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EMARKS
By
C. Everett Koop. M.D., Sc.D.
SURGEON GENERAL
OF THE
U.S. PuBLic HEALTH SERVICE
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

GAY)

PRESENTED TO THE JOINT ECONOMIC COMMITTEE
WASHINGTON, D.C.
JunE 23, 1988
THANK YOU, MR. CHAIRMAN,

T AM PLEASED TO JOIN YOU THIS MORNING AND TO CONTRIBUTE TO
THE RECORD BEING BUILT BY THIS COMMITTEE IN REGARD TO “THE FUTURE
OF HEALTH CARE IN AMERICA.”

I KNOW YOU’VE COVERED A GREAT MANY TOPICS IN MEDICINE AND
PUBLIC HEALTH IN YOUR PREVIOUS COMMITTEE HEARINGS, AND, OF
COURSE, A NUMBER OF EXCELLENT WITNESSES FOLLOW MY APPEARANCE THIS
MORNING. WHAT I WOULD LIKE TO DO, THEN, IS TO TOUCH UPON THREE
OVER-ARCHING ISSUES IN THIS BRIEF OPENING STATEMENT AND THEN
ANSWER QUESTIONS FOR THE REMAINDER OF MY TIME,
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THE FIRST ISSUE I WANT TO RAISE IS THE FUTURE RELATIONSHIP
BETWEEN TECHNOLOGY AND HEALTH CARE. TECHNOLOGY HAS HAD A VERY

PERVASIVE INFLUENCE SO FAR. BUT WILL IT ALWAYS BE SO?

FOR MANY YEARS WE’VE ASSUMED THAT THE HEALTH STATUS OF OUR
PEOPLE WOULD CONSTANTLY IMPROVE, AS LONG AS WE CONTINUED TO PUSH
AGAINST THE FRONTIERS OF BIOMEDICAL TECHNOLOGY. AND THE
AMERICAN PEOPLE HAVE SUPPORTED THAT ASSUMPTION IN A WAY THAT
COUNTS: THAT IS, THROUGH TAXES AND DONATIONS WILLINGLY GIVEN.

HOWEVER, IN RECENT YEARS, I‘VE BEGUN TO DETECT A COUNTER-
TREND, IN WHICH THE PUBLIC -- AND EVEN SOME MEMBERS OF THE
MEDICAL PROFESSION ITSELF -- QUESTION THE HIGH COST AND LIMITED
RESULTS OF NEW MEDICAL TECHNOLOGIES.
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THERE IS, FOR EXAMPLE, A LIVELY PUBLIC DEBATE OVER THE USE

OF SO-CALLED “EXTRAORDINARY” MEASURES TO SAVE OR PROLONG THE
LIVES OF THE TERMINALLY ILL. I’‘VE BEEN INVOLVED IN THAT DEBATE
FOR MANY YEARS, BOTH BEFORE AND SINCE BECOMING SURGEON GENERAL.

RECENTLY, HOWEVER, MUCH PUBLIC SENTIMENT HAS BEEN RAISED
AGAINST THE USE OF SUCH MEASURES. I WOULDN’T SAY THAT MOST
PEOPLE FEEL THIS WAY, BUT CERTAINLY A SUBSTANTIAL AND VOCAL
MINORITY DOES NOT WANT THEIR PHYSICIANS TO PROLONG THEIR LIVES,
IF THERE’S ANY CHANCE AT ALL THAT THE KIND OF LIFE BEING
PROLONGED WILL BE QUALITATIVELY LESS THAN THE LIFE THEY’VE KNOWN,
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IN OTHER WORDS, WHILE THE AMERICAN PEOPLE WELCOME THE

EXPECTATION OF LONGER LIFE, THEY DON’T WANT LONGEVITY AT ANY
COST AND THEY SEE TECHNOLOGY, IN A SENSE, “PERPETRATING”
LONGEVITY UPON A DUBIOUS AND EVEN UNWILLING PUBLIC.

IN OTHER AREAS THERE IS ALSO GROWING SKEPTICISM AS TO THE
ADEQUACY OF TECHNOLOGY TO SOLVE THE MAJOR CONTEMPORARY HEALTH
PROBLEMS OF OUR PEOPLE. IN FACT, THE KEYSTONE OF PUBLIC HEALTH
FOR THE PAST DECADE -- AND CERTAINLY FOR THE FUTURE AS WELL --
HAS BEEN THE IDEA THAT EACH PERSON MAKES THE KEY DECISIONS, DAY-
BY-DAY, THAT AFFECT HIS OR HER OWN HEALTH ... DECISIONS, FOR
EXAMPLE ...
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* TO EAT SENSIBLY AND EXERCISE REGULARLY ...

* TO STOP SMOKING AND STOP USING DANGEROUS DRUGS ...

* TO ENSURE THAT ONE'S WORKPLACE IS SAFE AND HEALTHFUL ...

* AND TO LIVE AT HOME OR AT PLAY IN A MANNER THAT WILL ENHANCE.
AND NOT IMPERIL ONE’S HEALTH STATUS,

IN FACT, AS MORE AND MORE PEOPLE MAKE -- AND BENEFIT FROM --
THESE KINDS OF PERSONAL DECISIONS, I THINK WE MAY FIND THAT FEWER
AND FEWER PEOPLE WILL RETAIN SUCH COMPLETE AND UNCRITICAL FAITH
IN HIGH-TECH MEDICINE AS WAS THE CASE, SAY, IN THE 1950s AND 60s,
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ALSO, THE NEW TECHNOLOGIES TEND TO RESPOND TO CONDITIONS

THAT ARE RARE IN THE PATIENT POPULATION OR THEY REQUIRE THE KIND
OF DIFFICULT ETHICAL AND MORAL CHOICES THAT MOST PEOPLE WOULD
RATHER NOT MAKE.

FOR EXAMPLE, I WOULD NOT MINIMIZE THE SIGNIFICANCE OF THE
ESOTERIC TECHNOLOGIES THAT REVERSE INFERTILITY. HOWEVER, THE
POPULAR PREFERENCES FOR DEALING WITH THIS MEDICAL PROBLEM STILL
SEEM TO BE ADOPTION, ROUTINE DRUG THERAPIES ... AND RESIGNATION,

DURING THE YEARS WHEN TECHNOLOGY WAS CONSIDERED THE SINE QUA
NON OF MEDICAL PRACTICE, THE PRESSURES OF THE MARKETPLACE TENDED
TO SKEW SUPPORT FOR RESEARCH AWAY FROM THE BASIC SCIENCES AND
TOWARD RESEARCH APPLICATIONS AND PRODUCT DEVELOPMENT. THIS IS
CLEAR FROM THE ANNUAL REPORTS OF THE NATIONAL SCIENCE FOUNDATION
FOR THE PAST TWO DECADES.
/
BUT WHAT IF, AS I'VE INDICATED, THAT MARKET PRESSURE BEGINS

TO EASE? THEN WE MIGHT SEE BASIC RESEARCH SUCCESSFULLY COMPETE
FOR MORE RESOURCES: MORE BENCH SCIENTISTS, ADDITIONAL ACADEMIC
FACILITIES, AND MORE GOVERNMENT AND PRIVATE FUNDS AS WELL.

CONCURRENTLY, I BELIEVE WE’LL ALSO SEE AN INCREASINGLY
IMPORTANT ROLE FOR THE FIELD OF SO-CALLED “LOW-TECH” APPLICATIONS
TO HEALTH CARE AND HEALTH ADMINISTRATION,

IN ONE OF HIS PLAYS, GEORGE BERNARD SHAW ASKED WHY WE PAY
DOCTORS TO TAKE A LEG OFF BUT WE DON’T PAY THEM TO KEEP A LEG
ON. NOW, ALMOST 80 YEARS HAVE PASSED AND WE STILL HAVEN’T COME
UP WITH A GOOD ANSWER. IN FACT, OUR TECHNOLOGY-DRIVEN
REIMBURSEMENT SYSTEM -- WHETHER BY GOVERNMENT OR OUT-OF-POCKET
-- ITS PREDICATED ON TAKING THE LEG OFF.
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THAT’S TODAY. BUT I DON’T THINK THE SYSTEM WILL REMAIN THAT

WAY TOMORROW BECAUSE OF THE SHIFT IN THE PUBLIC’S OWN PERCEPTION
OF WHAT IT REALLY NEEDS. AND I THINK WE‘RE BEGINNING TO HEAR THE
PUBLIC SAY THAT IT NEEDS AND WANTS THE KIND OF HARDWARE AND
SYSTEMS THAT PROMOTE HEALTHFUL LIVING OR THAT HELP OLDER PEOPLE
AND PEOPLE WITH DISABILITIES OR CHRONIC ILLNESSES TO LIVE SAFELY,
HEALTHFULLY, AND INDEPENDENTLY IN THEIR OWN HOMES.

I THINK WE SHOULD TRY TO UNDERSTAND HOW AND WHY THAT MAY BE
HAPPENING AND WHAT JT COULD MEAN FOR THE FUTURE OF BIOMEDICAL
RESEARCH AND OF HEALTH CARE IN GENERAL.

A SECOND ISSUE IS THE CHANGING RELATIONSHIP BETWEEN THE
PUBLIC AND THE HEALTH CARE SYSTEM.
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MANY FACTORS ARE BRINGING ABOUT THIS CHANGE. ONE IS THE

INCREASED MOBILITY OF THE AMERICAN PEOPLE. THIS PHENOMENON MAKES
IT LESS LIKELY THAT THE AVERAGE PATIENT WILL BE KNOWN AND SERVED
BY THE SAME PHYSICIAN AND SAME HOSPITAL STAFF FOR A LIFETIME,
YET, THAT HAS BEEN OUR NORM FOR ALMOST THREE CENTURIES.

ANOTHER FACTOR IS THE RISE IN PRE-PAID PRACTICES OF ONE KIND
OR ANOTHER. THESE, WHILE MORE COST-EFFICIENT, ALSO TEND TO

ATOMIZE PATIENT CARE, I’M NOT SAYING THE CHANGE IS GOOD OR BAD.
I’M SAYING IT’S DIFFERENT AND THE DIFFERENCE IS SIGNIFICANT FOR
THE LONG-TERM RELATIONSHIP BETWEEN HEALTH CARE AND THE PUBLIC.
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A THIRD FACTOR IS THE WELL-ADVERTISED AND WELL-DISCUSSED

SHIFT IN THE DEMOGRAPHY OF OUR COUNTRY, THE SO-CALLED "GRAYING OF
AMERICA,”

ALREADY THE SPECIALTY OF GERIATRICS IS RESPONDING TO NEWLY
RECOGNIZED HEALTH NEEDS OF THE AGED. NOW THIS SPECIALTY JOINS
TWO OTHERS -- PEDIATRICS AND FAMILY MEDICINE -- TO DIVIDE UP
PRIMARY CARE AND, AGAIN, CHANGE ALL OUR TRADITIONAL IDEAS ABOUT
CONTINUITY OF CARE.

I’M AFRAID THAT MANY OF THE ASSUMPTIONS UPON WHICH WE BASE
MUCH OF OUR HEALTH PLANNING -- AND FINANCING, I MIGHT ADD -- MAY
STILL REFLECT A PATIENT-TO-SYSTEM RELATIONSHIP THAT, FOR MANY
INDIVIDUALS AND MANY INSTITUTIONS, NO LONGER EXISTS,
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LET ME ILLUSTRATE THIS WITH A LITTLE ANECDOTE. LAST WINTER

I CONVENED A “SURGEON GENERAL’S WORKSHOP ON SELF-HELP.” MY
PURPOSE WAS TO GAIN A BETTER SENSE OF WHAT WAS GOING ON IN THIS
NEW AREA AND WHAT THE GOVERNMENT’S ROLE MIGHT BE -- IF ANY,

I DISCOVERED THAT AN ESTIMATED 15 MILLION AMERICANS ARE
INVOLVED IN THE SELF-HELP MOVEMENT ... THAT THEY REPRESENT ALL
SOCIAL, RACIAL, ETHNIC, GEOGRAPHIC, AND ECONOMIC GROUPS ... AND
THAT THEY ARE FIERCELY INDEPENDENT.

IT ALSO DISCOVERED THAT THEY ARE PROVIDING LEADERSHIP IN
THREE HEALTH AREAS IN WHICH TRADITIONAL MEDICINE AND PUBLIC
HEALTH ARE STILL SEARCHING FOR MEANINGFUL ROLES: HEALTH
PROMOTION, DISEASE PREVENTION, AND THE COUNSELING FUNCTION,
CALLED “COGNITIVE MEDICINE” BY SOME PHYSICIANS,
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THE SELF-HELP MOVEMENT EMBRACES ALCOHOLICS ANONYMOUS AND

A NUMBER OF ALLIED ORGANIZATIONS ... SMOKING CESSATION GROUPS AND
PROGRAMS ... AND COUNSELING AND TREATMENT GROUPS FOR DRUG
ADDICTS.

THERE’S ALSO AN EVER-EXPANDING ASSORTMENT OF “SUPPORT
GROUPS” FOR PERSONS WITH FAMILY, PERSONALITY, SEXUALITY, OR
INFECTIOUS DISEASE PROBLEMS; PERSONS WHO’VE JUST “KICKED A HABIT”
OF SOME KINDs OR PERSONS RETURNING HOME AFTER A MAJOR HEALTH
ORDEAL, SUCH AS A HEART ATTACK, CANCER TREATMENT DIAGNOSIS, A
STROKE, AND SO ON,
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YOU'LL NOTICE, MR. CHAIRMAN, THAT THESE DISEASES AND

DISORDERS ARE ALSO AMONG THE MOST SERIOUS PUBLIC HEALTH PROBLEMS
WE FACE TODAY: SUBSTANCE ABUSE, INCLUDING CIGARETTES ... THE
EPIDEMICS OF SYPHILIS, HERPES, GONORRHEA, AND AIDS ... AND THE
THREE PERSISTENT MAJOR KILLERS OF OUR PEOPLE: HEART DISEASE,
CANCER, AND STROKE.

TRADITIONAL FEE-FOR-SERVICE MEDICINE OR TAX-SUPPORTED
PUBLIC HEALTH PROGRAMS GENERALLY DO NOT RESPOND TO THIS INTENSELY
PERSONAL ASPECT OF THESE PERCEIVED HEALTH PROBLEMS. ALSO, SINCE
THE INDIVIDUAL DECIDES WHEN SUCH ASSISTANCE IS NO LONGER NEEDED,
THERE IS NO GENERALLY RECOGNIZED END-POINT; THEREFORE, THERE IS
NO SPECIFIC POINT AT WHICH EXPENDITURES MUST END OR REIMBURSE-
MENTS MUST BEGIN.
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I HONESTLY MARVEL AT THE EXTRAORDINARY DEGREE TO WHICH

AVERAGE AMERICANS ARE ENGAGED IN THESE “DO-IT-YOURSELF” HEALTH
PROGRAMS AND ALSO THE DEGREE TO WHICH THEY ARE TRULY HELPED BY
THEM,

MY ONLY CONCERN -- AND IT’S A MAJOR CONCERN -- IS THAT SOME
PEOPLE WHO NEED THE HELP OF EXPERTS WITH MEDICAL TRAINING AREN'T
GETTING IT OR ARE AVOIDING IT ... AND THEIR HEALTH AND POSSIBLY
THEIR LIVES MAY BE IN PERIL AS A CONSEQUENCE,

I'D LIKE TO SEE MORE PHYSICIANS, NURSES, AND ALLIED HEALTH
PROFESSIONALS BECOME INVOLVED IN WHAT IS NOW CALLED “SELF-HELP”
OR “DO-IT-YOURSELF” HEALTH CARE. MY INSTINCTS TELL ME IT WOULD
BE VERY USEFUL IF THEY DID.
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BUT WHETHER TRADITIONAL MEDICINE AND PUBLIC HEALTH DO OR DO

NOT GET INVOLVED, I BELIEVE THIS MOVEMENT WILL CONTINUE TO GROW

AND BECOME NOT MERELY AN “ALTERNATIVE” SYSTEM OF HEALTH CARE BUT
IN FACT OUR OTHER NATIONAL SYSTEM OF HEALTH MAINTENANCE, HEALTH

PROMOTION, AND DISEASE AND DISABILITY PREVENTION.

AND THAT LEADS ME TO THE THIRD AND FINAL ISSUE I WANT TO
TOUCH ON THIS MORNING, MR. CHAIRMAN, IT IS THE RELATED ISSUE OF

HEALTH, COMMUNITY VALUES, AND PUBLIC SUPPORT.

I MENTION IT BECAUSE, IN THE COURSE OF MY INVOLVEMENT WITH
THE AIDS EPIDEMIC, I‘VE SEEN THE OUTLINES OF THIS ISSUE ALREADY
FORMING. ALSO, IT IS A KIND OF COROLLARY OF THE ISSUES I'VE
DISCUSSED SO FAR.
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LET ME BEGIN BY SAYING THAT THE AMERICAN PEOPLE ARE GENEROUS

TO A FAULT, THROUGH TAXES AND THROUGH PERSONAL, OUT-OF-POCKET
DONATIONS THEY WANT TO HELP EVERYONE IN OUR SOCIETY ACHIEVE GOOD
HEALTH AND THE GOOD LIFE THAT COMES WITH GOOD HEALTH.

BUT THEY CAN ALSO BECOME IMPATIENT. FOR EXAMPLE, MOST
AMERICANS DISAPPROVE OF SMOKING AND WOULD LIKE TO SEE ALL SMOKERS
STOP, AND, THROUGH THE SELF-HELP MOVEMENT, MANY SMOKERS ARE
INDEED QUITTING THE HABIT. BUT IT’S HAPPENING VERY SLOWLY.

HENCE, THE NON-SMOKING PUBLIC IS ASKING FOR NEW AND STRONGER
STATE AND LOCAL LAWS TO CURB CIGARETTE SMOKING IN THE WORKPLACE
AND IN ALL PUBLIC GOVERNMENTAL AND COMMERCIAL BUILDINGS.
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MOST HEALTH AND LIFE INSURANCE COMPANIES NOW HAVE A SEPARATE

-- AND HIGHER -- PREMIUM FOR SMOKERS, ALSO, ON THE THEORY THAT A
PERSON WHO SMOKES OUGHT TO PAY A LARGER SHARE FOR THE CONSE-
QUENCES OF THAT UNHEALTHY BEHAVIOR.

NEW LAWS, HIGHER PREMIUMS, AND SEGREGATION AT THE WORKSITE
ARE EXAMPLES OF PUBLIC RETRIBUTION DIRECTED AGAINST SMOKERS. BUT
IT 1S BEING EXERCISED AGAINST OTHERS AS WELL: DRUNK DRIVERS,
DRUG ADDICTS, PROMISCUOUS AND PREGNANT TEEN-AGERS, AND OTHERS
WHO ARE PERCEIVED AS DEVIATING FROM THE COMMUNITY’S STANDARD OF
NORMATIVE BEHAVIOR,
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BUT THE AMERICAN PEOPLE ARE STILL VERY GENEROUS AND VERY

FORGIVING. THEY DO HONESTLY BELIEVE IN -- AND WILL CONTINUE TO
SUPPORT -- PUBLIC HEALTH PROGRAMS THAT PROMISE REDEMPTION.

BUT THEY AREN’T PUSH-OVERS. AND IT’S POSSIBLE THAT THE
AMERICAN PEOPLE -- ALREADY TRAVELING THE ROAD OF RETRIBUTION --
MAY BEGIN TO EXERCISE THEIR RETRIBUTIVE POWERS MORE AND MORE,

THE OBJECT WILL CONTINUE TO BE THE INDIVIDUAL WHO WILFULLY
BEHAVES IN A HIGH-RISK MANNER: DRUNKS, DRUG ADDICTS, CIGARETTE
SMOKERS, SEXUALLY PROMISCUOUS PEOPLE OF ALL AGES, DANGEROUS
DRIVERS, CHILD BEATERS, AND OTHERS.
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AND AT THE TOP OF THAT LIST RIGHT NOW IS THE PERSON WITH

AIDS ... SOMEONE WHO CONTRACTED THAT LINGERING BUT FATAL DISEASE
THROUGH WHAT THE COMMUNITY REGARDS AS AN UNSAVORY ACT: SODOMY OR
INTRAVENOUS DRUG ABUSE.

IT’S POSSIBLE THAT A PUBLIC REACTION OF RETRIBUTION TOWARD
PEOPLE WITH AIDS MAY COME ABOUT IN THE 1990s, WHEN THE ANNUAL
COSTS OF AIDS-RELATED RESEARCH AND PATIENT CARE ARE EXPECTED TO
REACH OR EXCEED $3 BILLION.

THE 1990s IS ALSO WHEN NEW CASES OF AIDS WILL BE REPORTED
AMONG PEOPLE WHO MOST LIKELY BECAME INFECTED SOMETIME AFTER --
AND MAYBE LONG AFTER -- THE HUMAN IMMUNODEFICIENCY VIRUS, OR
H.I.¥., WAS IDENTIFIED AND THE NATIONWIDE AIDS EDUCATION PROGRAM
WAS WELL UNDER WAY.
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SUCH A PUBLIC RESPONSE WOULD BE A TRAGIC DEVELOPMENT -- BUT

NOT UNEXPECTED. IT WOULD BE CONSISTENT WITH THE OTHER RETRIB-
UTIVE TRENDS I MENTIONED EARLIER,

OUR CHALLENGE, THEN, WOULD BE TO RECOGNIZE -- IF AND WHEN
IT COMES -- THIS REACTION BY THE GENERAL PUBLIC AGAINST HIGH-RISK
INDIVIDUALS AND TO TRY TO CHANNEL IT INTO MORE POSITIVE, MORE
TOLERANT RESPONSES,

AT STAKE IS THE VERY BASIS OF THE AMERICAN APPROACH TO
PUBLIC HEALTH ITSELF: THAT IS, THE MAJORITY OF THE AMERICAN
PEOPLE WHO LIVE THEIR LIVES IN A GENERALLY HEALTHFUL, LOW-RISK
MANNER HAVE BEEN WILLING TO SUPPORT -- SOMETIMES WILLINGLY AND
SOMETIMES GRUDGINGLY -- THE SERVICES THAT TAKE CARE OF A MINORITY
OF PEOPLE WHO LIVE IN A GENERALLY UNHEALTHFUL, HIGH-RISK MANNER,
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IN MANY RESPECTS, THIS IS THE MOST IMPORTANT ISSUE OF ALL.

WE KNOW THAT HEALTH COSTS ARE TAKING A LARGER AND LARGER SHARE OF
THE GROSS NATIONAL PRODUCT. IT STANDS TO REASON, THEN, THAT MORE
AND MORE AMERICANS WILL BEGIN TO LOOK WITH GREATER CRITICAL
INTEREST NOT ONLY AT OUR SYSTEM OF HEALTH CARE BUT ALSO AT THE
PEOPLE DIRECTLY BENEFITING FROM THAT SYSTEM,

THAT WOULD BE A VERY WELCOME DEVELOPMENT BECAUSE IT IS
ROOTED IN OUR SYSTEM OF PARTICIPATORY DEMOCRACY. BUT IT CAN BE A
PAINFUL DEVELOPMENT FOR MANY OF OUR CITIZENS, AND WE OUGHT TO BE
PREPARED FOR THAT.
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LET ME CLOSE, THEN, BY SAYING THAT I ANTICIPATE CERTAIN

MAJOR CHANGES IN AMERICAN HEALTH CARE OVER THE NEXT SEVERAL
DECADES. SOME WILL BE EASIER TO EXPERIENCE THAN OTHERS. BUT, ON
BALANCE, I SEE THEM AS CONTRIBUTING TO A STRONGER, MORE
RESPONSIVE, MORE CONTEMPORARY SYSTEM OF HEALTH CARE FOR THE NEXT
AND FOR SUCCEEDING GENERATIONS OF AMERICANS,

THANK YOU. AND NOW, IF YOU WISH, I’D BE PLEASED TO ANSWER
QUESTIONS.
HHH