Memorandum from C. Everett Koop [on trip to Paris, Marseille, and Madrid]
One of the responsibilities of the U.S. Surgeon General is to represent the Secretary of Health and Human Services and the
Assistant Secretary for Health at international health conferences. During his first European trip, Koop discussed maternal
and child welfare, drug addiction, and mental health problems with public health officials in Paris, Marseille, and at the
First Conference of Ministers of Health and Social Welfare of the American Countries and Spain in Madrid.
Number of Image Pages:
6 (567,221 Bytes)
ca. October 1981
Koop, C. Everett
This item is in the public domain. It may be used without permission.
Subject: Trip to Paris, Marseille, and Madrid, October 26-30, 1981
Meeting at Ministry of Health in Paris with Dr. Jeanne Broyelle and Professor Aujaleu, 2:30 p.m., October 26, 1981. I was
accompanied by my Embassy control officer, Mrs. Adrienne Stephan. Although both French physicians spoke English, the conversation
was carried on by them in French and was translated by the Information Officer, Monsieur Visin.
Infant Formula Code
The French expressed their understanding of the problem the United States faced at WHA, and were particularly sympathetic
that Dr. Bryant had to vote "no" under the circumstances. They understood that it was not a matter of health but a
matter of a decision made at a different level. I assured the French that we were pushing breastfeeding to the best of our
ability and had a target of 75% maternal hospital discharges by 1990. I told them that we would report to the WHA, but that
I did not yet know the content of that communication. There was no question that they understood full well why the United
States vote went the way it did in 1981.
The Infant Formula Code discussion led readily into a concern that we might be in a position of facing a similar situation
with pharmaceuticals. Professor Aujaleu was very firm in saying that his country did not support a pharmaceutical code in
any way and he agreed with me that it would be a poor use of the prestige of WHO. He also indicated that had the milk formula
code been legislation, rather than a guideline, that France would not have signed. It was not possible to get any word from
Dr. Broyelle about the status of things in reference to pharmaceutical discussions at E.U.R.O. of WHO. Her comment was that
discussions had just begun, nothing definite was decided, but that she would not anticipate any definite recommendations.
I made it clear that this information from the French would be welcomed by us and that we would look to France if possible
at E.U.R.O. to soft peddle any pharmaceutical control. We both agreed that pushing the essential drug program for LDC's
would do much to blunt the desire for any pharmaceutical code.
Health for All/2000
I indicated that we were trying to implement our recommendations of 1980, and that we had a half-way mark of 1990 when we
would be able to reassess the plans we had made.
Disabled and Handicapped
The French acknowledged that they did not separate as readily as we did true handicaps from other types of maladies and therefore
their statistics were not as good as ours. We talked a little bit about the definition of handicaps, the fact that our numbers
of disabled were increasing while other signs of improving public health were improving. We talked a good bit about the International
Year of Disabled Persons and the manner in which this was used as a spring board to alert the public to the plight of the
handicapped and to help change attitudes and opinions concerning those who are disabled. I explained my concern about the
aging handicapped and how the cost of caring for the disabled would increase over the course of the next decade.
They said they faced the same things. We talked about the role of the family in dealing with the handicapped. Although I thought
the family was the stronger unit in France, the French were not so sure that they had not deteriorated in this regard as rapidly
as we had over the past decade. They still make an effort for home care and increase their allotment to elderly people who
live independently in order to keep them out of nursing homes.
We discussed this on a philosophical basis and indicated that we both were faced with a varied picture in different parts
of the country and that it changed rapidly. Philosophically the French acknowledged that whereas drug addiction was something
found only in the intellectuals, the artist colony, and physicians 15 years ago (when Dr. Aujaleu was the administrator of
Public Health of France), now it was a universal problem. They also acknowledged that alcoholism in adults was on the decline
in France but inasmuch as the alcoholism rate was so high they did not think that they had anything to brag about in the slight
decline. They also acknowledged that, as in the United States, younger and younger people are becoming dependent upon alcohol.
This subject took the greatest portion of our time and ranged from the philosophy of teaching medical students, the advisability
of separating geriatrics from general medicine, the advisability of having gerontology courses in medical schools, to discussions
of senile dementia and the necessity for research programs to focus on these particular disabling elements of the aged. Their
problems are much the same as ours, their perceptions of them agree with my own, and they look forward to the economic problems
being far greater than the health problems in the future. My discussion was closed with my bringing up the White House Conference
and how that would prepare us for initiatives that might be taken to the UN Conference on Aging in Vienna in the summer of
The meeting was extremely cordial, and I think the impression was a mutually agreeable one. Professor Aujaleu was embarrassed
in not knowing of my surgical background and my acquaintance with a number of Parisian surgeons. Had he known, he said,
he would have had a luncheon for me and he made me promise that the next time through there would be a longer lead-time in
information so that proper social affairs might be arranged with people I had known in the academic community and in surgery
This is an overview of my time with the Public Health people in the city of Marseille, October 27, 1981.
It should be remembered as background material that the city of Marseille is the site of prominent medical activity that is
situated between two ancient universities: that of Montpellier, the oldest medical school in France, and Aix, with which university
Marseille has made an affiliation in recent years. Secondly, it should be remembered that the Mayor of Marseille has been
responsible for building the most modern children's hospital in France and that the Deputy Mayor in charge of Public Health
is also the Professor of Pediatric Surgery at the University of Aix Marseille as well as the Chief of the Surgical Staff at
the Children's Hospital. Their conversations and concerns expressed to me had more to do with the future of medicine in
France than it did with specific health problems in Marseille and its environments.
With the election of Mitterand as President, there came into being a socialist government in France. During the campaign the
French communists had been opposed to Mitterand but as soon as he was elected he appointed four high-level ministers from
the communist party. One of these was in health.
The trends which seem to be clear are the establishment of Public Health Clinics which will be patterned after some European
totalitarian clinics where the freedom of choice of physician and of hospital will be removed from the patient. These clinics
will serve specified groups of the population by geography and alphabet and will be staffed by government paid physicians.
The second trend would seem to be breaking down the old system of European medical hierarchies where there was a dominant
and powerful chief of staff for the various major disciplines within hospitals. Instead there will be very much smaller units
without any overall management at the discipline level. It is seen as the beginning of the end of strong services of ophthalmology,
pediatric surgery, cardiac surgery, etc.
It should also be remembered that these changes take place in a country which has, as far as the individual is concerned,
an ideal medical system. In France the patient has a complete freedom of choice of hospital or clinic as well as surgeon and
there is no cost to the individual.
Private practice by full time hospital physicians will cease on January 1, 1982.
Meeting of IAMER October 29 and 30 Madrid. I was welcomed at the meeting by the Secretary General, Dr. Jose R. Chelala Lopez,
and met Professor Dr. Jaime Villablanca who was the moderator and is a member of the faculty of the University of California
in Los Angeles. Before the meeting I had secured the support of Monique Begin of Canada, Francisco Beltran-Brown of Mexico
and Carl G. Samuda of Jamaica, the three English speaking representatives, concerning the wording of the document.
As it turned out no advance preparation was necessary; all of the things we were concerned about either were changed in the
final draft presented to us at the meeting or we were able to change without much controversy at the time of the debate.
I made a number of interventions during the day, including 30 deletions of a phrase "to elaborate legal provisions".
The controversial breastfeeding clauses were altered to produce bland statements with no specifics of the words "all"
or "majority" and no percentages were used.
In general it was obvious that the English translation of the Spanish deliberations was rather poorly done and there were
a number of absurdities in the English translation. Some of these could be corrected, but to have corrected them all would
have meant a revision of the English manuscript with a subsequent revision of the Spanish manuscript and there was not time
to accomplish this in the days in Spain.
The English translation of the final draft of the document to be signed at the closing ceremonies was due in the lobby of
the hotel Costelbanc at 11:00 a.m. The Spanish translation arrived at noon but there was no English translation. I was advised
to go to lunch and was even called at lunch to be told that the English translation was ready. It was not ready when I returned
to the hotel and I had a call at 3:ll which said it would not be ready until 5 or 10 minutes before the signing ceremony.
The reason for the delay was that at a purely Spanish speaking lunch additions were made to the document. I told Dr. Villablanca
that even if the ceremony was delayed there was no way that I could sign until I had read the entire document and particularly
had time to think about the amendments that had been made today.
Whereas the meeting on the previous day had been a very leisurely one with people nit picking re phraseology, the mood of
the signing ceremony was one of speed. Dr. Maureen Law of Canada and I, accompanied by Robert Goeckerman, the Science Attache
to the United States Embassy, went into an anti-room to read the English document while the remainder of the Ministers and
delegates read the Spanish document. We had barely finished three pages when it was announced that they were ready to sign.
They were obviously annoyed that we were not ready to sign and I was distinctly surprised a few minutes later to be told that
Jamaica and Canada had already signed the document without seeing it in English. Dr. Law and I continued to correct the English
translation until we found one substantive change that had to be made, namely the legal obligation to provide time off from
work for pregnant women.
It was suggested to me by Dr. Villablanca that I sign the English document but not the Spanish document but make no statement.
I said this is against my principles and asked to make a statement. This I did, explaining that the translation of the day
was even less accurate than the translation of the previous day, that had required considerable correction, that I had made
one substantive change and that I would be able to sign the English document but not the Spanish document. It was obvious
from the demeanor of the Spaniards on the dais that they were very displeased with my attitude and I was told later that they
could not understand why I was so particular about small things.
We completed the translation corrections and I secured the signatures on that corrected draft document from the Minister of
Canada and the delegate from Jamaica. We have the assurance from the Executive Secretary and the
Director-General that the corrected English version would be placed before the signatures in the final and official copies.
While we were completing the translation the Minister from Peru moved that we make the Spanish version conform to the English
version and this was apparently passed unanimously. After this I signed two Spanish documents and two English documents.
The substance of the foregoing was committed to paper at the Embassy for transmission to the State Department.