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The C. Everett Koop Papers

The 'Threshold Era' in Public Health: Presented to the First International Symposium on Public Health in Asia and the Pacific Basin, Honolulu, Hawaii pdf (1,164,586 Bytes) transcript of pdf
The 'Threshold Era' in Public Health: Presented to the First International Symposium on Public Health in Asia and the Pacific Basin, Honolulu, Hawaii
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19 (1,164,586 Bytes)
1983-03-07 (March 7, 1983)
Koop, C. Everett
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Medical Subject Headings (MeSH):
Public Health
Pacific Islands
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Biographical Information
Metadata Record "The 'Threshold Era' in Public Health: Presented to the First International Symposium on Public Health in Asia and the Pacific Basin, Honolulu, Hawaii" [Reminiscence] (2003) pdf (85,431 Bytes) transcript of pdf
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Folder Number: 92
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Series: Speeches, Lectures, Papers, 1958-2004
SubSeries: 1982-1983
Folder: Keynote- 1st International Symposium on Public Health- "The Threshold Era In Public Health"- Asia and Pacific Basin, Honolulu, HI, 1983 Mar 07
The "Threshold Era" in Public Health
By C. Everett Koop, M.D.
Surgeon General and Deputy Assistant Secretary for Health
Presented to the First International Symposium on Public Health in Asia and the Pacific Basin
Honolulu, Hawaii
March 7, 1983
(Greetings to hosts, guests)
It is a very great honor and great pleasure to be here to help open the First International Symposium on Public Health in Asia and the Pacific Basin. Let me begin by first extending a sincere word of congratulations to Dean Michael and the faculty and students of the School of Public Health at the University of Hawaii at Manoa for the outstanding job they have done in turning the dream of such a symposium a reality for all of us.
And now, even at the risk of repeating what many others have said or written so far, let me welcome to the state of Hawaii and to the United States the many guests here from Asia and from our neighbors who, with us, form the perimeter of nations around the Pacific Basin. The program is ambitious . . . the setting is just right . . . and the interest shown by your attendance is everything that any of us could have wanted.
Right at this point, if my hosts don't mind, I want to take just a moment to direct a few words to my American colleagues in public health who are here, also.
This month marks my second year in government service as your Surgeon General. It has been a time marked by many changes in the scope and direction of national health policy and programs. Each change has been, to a lesser or greater degree, a great challenge to each of us in the field of public health.
I believe that these two years have tested the best that is in us, as we have continued in our stewardship of the health of the American people. And I think the public health leadership of the United States has passed all its tests with exceptionally high marks. Throughout this time, I have constantly been impressed by the deep commitment shown by the public health community for the humanitarian goals of our profession. Your example and your good counsel have been of great help to me, as I have tried to master the work of my office.
It is my sincere hope that, in the years ahead we will continue to face our challenges together . . . that you will continue to offer me your good counsel -- and, yes, a bit of charity now and then, too . . . and I hope that we will do all this as partners and colleagues, working together for the good of our fellow citizens in the United States and, indeed, the improved health of all mankind. Thank you.
As your Surgeon General, I have been privileged over the past two years to have represented the United States in Geneva at meetings of the World Health Organization, one of the organizations who have made this symposium possible. And I have also worked closely with any number of health professionals from nations with whom we have bilateral agreements in the field of public health.
As I have reflected upon those experiences, I am again and again impressed with the scope of the issues we must face and the variety of new information we need to know. On more than one occasion, the thought has occurred to me that we may be living during a very important "threshold era" in the history of public health. It is a time of transition . . . a time when we find ourselves moving to a zone filled with innovation, confusion, excitement, and even a little mystery.
Much of what I am speaking of is evident in the program of this very symposium, in its range of subject matter covering not only disciplines in public health but a variety of national and cultural experiences as well. For the next several minutes, therefore, I would like to focus on what I believe might be the three key elements of this very exciting, very challenging "threshold era" in public health.
Certainly one aspect is the great progress the world is made in biomedical and behavioral research in little more than the past decade. In the past 5 to 7 years we've been the beneficiaries of new vaccines, new pharmaceuticals, and new medical devices . . . new methods of growing, harvesting, and processing nutritious foods . . . and new approaches to the detection and prevention of many of mankind's most dreaded diseases, such as heart disease and stroke. While the examples we might cite are indeed legion, yet they are also of very recent vintage:
There is our victory against smallpox, officially marked by the W.H.O. less than three years ago. It is an historic achievement for the forces of public health around the globe.
There is the technology for developing vaccines to combat a variety of infectious diseases that attack children, working adults, and the elderly. And most recently, we've added to the public health armamentarium a new vaccine to fight hepatitis B.
There also are victories against polio, tetanus, diphtheria, and other diseases of childhood. In the United States we are on the verge of eliminating indigenous measles, another historic development.
There has been almost breath-taking progress across a broad spectrum from curative through reparative to preventative medicine.
I grant we still have a very long distance to travel before we can say that research has given us the ultimate keys to perfect health -- if, in fact, we will ever be able to say that. But I won't hesitate to say that the past decade or so -- plus the years that remain in the century -- will be judged for many generations to come as being among the most challenging, exciting years in the history of public health.
A second factor that makes this a special "threshold era" is the degree to which people around the world are coming to understand the major developments in medicine and public health, not only in their own societies but for mankind generally.
The U.N. agencies, such as WHO and UNESCO, can certainly take part of the credit for this. But credit must also go to the nations themselves, the individual national governments and their media. Just last month, on February 23, a number of non-commercial television stations across the United States carried the first telecast for the general public -- live and in full color -- of a heart bypass operation. The operation was carried out by Dr. Edward B. Diethrich at St. Joseph's Hospital and Medical Center in Phoenix, Arizona. The station that produced the telecast, K.A.E.T. in Phoenix, has since had inquiries from Australia and Japan concerning the availability of the tape for re-broadcast in those countries. And I'm told that the U.S. Information Agency is also considering having a taped copy available in our American embassies around the world.
Through radio, television, motion pictures, satellite transmission, and now with the help of the computer we are able to distribute great quantities of high-quality health and medical information to the most remote villages in the world. And we are discovering that even these villages, an audience is waiting to learn the news.
The third factor is equally important, some might even argue it is the most important of all. It is the general acceptance of the notion that the "health status" of the people of a community or of a country is the real key to its economic, social, and even its political health.
The question has sometimes been asked, "which needs to come first, a strong gross national product from which to draw the resources for citizens health . . . or, conversely, a healthy people from which comes a robust GNP?" For me, the answer has always been clear: first, the people have to be healthy. All the good things you want come from that happy condition. I feel that my opinion is now shared by more political leaders around the world than at any time in the past.
And that is one reason I believe that each of us must keep pushing forward with the plans we have to achieve "health for all by the year 2000," an idea adopted by all the member governments of the WHO. The United States has put its own domestic strategy in place and, later this month, we will be reporting to the world health assembly on our progress in monitoring that national strategy.
The United States has active bilateral health agreements with 14 countries around the world. The U.S. Public Health Service is directly involved in most of these agreements. In addition, we have our own agency-to-agency agreements with nearly three dozen other nations. Most of these agreements contribute in some way to the success of the "Year 2000" programs in those other countries.
Once again, an idea such as "health for all by the year 2000" is possible at this time in human history because, first, we do have a great deal of appropriate health and medical technology available . . . Second, because there is sufficient understanding among the peoples of most countries to enlist their informed participation . . . And, third, because the political leaders in the world today are sensitive to the need for improved health status for their people, if they wish to gain the other fruits of this century.
These things are, I believe, generally true. But only "generally." The good things of modern life are distributed unevenly throughout the world. In some nations today -- and even some societies here in the Pacific area -- the health and medical advances of the century are not readily available. For many countries, the leading cause of death is pregnancy and childbirth. If the mortality figures in some developing countries go beyond the level of 200 deaths per 1,000 live births, which is as much as 20 times the rate in some industrialized, developed countries.
Maternal mortality can be just as alarming: in some countries the rate is about one maternal death for every 100 children who were born, a truly staggering figure. The rates between countries can vary by a factor of up to 200.
Life expectancy at birth among the developed countries tends to run between 65 and 75 years. Among many less developed countries in Africa and Asia, the expectancy is half that . . . falling in the third and fourth decades for males and not much better for females.
Among the developed countries, such as Canada, Australia, and United States, the major causes of death are the big killer diseases -- heart disease, cancer, and stroke -- with trauma, suffered mostly on the highways, is the leading cause of death for certain age groups. But among the developing nations, whose people smoke less and tend not to snack on candies, the major causes of death are the same ones that have dogged mankind for the past four or five millennia: pneumonia, tuberculosis, enteritis and diarrheal disease, nutritional deficiencies and disease, and the diseases and stresses that affect both the mother and the child during pregnancy and childbirth.
In the sphere of information transfer, the discrepancies are also evident, but they are of a different order. For example, literacy rates among most developing nations are still quite low, compared to the rates among the developed nations. Even when the measure is the ability to read and speak one's own tribal language, rather than the language officially adopted by the nation, the rates in many societies still quite low.
On the other hand, there's been a sharp rise in literacy for the electronic media. In French Polynesia, according to the most recent WHO figures, the number of TV sets rose from 5 per 100,000 population in 1965 to 110 per 100,000 population, or something over 15,000 sets, in 1977. The Korean rate for the same 12 years rose from 2 TV sets per 100,000 population 296 TV sets per 100,000 population. One of the ironies of our time is that, after close examination, you will find that in many countries the great majority of the population may well have access to a television set and could see a program like "The Operation," the heart surgery performed at Phoenix, Arizona. They could watch it and learn a lot from it. But they would not understand any of the subtitles, credits, charts and graphs, or any of the other "codes" requiring basic literacy skills.
And finally, we know there are still some nations in this world but do not believe in the value of "good health" as a goal unto itself for every citizen. Health status is viewed as linked tightly to productivity levels on farms or in factories. Good health in those societies is not a formal personal and community liberation but, instead, is an integral part of the system of national servitude.
The United States looks upon the achievement of improved health as an end in itself. We know full well that good health leads other good things for our country. But our essential motivation in supporting improved health and medical care has been -- must continue to be -- a concern for the welfare of each individual American. It is my personal hope that every other nation will, some day, come around to the same way of thinking.
I do not mean to imply that United States was already reached the heights of understanding and we're just waiting for everyone else to catch up. It is hardly appropriate for us to be smug about any aspect of health in America. As good a job as we may have done, we can do infinitely better. As vigorous as our research programs then, there are still some very large gaps in our understanding -- gaps, for example, that are left by the yet unsolved mysteries of arthritis, diabetes, cystic fibrosis.
Our communications revolution has been one of the wonders of the modern world. I don't doubt that. Yet, we seem to be fighting an uphill battle against sexually transmitted diseases like gonorrhea and genital herpes . . . against smoking, which is a cause for more deaths in the United States than the more widely discussed and visible automobile . . . and the abuse of alcohol and drugs. Communications are important -- but they are obviously not everything.
As for the third factor in this complex but challenging "threshold era," I believe the United States has made its commitment to improving the health of its people, irrespective of the "utility" of health. All our public health programs are predicated on that philosophy. Nor can I imagine our having anything like a Medicaid or a Medicare program without the support of the basic, national concept of helping our people keep their health, from childhood to old age, regardless of their social or economic station. Sometimes we confuse ourselves and, in the course of grappling with the cost of these programs, we are inclined to tamper with their underlying concepts. But that sort of thing doesn't get very far.
We will never abandon such programs, because they are examples of something that needs more recognition and more application elsewhere. That "something" is the expression of the "public will" in health matters. I think it has been amply demonstrated that public health leadership is wanted and welcomed by the general public, to help them maintain the social and political focus on how to give health matters the kind of strong substantive base needed in modern-day public dialogue.
Expression of the public will occurs not just at the national level but also at the state level and at the community and even neighborhood level. This is not just an observation; it is a great challenge for each of us. It means that we in public health must understand and identify more closely with social aspirations of the people we serve. We need to make sure that proper attention will be given to health matters in the councils of government. Maybe most important of all, we need to play an active, positive role in the priority-setting processes of our society, so that important tasks of health and medical care are not buried under layers of other pressing but more short-lived concerns.
Recognizing that there is a public will for improved health status and identifying and serving that public will are among the most important aspects of public health leadership today. In addition, they are among the keys to unlocking the gates of a healthful future . . . the future that lies just beyond "threshold era" in public health.
I cannot emphasize too often or too strongly the need for courage and foresight in public health today. I say that because now and in the future -- in whatever country, community, or society you call as your own -- the major tasks before us will be those that concern the health status primarily of the people who are most vulnerable to disease, trauma, the vagaries of Mother Nature. We've spoken of them before: their pregnant women, mothers, children, and the aged.
Worldwide, these are the populations that suffer the most from poor health care, poor diet, from both premeditated and accidental violence, and from epidemics of infectious diseases. As much as the United States has done and as much as other developed nations have accomplished for mothers, children, and the aged in their own homelands, as much can be accomplished still. In this task, I believe all public health personnel the world over have special kinship.
If I were asked to think about a public health agenda for the nations of Asia and the Pacific Basin, I would probably go back to those three factors that I thought constituted this "threshold age" in public health and I would interpret them so that they would relate these three important groups. I would probably say . . .
. . . First, let's try to make sure that our best science and our best technology include on their agendas to be questions that remain concerning the health of mothers, infants and children, and old people. What can we do to lower the incidence of low birth weight babies? What are the possibilities in the new genetic sciences for preventing or eliminating many of the most prevalent birth defects? What can we do to protect women and children from the potential of trauma in modern life? What is the etiology of senile dementia, Alzheimer's disease, incontinence, and what can we do about them? What are the special nutritional needs of the elderly and how can we meet them?
These would be some of the questions that are better contemporary scientists ought to be tackling.
. . . Second, I would advise developing much closer working relationships among personnel from public health, public education, and the media. What keeping up the steady stream of news about the latest developments in medicine and health, I would ask what the chances were for getting more and better messages across concerning the nutritional needs of women, children, and the elderly . . . the need for childhood immunizations . . . and the health consequences of smoking and of substance abuse for women and their unborn children, as well as for the elderly, who are beginning to have a problem with drugs.
. . . And third, I would explore all the ways in which public health could become positively and meaningfully involved in the total social and political life of the society. This kind of action would help us all to both propose and carry out -- with strong public understanding and support -- those activities that would contribute to improved health status for everyone. And, again, I would pay special attention to women, children, and the elderly.
That would be my "wish list." And I anticipate that, after more thought and more discussion by me with my colleagues in public health, the list would gain both in substance and depth.
That, it seems to me, is a great virtue of this symposium and of the plan to have another in three or four years, and another after that. It gives us the opportunity to gain some perspective on where we've been . . . what kind of time is has been for us and for the people we serve . . . and where we hope to be in near term and in the long term.
Not long ago, while reviewing what might be our public health role in the President's Caribbean Basin Initiative, I was reading here and there and came upon this observation by Jose Marti, the great poet, doctor, and patriot of 19th-century Cuba. I particularly like one line of his that sums up what should be our attitudes as we gather in meetings such as this. It had special meaning for him and for his time, but it can be applied to our time as well. He wrote, "This is the age in which hills can look down upon the mountains." In the battle to improve the health of our people -- especially the health of those who are most vulnerable to nature and to fate -- we all stand as colleagues and as equals.
Again, thank you for your kind invitation to speak with you today. And best wishes for a most successful symposium here in Hawaii.
Thank you.
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