numbers
of low birth weight babies born to adolescent women. Their survival rates are poor. As a matter of fact, if you could take
out of the statistical base those high-risk babies who are brought into the world alive but who can't hang on to life
for more than a couple of weeks, then the United States would have a truly remarkable record on infant mortality, since we
do extremely well for just about every other kind of birth.
We have no vaccine to insure every adolescent mother a healthy, normal weight infant in the delivery room. There is no magic
potion that will supply all the maternal nutrition needed for both mother and baby throughout a full-term pregnancy. There
is no medical way to compensate for environmental insults, poverty, misunderstandings, and such harmful maternal behaviors
as smoking and immoderate drinking.
You have probably seen some of the materials produced by the members of the national "Healthy Mothers, Healthy Babies
Coalition." This is an effort by more than 50 national organizations -- professional, voluntary, and public interest --
plus health-related government agencies to get an effective health promotion message to potentially high-risk mothers. It's
a very important effort and one of the best demonstrations of initiative by the private sector. I want to congratulate the
American Academy of Pediatrics for taking a keen interest in this program from the very beginning and a special thanks to
those individual pediatricians who are using the materials, or providing feedback to the coalition, and who in other ways
are contributing toward the continued decline in the infant mortality rate in this country.
This is our slow but steady record of continued success and child health. I'm proud of it and I know the Academy is also
proud of it and well you should be. But, as I noted earlier, we have directed so much of our energies and attention to these
issues of infectious disease and infant mortality that we have not really noticed the rise of this other issue . . . an issue
every bit as alarming as infectious disease and as tragic as distressed births. It is the issue of adult violence against
This is not a brand-new subject for pediatricians. Members of the Academy taken strong leadership positions at both the local
and national levels and supportive measures to curb child abuse, to help the victim, and to deal more effectively with the
adult abusers -- whether through health services or the criminal justice system.
This subject is not new . . . but it is taking on new urgency, I believe. While we might like a firmer research base and better
statistics behind the battle against child abuse, there does seem to be general acceptance of the fact the violence within
the family -- particularly parental violence toward children -- tends to escalate during periods of economic stress.
Indebtedness . . . unemployment . . . eviction . . . layoffs . . . repossessions . . . these are the stuff of trauma for many
families. They can overwhelm parents and open them to the terrible impulses of violence against their children. In some areas
of the country we are experiencing very difficult economic conditions and, if the research and the anecdotal material we have
is any guide, those areas are also experiencing a rise in child abuse.
I wish we were at the stage in our development of the data base that could present an accurate statistical or demographic
picture of just where and how this is taking place. But such a picture is not yet possible for at least two reasons -- possibly
many more. First, there is still no generally accepted definition of child abuse; many local jurisdictions have their own
unique definition of what they consider to be reportable. Also, we strongly suspect that there is still a substantial degree
of under-reporting -- even among those health and social service professionals who have a generally accepted definition of
The experience of the National Center for Child Abuse and Neglect is a case in point. The staff of the center received some
400,000 reports in 1976, their first year. The annual totals have steadily increased each year. For 1980, the last year for
which they have a full tally the staff received close to 800,000 reports of child abuse. That is a 100 percent increase in
reporting, however, not in the actual incidence of child abuse. But, after analyzing the reporting system in its present stage
of development, the staff feels that a conservative estimate of actual incidence of child abuse could be something like 2
million each year.
The Center defines abuse children as "children who are harmed," either physically or mentally. The overwhelming number
of reported cases involve violence by parents, but the data does not necessarily come in that way, since a person making that
judgment underreporting form may be consigning one or another parent to the criminal justice system without good cause.
I've dwelt on the status of reporting because that problem provides a kind of window that looks through to a much broader
issue for the practicing physician. That issue is the degree to which physicians are comfortable working with non-medical
professionals in such a sensitive area. The data from the medical community seems to be of uneven quality, which, I think,
may be symptomatic of a deeper sense of unease, if not ambivalence.
The best kind of physician cooperation in the most consistent data come from hospital-based physicians. It is clear that the
physician in the hospital setting feels supported by other personnel who also take part in the data collection most often
do the actual reporting, also. Professionals in nursing, social services, and even staff clergy are among this larger staff.
We know that child abuse is not a phenomenon found only among one social or economic class. Unfortunately, an abused child
can be found living in wealth as well as poverty, its parents among the communities leading citizens as well as among its
most destitute poor. Since that is the case, why are there so few instances of child abuse reported by pediatricians in private
practice? Why is the level of participation so low by practitioners who serve middle- and upper-income families?
The first answer that might come to mind is the uneasiness of the physician and what he or she may regard as a breach of the
confidential physician-patient relationship. After all, the treatment situation is made possible because both parties have
established a one-to-one bond of trust. A physician understandably does not want to compromise that bond. The risk would not
be just the physician's loss of the patient and the patient's family. There's also the risk of the patient's
loss of good medical care -- the kind that is based upon personal and even intimate knowledge shared over time in an atmosphere
of total mutual trust. If there is a breach of confidence, both parties in the physician-patient relationship stand to lose
I think that's an important consideration . . . but it's not the only consideration and very possibly it's not
the most significant one either. Of much greater concern may be the physician's imperfect perception of what medicine's
role actually should be within this complex and highly charged issue of child abuse family violence.
It's my feeling that the medical profession needs to accept the fact that many physicians are simply unclear about the
role of social service personnel in these highly sensitive areas. Physicians are generally unfamiliar with the education and
training of these personnel . . . they are usually also unclear about the nature of their services . . . and physicians are
not fully aware of the high degree of discretion those personnel exercise or the similarity of the ethical imperatives shared
by both medicine and social services. Because of their unfamiliarity with the value of these services, physicians -- especially
those in private practice -- tend not to refer to patients as often as they should nor do they seek the counsel of social
service professionals when a possible child abuse problem comes to their attention.
This may be a problem now, but I believe it will be less the problem in the future, as physicians become more familiar with
the total constellation of research service that is becoming available for the protection of victims of family violence. Let
me note just one example where we are making some progress. This is the work of Dr. Eli Newberger at Boston Children's
Hospital. With the support of the National Institute of Mental Health, Dr. Newberger, a pediatrician, has been carrying out
a program of interdisciplinary training and research in the detection and treatment of victims of family violence.
In this program, Dr. Newberger brings together a group of professionals on the staff of Boston Children's Hospital. They
include pediatricians, social workers, researchers, psychologists and psychiatrists, sociologists, and computer analysts.
Working as a team, they provide hands-on clinical care for children who have been abused and they seek to understand the causes
of the violence within the family, in order to prevent it from recurring. The result is a program that draws upon a variety
of skills right at the time they are needed most. Research information is translated into direct patient care. In addition,
the program adds new information to the knowledge base regarding child abuse and neglect.
By the way, Dr. Newberger is the editor of a new book titled Child Abuse, published by Little, Brown for its series on Clinical
Pediatrics. The book brings together the kind of research material that can be applied by the practicing pediatrician. It
was just released earlier this month. I recommend it to any of you who want to explore this issue in greater depth.
And I sincerely hope you do. I feel certain that the pediatrician can be the key figure in obtaining life-protecting services
for abused children and in initiating a program of treatment for the parents as well. I am aware of the sense of hopelessness
felt by so many health and medical personnel -- particularly emergency room personnel -- when they are confronted by patients
who have suffered the terrors of family violence. Yet, we must resist that feeling and move on to the business of treatment.
Otherwise we are consigning the children and their parents to a lifetime of chronic suffering and decline.
Without good professional help, the abused child will grow into an adult who may exhibit a range of abnormal responses to
family, friends, and the community: angry or depressed . . . aggressive or withdrawn . . . physically violent or almost totally
immobilized. Although the "cycle of abuse" is not a certainty, the possibility always remains that the abused child
will grow up and, in turn, abuse the child he or she has. These young victims of adult terror tend to abuse alcohol, drugs,
and other substances . . . pose a clear danger on the highway . . . place themselves and others at risk at their worksite
. . . require constant care for their acquired physical or mental illnesses . . . and, in a word, become a chronic burden
to themselves into society.
Abuse to children who enter the adult world have in common their very un-commonness: they will be different from their peers,
they will see the world through a cruelly obscured vision. Their only hope is to have landed within the care of a physician
who has a sense of what other kinds of services are available for the child and its family and who can proceed with a course
of research-based care.
Early detection and treatment can save both child and parents. And, as pediatricians know so much better than others, children
are the most optimistic of people and, miraculously, the most resilient. It was my privilege for some 35 years to be a pediatric
surgeon to perform some of the most delicate procedures upon children who were suffering profound, life-threatening impairments.
I am comfortable with the knowledge that I was a good surgeon. But I also know that in most instances it was something else
. . . something more powerful within the child itself . . . that absorbed the hurt, the confusion, the frustration, and the
shock and cling to life and hope. Children also tend to be forgiving, long after adults have pocketed their own meager charity
and turned away.
Children read The Diary of Anne Frank as a book that is uniquely theirs. Adults read it with unmixed wonder. But I would like
to close with that most-quoted section of Anne Frank's diary, since it sums up, for me, the extraordinary treasure embodied
in our children is the most appropriate inspiration for all of us to confront violence against children -- and to stop it.
Just two weeks before she was found by the Nazis and deported, Anne Frank wrote . . .
" . . . In spite of everything, I still believe that people are really good at heart."
Then she closed her entry for that Saturday, July 1944 by writing . . .
"If I look up into the heavens, I think that it will all come right and this cruelty too will end and peace and tranquility
will return again . . . "
Again, thank you for your invitation and best wishes for this meeting.