Perspectives on the Future of Health Care: Keynote Address Presented to the Fifth Annual Medical Conference of the Medical
Association of the British Virgin Islands, Tortola, British Virgin Islands
Number of Image Pages:
21 (1,270,727 Bytes)
1983-02-05 (February 5, 1983)
Koop, C. Everett
This item is in the public domain. It may be used without permission.
Medical Subject Headings (MeSH):
Health Care Reform
"Perspectives on the Future of Health Care: Keynote Address Presented to the Fifth Annual Medical Conference of the Medical
Association of the British Virgin Islands, Tortola, British Virgin Islands" [Reminiscence] (2003)
Surgeon General and Deputy Assistant Secretary for Health
Keynote Address Presented to the Fifth Annual Medical Conference of the Medical Association of the British Virgin Islands
February 5, 1983
(Greetings to hosts, guests)
I'm delighted to join you this morning to add my "Perspectives on Health Care" to those already offered from this
When Minister O'Neal and Dr. Blocksma extended their gracious invitation to me to speak at this conference, they enclosed
the program. It is very impressive and, at first reading, a bit intimidating, also. I saw that, by this time in the program,
you will have had more than three days of intensive, substantive of presentations by excellent faculty.
The invitation presented me, therefore, with an exquisite challenge. Were I not a surgeon, I doubt that I could stand up to
it. However, after more than 35 years as a surgeon and, for these past two years, a "Surgeon General," I decided to
rise to your challenge. I happily accepted your invitation to come here and speak of the future in health care.
I should begin, however, with the acknowledgment that the future of health care in any country depends to a very great extent
on its general economic, social, and political health.
That is not only true for each nation, but for all the nations in this hemisphere as a single community of nations. When John
Adams was president of the United States, at the turn of the 19th century, he was -- and many of his colleagues were at that
time -- very much aware of the other emerging societies and Nations in the Western Hemisphere. He observed, "They can
neither do without us nor us without them," an observation that has remained true for 180 years.
And it was in that spirit that President Reagan presented his "Caribbean Basin Initiative" to the Organization of
American States a year ago this month. "What happens anywhere in the Americas affects us in this country," he said,
adding, "We share a common destiny . . . in the commitment to freedom and independence, the people of this Hemisphere
are one. In this profound sense, we are all Americans."
Of course, people talk of the "Giant to the North," and I presume they still mean the United States and not Canada.
But I like to recall the simple line by Jose Marti, the great patriot of the Americas, who dryly noted that "This is the
age in which hills can look down upon the mountains." He was right then. And he is right today, too.
I am pleased to be here, then, as an American among fellow Americans who are engaged in the pursuit of good health and well-being
for all peoples. Of course, I must speak from the United States perspective. Nevertheless, while our experiences may be different
from yours in their details, I believe the overall challenges are quite similar. For example, in the next several decades
. . .
All of us will be serving the health needs of a demographically different population in age, in family structure, and in work
and in life experiences . . .
We will most certainly be practicing much more preventive medicine, while our curative and reparative medicine will be radically
changed by new research results, such as the application of the new hybridoma technologies and non-invasive diagnostic technologies
. . .
And I think the fundamental relationships between patients and physicians will be more open, more informed, more sensitive,
and, as a result, they ought to be more routinely successful.
I will grant you that the numbers associated with these changes may be different from country to country -- the orders of
magnitude, for example -- but, in most cases, all of us in health and medical care perceive the health problems of the world
through similar sets of lenses.
Let me begin, therefore, with that first point I made a moment ago, the one concerning the demography of care. I believe it
is essential for each of us, wherever we practice, to understand our populations are changing. This is a major challenge to
anyone in health care. The old ways of doing things -- no matter how successful they've been -- will probably not be adequate
for the future.
You may have come upon 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 is the best educated adult cohort in our history. It
runs our factories and farms, dominates our political life, and is at the core of our national vitality. During this decade
and the 1990s, this age group will represent 40 percent of our total population, as its members move up and dominate the U.S.
population age pyramid.
This generation is living better and will be living longer because it is the beneficiary of about 30 years successful research
on the detection and treatment of societies 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. Of course, that means reducing the number of premature deaths among the "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 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. 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. At that time there will be something like 50 million persons over the age of 65, compared to about 25 million
that age today. I should also point out that the median age in the United States today is 28 years and 10 months, but in the
year 2010 we expect the median age to be 35 years and 7 months.
Many persons and organizations that deliver health and medical care have 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 are also reevaluating
their plans for institutionalizing the infirm elderly. Instead, they are emphasizing home health care services for individuals
and families. In fact, I would go so far as to say that many of the major developments in medical and health care technology
in the next several decades will be in this very area of home care or family-centered care.
I wish I could stop there, but I can't. The fact of the matter is that the "Graying of America," as significant
as it may be, is only half the story.
This aging "Baby Boom" generation is having babies of its own. In fact, the United States is experiencing what is
called an "echo effect." Let me explain how that is working. The fertility rate in 1980 among "Baby Boom"
women -- that is, child-bearing women in their twenties and thirties -- was 68.4, our most current statistic. The rate for
their mothers, the child-bearing women in the 1950s and early 60s, hit a record high of 122.7 in 1957, nearly twice the current
fertility rate. But while that earlier generation had, in 1957, about 4.3 million live births, the women in 1980 and 3.6 million
live births -- or only 16 percent fewer births then their mothers' generation.
Let me put it another way: if United States fertility rate with the same today as it was 25 years ago, then, instead of an
estimated three and a half million babies to be born this year, we would have something like 7 million babies, nearly twice
the number born in our all-time "Baby Boom" year.
But there is yet another factor: more of today's babies are surviving. In 1957 United States had infant mortality rate
of 26. Our latest estimate is an infant mortality rate of 11.3 infant deaths for every 1,000 live births. So in just one generation,
we reduced the infant mortality rate by more than half. During the same period, by the way, we also reduced the death rate
for children ages 1 through 14 by nearly half. That's why I believe we can draw only one conclusion from all this: we
may be in the midst of yet another -- and only slightly less dramatic -- "Baby Boom."
What does all this mean for persons such as ourselves, people who organize and deliver health and medical care to individuals
and families. It's my best guess that, over the next 25 years or so, we are going to have the unusual task of providing
quality geriatric and quality pediatric health care at the same time.
Will we in United States be able to do it? I think we will. But I am not at all sure how we will do it. We have no experience
for such an historic set of circumstances. And no other country has had that kind of experience either.
If we have any major hurdles to overcome, they would be the hurdles of too little time and not enough money. And I guess everyone
in this room has heard that before. I don't pretend that I discovered anything unique. Nevertheless, I think these pressures
are especially severe in the current period.
In the past we've had at least a few years to make some adjustments. But we really don't have the luxury of time anymore.
I suspect we have a decade or two -- at best -- to prepare our physicians and nurses, are dentists and therapists, our technicians,
administrators, trustees, and social service workers to deal with a nation with many millions of the aged and many millions
of children -- and a lot of other people of all ages scattered in between.
As for money -- particular new money to buy more services for our expanding population -- that also is in short supply right
now. The United States, like many of its neighbors in this hemisphere and its friends in Europe, is focusing its attention
on ways to shift priorities, to break old and costly habits, and to do whatever else may be necessary to maintain our record
in fighting disease and disability and still, wherever we can, raise the level of health and medical care in United States.
These objectives require that we take a closer and more critical look at the way we provide health and medical service in
United States. The traditional way has been to cure or repair our patients after they have come down with something. That
is a very costly approach for the patient and for society as a whole. Under the circumstances, it is less than an adequate
approach for meeting the health needs of tomorrow.
What we are doing, therefore, is significantly raising the level of interest and effort in the promotion of good health and
the prevention of disease and disability. Such an approach emphasizes self-care as a way to avert the "the four D's":
discomfort, disease, disability, and death. It is much cheaper for the individual and for society. Prevention also tends to
produce positive, long-term, generational effects.
I do want to emphasize, however, that we have no intention of abandoning or compromising traditional curative reparative medicine.
Far from it. Rather, our goal is to establish a new and more effective balance between preventive and curative medicine.
While this administration has made prevention and health promotion the keystone of National Health Policy, I must be candid
and tell you there is nothing really new about it. You can go back to the deductive genius of Dr. John Snow during the great
London cholera epidemic of 1854. You will recall that Dr. Snow took the handle off the community water pump Broad Street and
-- with that simple preventive measure -- he interrupted the transmission of cholera among the London poor.
Since then, we've advanced the notion of prevention quite a bit. Still, we ought not to get carried away by it. It is
good to remember the homely example of Dr. Snow or, now and then, to recite the blunt opinion of the philosopher, Jean Jacques
Rousseau, who said that "hygiene was less a science that a virtue." I suppose he's right.
But whether you subscribe to "science" or to "virtue," I believe you'll be interested in two basic documents
produced by the U.S. Public Health Service. The first is titled Healthy People, the Surgeon General's report on health
promotion and disease prevention. The second is called Objectives for the Nation, and it spells out in some detail how we
hope to achieve better health status and a reduced level of disease and disability among the people of the United States.
These two slim volumes were prepared with the help of about 2,000 non-governmental experts across a broad spectrum of disciplines.
I strongly commend them to you.
In the Objectives, for example, we review 15 different priority areas such as accident prevention, nutrition, toxic agent
and radiation control, drug abuse, and so on. This information is then translated into goals we believe we can achieve by
the year 1990. Personally, I think is one of the most ambitious public health programs in recent memory.
We have already started along the road leading to those objectives, in partnership with state and local health agencies, private,
professional and voluntary associations, and with the active support of business and industry. In addition, within our own
department of Health and Human Services, we have a wide-ranging "Health Promotion Strategy" with specific tasks the
Social Security Administration, Medicare and Medicaid, and, of course, the Public Health Service.
The kinds of objectives we have in mind are fairly specific and measurable. For example, we look forward to achieving . .
Full immunization for at least 95 percent of all school-age children by the year 1990 . . .
A decline in the infant mortality rate from the present 11.3 deaths per 1,000 live births down to nine deaths per 1,000 .
We'd like to achieve 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 or higher . . .
We hope to see you drop in the number of adult smoking cigarettes from the current 1 in 3 down to 1 in 4 . . .
And the reduction in the motor vehicle fatality rate from its present level of about 24 per 100,000 population to a level
of 18 -- or even lower.
These are not all of them. There are multiple objectives among those 15 different health areas. But I hope you are stimulated
by my few remarks to read both reports, since they do provide the American people in the professional health community with
a kind of roadmap of where we're headed and how we hope to get there.
The basic route we need to follow takes us deep into the behaviors of both patients and physicians. As an example of what
lies ahead of us, I will return for a moment to that demographic phenomenon I mentioned earlier . . . The one called "the
graying of America." Let me offer three vignettes of patient behavior and physician response.
The first concerns smoking. It should come as no surprise that I would raise this issue somewhere in my remarks this morning.
After all, if I were not here I would be back in Washington stamping my little message on every pack of cigarettes.
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 about the person who is, say, 60 years old and has smoked for the past 40 years? Should a physician advise that person
to stop smoking, too? I would certainly hope so. But I have to tell you that we have very little evidence showing physicians
and other health workers giving such advice to their 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 . . . and they are the very people who are today's 60-years-olds.
In other words, the simple preventive counsel -- "stop smoking" -- ought to be given to persons of all ages. We must
eliminate any feelings that, for some older people, a change of habit may be "too late." For those elderly patients
-- and for their friends and family, too -- the advice must be offered vigorously and repeatedly: don't smoke.
My second example involves physical fitness and exercise. I confess that I am just delighted to see so many nurses and physicians
jogging and hiking and playing handball or squash. Good for them. But I wonder if they advise their older patients to keep
physically fit, also. They might not advise handball and squash or even jogging, but were really no loss for good alternatives.
The point to remember is that elderly people need to maintain their muscle strength, too, in order to live full and active
lives. There's a real danger that, through inactivity, they may begin to gain weight, which adds stress to the heart.
They may also lose the essential "tone" of their muscles. That possibility reflects the old saying . . . and you've
all probably heard it . . . "You don't stoop because you're old, your old because you stoop." It's true
that older people who keep good posture do look and act younger than their chronological age.
The President's Council on Physical Fitness and Sports, which is part of the U.S. 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 such a title was too limiting. Working adults and senior citizens needed help in this area,
too, and so the word "youth" was taken out.
My third and last example is nutrition. We know that older people do not metabolize fats and carbohydrates as efficiently
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 senior citizens. As I said earlier, the
members of the "Baby Boom" generation are now 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 that could 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
we want to keep people out of institutions and help them adopt healthful lifestyles, we're going to need a much better
knowledge base. A great deal of prevention information still needs to be generated and applied to patient care in the years
We hope to understand a little better which kinds of physician interventions work with patients coming in for routine care.
We need to know why some people can be more easily influenced than others to change their health behaviors for their own good.
In a word, we have quite a far-reaching agenda of biomedical and behavioral research to accomplish.
The National Institutes of Health, for example, are supporting a number of projects that could lead to new vaccines, new protective
and preventive pharmaceuticals, and new diagnostic agents and procedures. There are many other research efforts across the
whole spectrum of prevention . . . in genetics and neurobiology . . . in the uses of the new hybridoma technology . . . in
containing the sexually transmitted diseases . . . in the control of toxic agents in the environment . . . in the field of
immunology in the development of new vaccines . . . in the role played by nutrition and diet . . . in stress control, dental
caries, and in the etiology of the major metabolic diseases. I'd say we are not lacking for research challenges in this
part of medicine.
This, then, is a kind of synopsis of the current public health perspectives in the United States. I said at the beginning
of my remarks that many of you undoubtedly share the same or very similar vision of the future of health and medical care
for your own communities. I think it can be said generally for your societies as well as for ours that . . .
Fewer babies are dying . . .
That even with lower birth rates, there are more people around . . .
And they are living a longer, with better chance for missing -- or recovering from -- the major diseases of mankind . . .
And that by and large the quality of life in one's twilight years is gradually improving.
That's got to add up to progress, even giving the many kinds of restraints -- fiscal, social -- under which we must function.
In any case, I tend to be an optimist mainly because the United States remains a nation with an unending sense of adventure
and a vigorous tradition of free inquiry. As a people, I believe we share the view held by Albert Einstein, who wrote that
"the eternal mystery of the world is that it is comprehensible." Like him, we are intrigued by the future, we are
impatient for it to arrive, and we are absolutely positive we will understand.
We may not all handle the future as well as Dr. Einstein, but we nevertheless share his optimism and enthusiasm. And, if I
have relayed those feelings to you as well, I will count my appearance here in Tortola as having been a great success.