ORIGINAL : eee) i | nN rf DDRESS BY C. Everett Koop, MD, ScD SURGEON GENERAL OF THE U. S, Pupirc HEALTH SERVICE » U. S,. DEPARTMENT OF HEALTH AND HUMAN SERVICES =e PresenteD TO 45TH ANNUAL CONFERENCE OF THE AMERICAN ASSOCIATION FOR MARRIAGE AND FAMILY THERAPY CHICAGO, ILLINOIS OctoBer 30, 1987 l GREETINGS TO HOSTS, GUESTS, FRIENDS, ETC.) 1 AM VERY PLEASED TO JOIN YOU THIS EVENING AND AM GREATLY HONORED BY THE RECOGNITION OF THIS VERY SPECIAL ASSOCIATION. MY SPECIFIC AGENDA AS SURGEON GENERAL DOESN’T REALLY HAVE ANYTHING ON IT THAT SAYS “FAMILIES,” OF COURSE, I HAVE A ROLE TO PLAY IN THE FIGHT AGAINST AIDS, AND I‘VE DONE SOME WORK ON OTHER ISSUES, SUCH AS “BABY DOE” AND ORGAN TRANSPLANTATION AND, OF COURSE, SMOKING. 2 BUT “FAMILIES” AS SUCH,...NQ, HOWEVER, I DON’T BELIEVE I’VE FUNCTIONED ONE DAY IN THIS JOB -- OR IN ANY POSITION WHILE IN MEDICINE -- WHEN I WASN’T DEEPLY CONSCIOUS OF THE PRESENCE OF THE FAMILY... THE PRESSURES UPON THE FAMILY...THE SPECIAL NEEDS... THE SPECIAL CARE...AND THE SPECIAL SUPPORT WE OUGHT T0 BE GIVING TO THE AMERICAN FAMILY, AS I SAY, THE FAMILY IS NOT STATED SPECIFICALLY ON MY AGENDA. I GUESS THAT’S THE CASE ALMOST EVERYWHERE. YET, THE NEEDS OF THE AMERICAN FAMILY OUGHT TO PERMEATE EVERY ONE OF OUR POLICY DISCUSSIONS AND DECISIONS AT EVERY LEVEL OF GOVERNMENT AND THROUGHOUT THE PRIVATE SECTOR AS WELL, 3 JUST BECAUSE THEY ARE NOT ALWAYS MENTIONED DOES NOT MEAN THAT FAMILIES ARE NOT ALWAYS THERE. FAMILIES ARE. AND THEY NEED OUR HELP...IN SO MANY WAYS AND IN SO MANY DIFFERENT ARENAS. BUT I HAVE TO TELL YOU THAT FOR THE SURGEON GENERAL OF THE UNITED STATES TO SAY THAT IS RATHER NEW, OVER THE PAST FEW YEARS, WE'VE COME TO SEE THAT FAMILY HEALTH -- THAT IS, THE PHYSICAL, MENTAL, EMOTIONAL, AND SOCIAL HEALTH OF FAMILIES -- IS FUNDAMENTAL TO WHAT WE HAVE CAVALIERLY REFERRED TO OVER THE YEARS AS “THE NATIONAL HEALTH STATUS" OF ALL AMERICANS, FOR EXAMPLE, WE HAVE BEEN SO CONCERNED OVER THE YEARS WITH THE TECHNOLOGY OF EMERGENCY MEDICINE, THAT WE NEGLECTED TO THINK MUCH ABOUT THE REASONS WHY EMERGENCY MEDICINE WAS SO VITALLY IMPORTANT. 4 ONE REASON, OF COURSE, IS THE UNACCEPTABLY HIGH LEVEL OF FAMILY VIOLENCE IN THIS COUNTRY. I’M APPALLED AT THE DATA CONCERNING THE CRIME OF WOMAN BATTERING. OVER A MILLION WOMEN ARE ABUSED AND BEATEN EACH YEAR IN THEIR OWN HOMES BY HUSBANDS, EX-HUSBANDS, OR BOYFRIENDS. MANY OF THOSE WOMEN NEVER TURN TO THE POLICE OR TO THE COURTS. THEY DON’T KNOW HOW TO ENTER THE SOCIAL SERVICES SYSTEM EITHER. INSTEAD THEY RELY ON HOSPITAL EMERGENCY ROOMS, PUBLIC CLINICS, OR THEIR OWN FAMILY DOCTORS TO PATCH THEM UP AND KEEP THEM GOING, 5 BUT YOU NEVER SEE A BATTERED WOMAN ONCE...YOU ALWAYS SEE HER AGAIN AND AGAIN. THE BATTERED WOMAN SYNDROME, THEN, REPRESENTS NOT ONLY A PROFOUND PERSONAL TRAGEDY BUT ALSO A MAJOR BURDEN TO THE HEALTH SYSTEM OF THIS COUNTRY. BATTERED WOMEN BETTER MEDICAL HELP THAN WHAT THEY'RE NOW GETTING. THEY NEED IT AT THE TIME OF THE ASSAULT AND THEY NEED IT LATER, WHEN THEY COME BACK INTO THE SERVICE SYSTEM BECAUSE OF ABUSE- RELATED ALCOHOLISM AND DRUG ADDICTION.,. MISCARRIAGES AND ABORTIONS . HYPERTENSION AND COLITIS, AND A WHOLE RANGE OF IMMOBILIZING NEUROSES, 6 AND WE CAN NO LONGER IGNORE THE FACT THAT THE RECURRING CYCLE OF WOMAN BATTERING TENDS TO ESCALATE AND MOST OFTEN ENDS IN A HOMICIDE... USUALLY THE WOMAN'S, SO WE NEED TO DO A BETTER JOB AS PROVIDERS OF HEALTH CARE TO THIS GROUP OF VULNERABLE AND ENDANGERED PATIENTS: ABUSED AND BATTERED WOMEN. THEREFORE, I BELIEVE IT’S TIME FOR MY COLLEAGUES IN EMERGENCY MEDICINE, IN GYNECOLOGY, AND IN FAMILY MEDICINE TO TAKE OFF THEIR BLINDERS AND DEAL CANDIDLY WITH THE ISSUE OF FAMILY VIOLENCE, AND THE SPECIFIC PHENOMENON OF SPOUSE ABUSE, OR WOMAN BATTERING. 7 AND I MIGHT ADD THAT IT WOULD CERTAINLY HELP IF THE CRIMINAL JUSTICE SYSTEM -- IN EVERY JURISDICTION -- ACKNOWLEDGED THE FACT THAT RAPE AND SEXUAL ASSAULT ARE CRIMES OF VIOLENCE AND THAT THE PERPETRATOR OF SUCH A CRIME MUST BE BROUGHT TO JUSTICE... REGARDLESS OF THE RELATIONSHIP -- PAST OR PRESENT -- BETWEEN THE PERPETRATOR AND THE VICTIM, I HAVE SAID THAT GYNECOLOGISTS WHO IGNORE THE PHYSICAL SIGNS OF BATTERING AMONG ANY OF THEIR PATIENTS ARE PRACTICING BAD MEDICINE. AND I WILL ADD THAT JUDGES WHO TRIVIALIZE FAMILY VIOLENCE -- ESPECIALLY THE CRIMES OF WOMAN BATTERING AND SEXUAL ASSAULT -- ARE PRACTICING BAD LAW. 8 IN A RELATED AREA, I’M NOW IN THE PROCESS OF PRODUCING A SURGEON GENERAL’S LETTER CONCERNING THE HANDLING OF VICTIMS OF CHILD SEXUAL ABUSE. THE PROJECT HAS BEEN SUPPORTED AND CO-SPONSORED BY THE OFFICE FOR VICTIMS OF CRIME OF THE DEPARTMENT OF JUSTICE. WHEN THE DOCUMENT 1S COMPLETE, I WILL SEND IT AS A KIND OF "EXTENDED LETTER” TO MY COLLEAGUES IN MEDICINE, NURSING, PUBLIC HEALTH, SOCIAL SERVICES, AND LAW ENFORCEMENT, IT WILL NOT BE “THE LAST WORD” ON THE MATTER BY ANY MEANS, BUT BOTH WE AND THE JUSTICE DEPARTMENT HOPE THAT THE NET EFFECT OF THIS “LETTER” WILL BE TO INCREASE THE LEVEL OF COOPERATION AND COLLABORA- TION AMONG PUBLIC HEALTH, MEDICAL PEOPLE, LAW ENFORCEMENT, AND SOCIAL SERVICES PEOPLE IN THE HANDLING OF THESE DIFFICUJLT AND TRAGIC CASES, g WE HOPE THIS “LETTER” WILL CONTRIBUTE TO BETTER AND QUICKER SERVICES FOR CHILD VICTIMS AND THEIR FAMILIES AND TO MORE CONVICTIONS THAT STICK AMONG THE PERPETRATORS OF THIS HEINOUS TYPE OF CRIME...AND THAT IT WILL ALSO HELP PROTECT INNOCENT PEOPLE WHO MAY BE FALSELY ACCUSED OF SUCH A CRIME. AND WE KNOW THAT THAT SOMETIMES HAPPENS AS WELL, IVE BEEN TALKING ABOUT ABOUT OUR PUBLIC HEALTH INTEREST IN THE ISSUE OF FAMILY VIOLENCE AND I COULD CONTINUE IN THIS VEIN FOR MANY MORE MINUTES, BUT INSTEAD, IN THE TIME I HAVE REMAINING, I’D LIKE TO TOUCH UPON THREE ISSUES IN WHICH PUBLIC HEALTH, LAW. AND SOCIAL SERVICES ALL HAVE AN INTEREST, 10 THE ISSUES CONCERN FAMILY, CHARITY, AND EQUITY. TO BEGIN WITH, I HONESTLY DON’T BELIEVE THE AMERICAN PEOPLE ARE REALLY HAPPY WITH THE PRESENT AMBIVALENCE WE HAVE ABOUT THE WORD “FAMILY.” WE'VE WANTED TO LIBERATE OURSELVES FROM THE FAMILY CLICHES AND STEREOTYPES OF THE PAST. AND, ON THE FACE OF IT, THAT’S NOT A BAD IDEA. BUT I THINK WE’VE LOST OUR WAY IN THE EVOLUTIONARY PROCESS, | THINK WE KNOW WHAT WE’RE EVOLVING FROM.,.BUT WE DON’T YET KNOW WHAT KIND OF STRUCTURE OR SET OF HUMAN RELATIONSHIPS WE’RE EVOLVING TOWARD. Il I’VE ALWAYS CONSIDERED MYSELF TO BE ”PRO-FAMILY.” I BELIEVE VERY STRONGLY IN THE FAMILY VALUES OF RESPONSIBILITY AND LOYALTY AND MUTUAL LOVE AND RESPECT. BUT THOSE VALUES ARE ALL UNDER GREAT STRESS THESE DAYS, AS IS THE CONTEMPORARY FAMILY ITSELF.,.HOWEVER YOU DEFINE IT. AND THAT WORRIES ME, SINCE SO MUCH OF THE HARMONY OF COMMUNITY LIFE IN THIS COUNTRY HAS SPRUNG FROM AN ESSENTIAL HARMONY IN FAMILY LIFE. BOTH KINDS OF HARMONIES SEEM TO BE FADING...AND I DON’T SEE OR HEAR ANYTHING THAT CAN REPLACE THEM. 12 THAT’S AN ISSUE FOR ALL AMERICANS, BUT UNFORTUNATELY. IT’S ALSO AN ISSUE THAT TRANSLATES INTO ANTI-SOCIAL AND ANTI-PERSONAL BEHAVIOR...BEHAVIOR THAT PLACES MORE STRESS UPON HUMAN RELATIONSHIPS AND UPON THOSE COMMUNITY SERVICES DEDICATED TO IMPROVING THE HEALTH OF THOSE RELATIONSHIPS. ANOTHER ISSUE -- ONE THAT’S RELATED TO THE FAMILY ISSUE BUT WITH A LITTLE DIFFERENT SLANT -- IS THE ISSUE OF SOCIAL RESPONSIBILITY OR SOCIAL CARING, IN THE OLD DAYS IT WAS KNOWN AS “CHARITY.” BUT 1 THINK THE WORD “CHARITY” HAS FALLEN OUT OF FAVOR, SO I'LL USE THE PHRASE “SOCIAL RESPONSIBILITY” INSTEAD. 13 | WRESTLED WITH THIS PROBLEM AT THE TIME WE WERE DEALING WITH "BABY DOE.” I] BELIEVE TODAY -- AS I DID BACK IN 1984 -- THAT WE WERE CORRECT IN ASSERTING THE RIGHT OF THE STATE TO INTERVENE AND PROTECT THE LIFE OF A NEWBORN HANDICAPPED INFANT. BUT SOME OF OUR FELLOW CITIZENS ARE STILL VERY UNCOMFORTABLE ABOUT THE RIGHT OF THE STATE TO DO THAT. AND 1 THINK MANY PEOPLE ARE ALSO UNCOMFORTABLE ABOUT THE STATE EXERCISING ITS RIGHT IN THE NAME OF ALL THE PEOPLE. 14 I’M CONCERNED ABOUT THIS BECAUSE THE ISSUE GOES FAR BEYOND “BABY DOE.” IT TOUCHES ON "GRANNY DOE,” SOMEONE WE HAVEN’T DEALT WITH YET BUT WHO, I’M SURE, IS WAITING OUT THERE SOMEPLACE FOR OUR ASSISTANCE, AND 1’M CONCERNED BECAUSE MEDICINE, THE LAW, AND SOCIAL SERVICES HAVE GIVEN NEW LIFE -- LITERALLY AND FIGURATIVELY -- TO PEOPLE WHO, IN FORMER YEARS, WOULD NOT HAVE BEEN SO VISIBLE...OR WHO MIGHT NOT HAVE BEEN PRESENT AT ALL, THE LIST WOULD INCLUDE HANDICAPPED OR DISABLED CHILDREN AND ADULTS... THE CHRONICALLY MENTALLY ILL... THE FRAIL ELDERLY... THE HOME- LESS PERSON...AND NOW A NEW CATEGORY, THE “HIGH-RISK” PERSON, THE PERSON WITH AIDS, 15 THIS GROUP OF PEOPLE TEND TO DO THINGS THAT THE MAJORITY OF AMERICANS DON’T USUALLY DO, WHETHER IT’S A SEXUAL ACTIVITY OR A DRUG- RELATED ACTIVITY. I’VE REPEATEDLY ASKED THE COUNTRY TO JOIN ME IN FIGHTING A DISEASE,..NOT THE PEOPLE WITH THE DISEASE, BUT THAT REQUEST IS ACCEPTED GRUDGINGLY BY MOST PEOPLE...AND NOT ACCEPTED AT ALL BY SOME. WE STILL HAVE NEIGHBORHOOD ASSOCIATIONS FORMED TO EXCLUDE GROUP HOMES FOR SELF-SUPPORTING, MOMDERATELY RETARDED ADULTS. 16 WE HAVE COMMUNITIES THAT CANNOT DIFFERENTIATE AMONG THE HOMELESS ...BUT CONDEMN THEM ALL AS NUISANCES, PARASITES, OR WORSE, AND WE HAVE SCHOOL SYSTEMS AND HOSPITALS WHO WILL TURN AWAY PERSONS WITH AIDS, EVEN THOUGH THEY HAVE NO LEGAL OR ETHICAL REASON FOR DOING SO, I FIND ALL THAT TO BE OUT OF CHARACTER WITH THE REST OF OUR HISTORY AS A SOCIETY. WE'VE ALWAYS BEEN MORE GENEROUS... MORE CHARITABLE... THAN THAT. IF WE BEGIN TO CATEGORIZE PEOPLE WITH PROBLEMS AS PRESENTING ONE OR ANOTHER KIND OF “BURDEN” ON THE REST OF THE SOCIETY. THAN I BELIEVE OUR SYSTEM OF JUSTICE IS THREATENED AND THE FUNDAMENTAL ETHIC SUPPORT- ING HEALTH CARE AND SOCIAL SERVICE IS SIMILARLY THREATENED. 17 AND FINALLY, A THIRD AND RELATED ISSUE IS THE ISSUE OF EQUITY IN OUR SOCIETY. I'M NOT TALKING ABOUT FINANCIAL EQUITY. CERTAINLY NOT AFTER THE LAST COUPLE OF WEEKS OF WALL STREET FIREWORKS. NO, I’M TALKING ABOUT THE EQUITY -- OR RATHER THE LACK OF IT -- IN HUMAN RELATIONSHIPS...BETWEEN MEN AND WOMEN, BETWEEN ADULTS AND CHILDREN. AND BETWEEN THE ELDERLY AND EVERYBODY ELSE. MY AWARENESS OF THIS ISSUE GOES BACK TO MY EARLY EXPERIENCE WITH THE ISSUE OF FAMILY VIOLENCE, A STRONG UNDERCURRENT OF THAT ISSUE, IT SEEMED TO ME, WAS THE FACT THAT MEN AND WOMEN DO NOT GENERALLY INTERACT AS EQUALS, AND MEN IN PARTICULAR TEND NOT TO TREAT WOMEN EQUITABLY. 18 IN THE MILDER FORMS OF THIS PROBLEM WOMEN ARE STRESSED, FRUS- TRATED, AND ANGERED, IN MORE SEVERE FORMS, THEY ARE PHYSICALLY, EMOTIONALLY, AND PSYCHOLOGICALLY VICTIMIZED. AND THEY ARE KILLED, BUT THEN I WAS SHOCKED TO LEARN THAT IN A RECENT NATIONAL SAMPLE OF COLLEGE WOMEN, 27.5 PERCENT SAID THEY HAD BEEN VICTIMS OF RAPE OR ATTEMPTED RAPE SINCE THE AGE OF 14, AND OVER A 6-MONTH PERIOD, THE VICTIMIZATION RATE FOR THIS GROUP OF YOUNG COLLEDGE WOMEN WAS 83 PER 1,000. IN YET ANOTHER STUDY OF YOUNG MEN IN COLLEGE, 25 PERCENT OF THEM HAD COMMITTED -- OR HAD ATTEMPTED TO COMMIT -- A SEXUALLY VIOLENT ACT AGAINST A FEMALE COMPANION, 19 THAT’S A CRIMINAL ACT, BUT THOSE YOUNG MEN DIDN'T SEE IT AS SUCH. TO THEM, THEIR BEHAVIOR WAS MERELY PART OF THE “GAME” OF MALE- FEMALE RELATIONS. CLEARLY SOMETHING IS WRONG IN OUR SOCIETY WHEN SUCH A SIZABLE PERCENTAGE OF AN ENTIRE GENERATION OF YOUNG MEN RESPOND TO YOUNG WOMEN THIS WAY,.,.AND WHEN AN EQUALLY LARGE NUMBER OF WOMEN ARE INDEED VICTIMIZED IN THIS WAY, SOMETHING IS VERY WRONG, 20 WE HAVE A SIMILAR SITUATION IN REFERENCE TO CHILDREN, THE STATISTICS FOR CHILD ABUSE AND CHILD SEXUAL ABUSE ARE -- 10 ME. AT LEAST -- CLEAR INDICATIONS OF THE EXTENT TO WHICH SOME ADULTS STILL LOOK UPON CHILDREN AS PROPERTY, EVEN AS PLAYTHINGS, AND THE REST OF SOCIETY, I’M ASHAMED TO SAY, SEEMS TO HAVE TROUBLE FOCUSING ON THIS. I’M SURPRISED, FOR EXAMPLE, AT HOW DIFFICULT IT IS TO GET COMMUNITIES TO LOOK MORE CLOSELY AT THE CUASES BEHIND INFANT AND CHILD DEATHS, I SUSPECT THAT MANY FEWER OF THESE DEATHS ARE REALLY THE “ACCIDENTS” THEY ARE REPORTED TO BE. 21 | BELIEVE MANY OF THESE SO-CALLED ACCIDENTAL INFANT DEATHS WOULD BE RECOGNIZED AS HOMICIDES, IF ONLY WE COULD FOCUS THE INTEREST OF THE COMMUNITY UPON THE ESSENTIAL INEQUITY OF WHAT IS GOING ON AROUND THEM, 1 THINK THERE IS A CONSPIRACY OF ADULTS AGAINST CHILDREN...AND WE OUGHT TO BE ASHAMED OF OURSELVES FOR LETTING IT CONTINUE. BUT I WANT MORE THAN ADULT CONTRITION AND CONFESSIONS OF GUILT. I WANT ADULTS TO CHANGE THE WAY THEY ACT TOWARD CHILDREN. 1 WANT THEM TO SEE CHILDREN AS HUMAN BEINGS DESERVING OF LOVE AND RESPECT...DE- SERVING OF EQUITY IN ALL HUMAN RELATIONSHIPS. 1 DON’T THINK IT’S TOO MUCH TOO ASK, IN FACT, IT STRIKES ME AS BEING AN IRREDUCIBLE MINIMUM. 22 AND I WOULD MAKE THE SAME CASE FOR OUR ELDERLY, WE STILL TREND TO SEE OLD PEOPLE AS SOMEHOW “LESS THAN” TOTAL PERSONS, AND MAYBE CLINICALLY YOU CAN SAY THAT FOR SOME OLDER PEOPLE, WHO MAY NOT HAVE THE VISION OR THE HEARING OR THE STRENGTH OR THE MEMORY THEY MAY ONCE HAVE HAD. BUT THEIR ESSENTIAL HUMANITY REMAINS WITH THEM ALWAYS, AND IT OUGHT TO BE RECOGNIZED AND TREATED EQUITABLY IN ALL THEIR HUMAN RELATIONSHIPS, I THINK WE AMERICANS, BY LAW AND BY TRADITION, ARE ABLE TO DO BETTER THAN WE’RE NOW DOING -- AND I’M IMPATIENT FOR THE IMPROVEMENTS TO BEGIN. 23 AS I SAID EARLIER, I WILL ONLY TOUCH UPON THE ISSUES OF FAMILY. CHARITY. AND EQUITY THIS EVENING, BUT, LET ME TAKE ADVANTAGE OF YOUR GOOD NATURE -- AND MY ROLE AS HONOREE -- AND LET ME COMMEND THESE ISSUES TO YOU FOR YOUR EXPLORATION, HOPEFULLY, IN MUCH MORE DEPTH. AND NOW. A FEW CLOSING WORDS, ACTUALLY, THEY‘RE NOT MINE, THEY BELONG TO A FINE PHYSICIAN, PSYCHOLOGIST, AND PHILOSOPHER, DR. WILLIAM JAMES, A NAME WELL-KNOWN, I AM SURE, TO THE MEMBERS OF THIS ASSOCIATION, THESE WORDS COME FROM A COLLECTION OF HIS WORKS ENTITLED, ESSAYS ON FAITH AND MORALS, IN ONE OF THESE PIECES, CALLED “THE WILL TO BELIEVE,” JAMES SPEAKS OF HOW YOU DEAL WITH “MORAL QUESTIONS”: 24 "SCIENCE CAN TELL US WHAT EXISTS,” SAYS JAMES, BUT AS TO THE WORTH OF WHAT EXISTS, “WE MUST NOT CONSULT SCIENCE, BUT...OUR HEART.” AND HE GOES EVEN FURTHER. HE SAYS... "IF YOUR HEART DOES NOT WANT A WORLD OF MORAL REALITY. YOUR HEAD WILL ASSUREDLY NEVER MAKE YOU BELIEVE IN ONE.” IN OTHER WORDS, AS YOU AND I AND OUR COLLEAGUES IN HEALTH AND LAW AND SOCIAL SERVICES MOVE FORWARD ON THE MANY ISSUES AFFECTING THE QUALITY OF AMERICAN LIFE. WE MUST BE SURE THAT OUR HEARTS ARE IN IT. BUT EVEN THAT’S NOT ENOUGY. WE MUST LET OUR HEARTS TELL US THAT THIS IS REALLY WHAT WE HAVE T0 DO, 25 THERE ARE LIMITS TO WHAT MEDICAL AND SOCIAL MEASUREMENTS CAN REVEAL TO US. WHEN ALL IS SAID AND DONE, WE MUST GO OUT AND DO THE RIGHT THINGS FOR NO OTHER REASON THAN OUR FEELING THAT THEY’RE SIMPLY THE RIGHT THINGS TO DO. 1 STILL HAVE TWO YEARS TO GO IN MY SECOND TERM AS YOUR SURGEON GENERAL AND MY HEART TELLS ME I MUST KEEP MOVING FORWARD ON A NUMBER OF ITEMS ON MY AGENDA: TO HELP REDUCE THE LEVEL OF VIOLENCE, ESPECIALLY FAMILY VIOLENCE 1.170 STRENGTHEN FAMILY LIFE...70 REVIVE THE SPIRIT OF CHARITY .. AND TO RECOGNIZE THE PRINCIPLE OF EQUITY AS CENTRAL TO ALL HUMAN RELATIONSHIPS, 26 THESE ARE THINGS NO ONE PERSON CAN ACCOMLPISH, AND I DON’T EVEN PRETEND TO BE ABLE TO DO IT ALONE, BUT I DO WANT TO BE PART OF THE PROCESS. 1 HOPE YOU ALL FEEL THE SAME WAY...AND I HOPE THAT YOUR SKILLS AND EXPERIENCES AND KNOWLEDGE WILL JOIN WITH OURS IN PUBLIC HEALTH SO THAT WE MAY DO MANY OF THOSE GOOD THINGS FOR THE AMERICAN PEOPLE... TOGETHER, THANK YOU, hid # &