Keynote address C. Everett Koop, MD, ScD Surgeon General, US Public Health Service Deputy Assistant Secretary for Health US Department of Health and Human Services The following address was presented to the 54th Annual Clinical Assem- bly of Osteopathic Specialists in Boston, MA, on 18 October 2981. In my former position as a sur- geon in Philadelphia, I was al- ways a close friend of the os- teopathic specialists and pioneered in the training of OS- teopathic medical students and residents in pediatric surgery. Had I not left Philadelphia, I might have been the first to turn out a full-fledged osteopathic pediatric surgeon. I would have liked that. But training is not enough. We only merit the term "profes- sional" if we put that training to work in the service of improved health and well-being for the American people. In this area, the members of the osteopathic specialties continue to earn the right to be called "professional" and merit the high regard of all American citizens. This is not an easy thing to do, particularly in a period when this country is under intense economic pressure. Our col- leagues and patients have had to negotiate their way through an economic landscape that is riddled with potholes: inflation, scarcity, imbalance, and in- equity. As the surgeon-in-chief of Children's Hospital in Philadelphia, I saw the cost of care rise beyond our control. Materials, energy and fuel, per- sonnel, maintenance, and medi- cation-all the thousands of items and services that combine to make up what we call medi- cal care-continue to rise. Yet, all persons involved in health and medical care have managed to maintain a high level of qual- ity and productivity. But the question that confronts us is "How long can we continue to do that?" This is the question that Presi- dent Reagan has posed to the nation since the day he took of- fice. He described the situation in a recent speech: "Eight months ago . . . few of us could keep our heads above the rising inflation rate. Our economy was sinking and taking most Ameri- cans with it." For many of us in medicine, whether practitioner, trustee, or administrator of an institution of care, the presi- dent's description could be called an understatement. The president's economic recovery program was launched on in- auguration day and it has been a top priority for the govem- ment ever since, and I believe it has finally penetrated the con- sriousness of most Americans and has become their top prior- ity as well. It used to be that, if you asked a physician to list the major in- fluences in contemporary medicine, his or her response would tend to include things like the breaking of the genetic code, the development of the CAT scanner, the possibility of a physician surplus or a nursing shortage. However, I think most of us have broken out of that co- coon. We would now put infla- tion at the head of the list. Next would come those things that we have to do as a society to bring inflation under control and stabilize our economy. Clearly, one of the major influ- ences on the inflation spiral has been the federal government it- self. In 1980 this country spent, from all sources, a total of $247 billion for health services, per- sonnel, facilities, materials, and research. Of that total, some $57 billion or 23% was spent by the federal government. This has been a rising figure, giving gov- ernment extraordinary interest and leverage in the health mar- ketplace. The purchasing de- mands of government have skewed the costs of goods and services as well as contributed to their overall rise. It is the devastating effect of federal pur- chasing to which the White House, the Department of Health and Human Services, and Congress have addressed themselves this year. You have read the newspapers, watched television, and read the journals and newsletters serving health. You know the kind of effort that has been expended so far to cool down the growth of the federal health budget. It has been nothing short of extraordi- nary and it has been very, very difficult from almost every per- spective. We have had to take a hard look at every federally sup- ported health program and ask some tough questions about it. @What is its purpose? 01s that purpose being fulfilled? o To what extent is it being ful- filled? Could it be more effec- tive? Would that be a good thing? 01s it something that gov.ern- ment intrinsically does well or could some other sector of soci- ety do the job better? o What is its impact on the rest of health and medical care, Keynote address 33 `% - whether federally supported or all familiar with the history of not? Professional Standard Review The questions are tough and. Organizations (EROS), and a the answers have not come eas- checkered history it has been at ily for several reasons. Some that. I do not believe that a wad people feel that the asking of of federal money can insure the such questions is a challenge to public that physicians or anyone the motivation of those persons else will abide by high profes- ! who fought for the programs in sional standards. That is the job the first place. That is under- of the professions themselves. standable, but it is also not rele- You cannot make them stick by vant. The motives are unques- publishing them in the Federal tioned. Register. I think it is generally accepted The setting of standards and by everyone in Washington and the enforcement of those stan- elsewhere around the country dards of practice are the respon- that the great expansion of fed- sib&ties of the professions. era1 health and social services Therefore, this .administration sprang from decent impulses. intends to phase out federally The kind of impulses that have supported PSROs. The PSRO is been the mark of our society a good idea, but not for Wash- among all other societies on this ington to impose on the physi- planet. We see a problem, cians of America. We as physi- people in need, and we want to cians must voluntarily enforce help. We crank up a new tool- those standards, monitor our federal aid-and feel reasonably performance, and police our- secure in our compassionate re- selves with maximum effort and sponse to the need. Unfortu- integrity. The dividends will be nately, we did a great deal of high for us and our patients. cranking up over the past two decades. Last year there were The government finances and nearly 500 separate or categori- regulates other activities of cal aid programs funded by the which it has very little direct federal government to deal with knowledge and ex@ence. A virtually every known medical case in point is health planning. and social ill. There were addi- We know that planning can be a tional programs that had be- complex activity. If done well, it come law, but Congress has not will take into account all the ;;;Etten around to funding variables in a state, county, or municipality and adjust for Over the past eight months, them. However this is a big, di- these programs, along with verse nation with a multitude hundreds of others in the execu- of such variables. The federal tive branch and in many inde- government made a valiant ef- pendent agencies were fort to construct a national pro- scrutinized very closely. Several gram of health planning with a conclusions were reached that regulatory and administrative seem to fit together into a co- structure broad enough to take herent, national policy for the all those state and local variables support of health and medical into account. The program gen- care in this country. It is dif- erated a blizzard of paper and ferent from past policy. It has to very little evidence that such be to meet the total needs of federal direction really helped this country. Let me briefly state and local planners get a sketch out a couple of these handle on health care and conclusions. health costs. In some instances, it simply got in the way. .%, The government has been This kind of program is best" spending a lot of money on ac- left to the states to initiate, tivities that really cannot be fund, and control. The federal bought. The prime example is supports are being phased out professional standards. You are over a two-year period. By then, THE DO JANUARY 1982 the planning agencies that are dent's proposal, I am neverthe- ing the kind of contributions doing a good job and making a less heartened by the fact that other levels of government or positive contribution will no the idea of block grants to the the private sector make. That doubt continue to receive state states has been accepted by has now changed. Under the and/or local support, Those that Congress and enacted into law. president's leadership and with do not will gradually disappear. I am happy to report that all the presence of former Senator The desire or intuition of a dis- states have applied for the ma- Richard Schweiker as the secre- tant federal agency will no ternal and child health block tary of health and human ser- longer matter. grant and it looks as though vices, I believe that the execu- That leads quite naturally into they all will apply for the health tive branch of the federal gov- another conclusion about the services and prevention block ernment has a real opportunity structure of federal support for grant. to regain its own sense of bal- health; a conclusion that is also There had been much talk ante and see how it can make part of a much larger issue in about the willingness of the its own unique contribution to American society. states to accept responsibility for the conduct of public business, these programs. The implication and do it as a partner, rather Many activities ought to be con- was that the states were some- than as the master of the situa- tinued, but the authority for how aware of their own limita- tion. conducting them should be tions, that they might elect to One of the best examples of vested in the states and no turn back the clock of social this is the campaign, launched longer in the federal govem- progress, and that their level of this summer, called "Healthy ment. This was not conceived professionalism and dedication Mothers, Healthy Babies." It is overnight. Rather, for several was somehow of a lesser order based on the data generated by years there has been a general than the level among federal the National Center for Health uneasiness about the degree to personnel. Such implications are Statistics. Those data show a which the balance of power in completely groundless and to- continuing high risk of infant our democracy has shifted so tally unfair. Of course, there are mortality or morbidity among dramatically away from state differences of style, approach, disadvantaged and minority government and toward the and capacity among the states, women and teenage girls who federal government. just as there are among federal give birth. The cost to those The president set about to re- agencies. Those differences are women, to their families, to the store the balance of power be- precisely what federalism is all surviving infants, and to society tween the states and the federal about: different local, state, and as a whole is enormous, in both government, and those of us in regional approaches to the solu- dollars and psychosocial terms. public health have made our tions of common problems. While the public health service contribution to that effort. The has been the catalyst for this mechanism chosen by the presi- The president's program of campaign, it remains a partner dent to accomplish this is the "New Federalism" is especially with over a dozen major na- block grant, a consolidation of important for health and medi- tional organizations representing several similar federal programs cal care, where state, county, health professions, educators, that is transferred to the states, and municipal agencies, both and concerned lay persons. The along with a consolidation of public and private, are on the cosponsors of the organizational the federal funds behind those front line of service. It has been conference last month included programs. Authority to run the intention of this administra- those programs, to adjust the al- tion that state and local gov- the American College of Obste- tricians and Gynecologists, the location of resources among the ernment, and the private sector American Academy of Pediat- programs within the block, and the professional associations, Tics, the American Nurses Asso- to set program priorities is the voluntary organizations, ciation, Parent-Teachers Associ- transferred to the state. charitable groups, and founda- ation, and the March of Dimes The president's original propo- tions would become involved to sal last March would have con- which played a major leadership solidated the authorities and a higher degree than may now role in this campaign thus far funds for 25 public health pro- be the case, and would directly participate in the shaping and and has pledged to continue it. conduct of health and medical The partner idea works and grams into two block grants to the states and territories. After care in the United States. people benefit. many months of discussion, Finally, in this overview of na- There has always been a mea- Congress produced four block sure of participation, sometimes tional health policy as it is being grants that consolidate, in dif- quite high and quite visible and redefined in Washington today, ferent fashion, 22 categorical let me say that there are-some other times rather muted. But public health grant-in-aid pro- the executive branch of the fed- things that the federal govern- ment does well and should con- grams. While I am disappointed era1 government has the capac- in the change from the presi- ity to shield itself to avoid mak- tinue to do.The first activity that usually comes to mind in this Keynote address 37 \ - regard is support for biomedical and behavioral research. This country can be proud of its ex- ceptional research enterprise at the federal level: The National Institutes of Health, of Mental Health, of Drug Abuse, and of Alcohol Abuse and Alcoholism; the National Science Founda- tion, the epidemiological and bench research in the Centers for Disease Control and the Food and Drug Administration; and the vast research enterprise that is supported by federal funds outside government in our universities, medical cen- ters, foundations, private labora- tories, and among expert inves- tigators overseas. We cannot let this outstanding research capacity wither or be denied its essential nourishment of interest and dollars. Within austere budgetary periods such as the one we are now in, it may be necessary to set some priorities for the investment of scarce dollars, but to risk the continued vitality of our re- search capability would be to risk the very foundation of med- ical care itself. How we practice and how and why we make the judgments we do in our spe- cialties reflects the knowledge that has been developed and transmitted by the research community. Clearly this is a federal priority, a responsibility to be exercised at the national level. We also look to the federal government to have the exper- tise and the mobility to attack a variety of health emergencies or tasks that reflect national, not regional or state, needs. We in the public health service are es- pecially proud of the way we have carried out our profes- sional responsibilities in dealing with the eruption of Mount St Helen and the health risks of that natural event; the environ- ' mental challenge of the Love Canal area and similar areas around the country that have been put at risk by toxic waste discharges; and the teamwork required to protect the residents in the area of the Three Mile Is- 1 land nuclear power plant. These are just a few of many examples in which the federal govemmen is the agent of choice to handle I a sudden threat to public health Of quite a different nature, but no less threatening, are the 1 sudden appearances of unfamil- iar disease conditions: toxic shock syndrome, Legionnaire's disease, dengue fever, and others. This also requires mobil- ity, instant expertise, and legal as well as medical authority. In most of those instances, the first men and women to arrive at the scene and begin the pro- cesses of identifying the nature of the event, caring for the people involved, and working with local and state authorities were the members of the uni- formed commissioned corps of the US Public Health Service. There has been much discussion lately about the establishment of a rapid deployment force for the American military, an important part of our total American de- fense effort. But I would suggesi that there is, in the service of civilian health needs, a rapid deployment force that has been doing an effective job for more than a century-the US Public Health Service Commissioned Corps. For many years the medical profession has tried to hold back the relentless growth of gov- ernment. The profession argued that it could best handle the health needs of our citizens, particularly when in partnership with public and private state and local agencies. Because those persons and groups closest to the patient were the most qualified to handle his needs. That has been a rallying cry for quite a while. Well, the physicians' turn has finally come around. I am reminded of a remark attributed to Alfonso X, King of Spain, 700 years ago. He was known as Alfonso the Learned and he apparently took that title seriously. He sup- posedly once said, "Had I been present at the creation, I would have given some useful hints for the better ordering of the uni- verse. " It is hard to top that for smug- ness. Yet I must say that you are today "present at the cre- ation" of a new direction in fed- eral health policy and in the "ordering" of the way you de- liver health and medical care in America. What is more, you even have the chance that was denied poor King Alfonso: you cm give "some useful hints" and in other ways contribute to the public business being created. I must confess that there is many a day when I wish I were back practicing surgery, directly involved in an immediate, pal- pable human problem and solv- ing it. But then there is the chal- lenge of taking part in the re- shaping of health service in our society and knowing that, if it works, millions. of Americans alive today and coming along in the days and years ahead may. ' ' benefit. It is an exhilirating feeling. I hope all of you may find a way to share in it. 38 Keynote address THE DO JANUARY 1982