ORIGINAL

ADDRESS

BY

L EVERETT KOOP, M,D,, Sc,D,

SURGEON GENERAL

        OF THE

U,Sl PUBLIC HEALTH SERVICE

U& DEPARTMENT OF HEALTH AND HUMAN SERVICES

PRESENTED AT A SPECIAL ~ANNUKAH CONVOCATION

       YESHIVA UNIVERSITY
       DECEMBER 18, 1988


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(GREETINGS TO HOSTS, HONOREES, GUESTS, FRIENDS, ETC,)

  I WANT TO THANK THE TRUSTEES, THE ADMINISTRATORS, AND THE

FACULTY OF YESHIVA UNIVERSITY FOR BEING MY HOST TODAY AT THIS

CONVOCATION,  I DEEPLY APPRECIATE YOUR RECOGNITION AND YOUR

AWARD TO ME OF AN HONORARY DEGREE.

  I AM TOLD THAT THE FIRST PERSON TO RECEIVE SUCH A DEGREE

FROM YESHIVA WAS DR, ALBERT EINSTEIN,   IT IS HUMBLING TO KNOW

THAT, IN SOME SMALL WAY, I MIGHT BE FOLLOWING IN HIS FOOTSTEPS




I I I AT LEAST, UP TO THIS PODIUM,


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  AS A SURGEON, OF COURSE, I'VE NEVER REGARDED HUMILITY AS MY

STRONG SUIT, BUT MAYBE THE OFFICE OF SURGEON GENERAL HAS

MELLOWED ME OVER THE PAST 7 YEARS,

  DR, MILLER INDICATED I COULD HAVE THE PODIUM FOR A FEW

MINUTES THIS EVENING AND VERY KINDLY SUGGESTED THAT I COULD SPEAK

ON ANY MATTER I THOUGHT WORTHY OF THE OCCASION,

  SO LET ME HARK BACK ONCE AGAIN TO DRm EINSTEIN AND A LITTLE

SENTENCE TAKEN FROM HIS VOLUME ON SCIENCE, HE WROTE THAT

"IMAGINATION IS MORE IMPORTANT THAN KNOWLEDGE," A QUOTE THAT HAS

BECOME ONE OF MY FAVORITES,


  AND SO, IN THAT SPIRIT, I'D LIKE TO EXERCISE A LITTLE

IMAGINATION THIS EVENING AND TRY TO LOOK AHEAD TO WHAT MIGHT

OCCUR IN MEDICINE AND IN PUBLIC HEALTH IN THE CENTURY AHEAD,

ELEVEN YEARS 1.1 IT'S NOT THAT FAR AWAY,

  I THOUGHT I'D TAKE THIS LONG VIEW BECAUSE YESHIVA

UNIVERSITY ITSELF IS TWO YEARS INTO ITS OwrJ SECOND CENTURY, I'M

SURE IT WILL BE AS STRONG A CONTRIBUTOR TO OUR COLLECTIVE

EXPERIENCE IN THE NEXT 100 YEARS AS IT HAS BEEN IN THE LAST 100,


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  BUT WHAT WILL THAT COLLECTIVE AMERICAN EXPERIENCE BE IN

MATTERS OF HEALTH AND MEDICINE? WHAT KINDS OF CHANGES MIGHT WE

ANTICIPATE?

  I SUGGEST THAT THERE MAY BE THREE AREAS IN WHICH

SIGNIFICANT CHANGES MIGHT OCCUR, AND, GUIDED BY DR, EINSTEIN'S

OPINION, I RELY ON KNOWLEDGE TO SOME EXTENT AND ON IMAGINATION A

GREAT DEAL,

THE FIRST AREA IS IN THE RELATIONSHIP BETWEEN TECHNOLOGY

AND HEALTH,


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  FOR OUR PURPOSES THIS EVENING, LET'S SAY THAT TECHNOLOGY IS

THE APPLICATION OF NEW SCIENTIFIC KNOWLEDGE TO REAL EVENTS, IF

THAT'S THE CASE, THEN HEALTH CARE AND MEDICAL PRACTICE IN OUR

SOCIETY HAVE BEEN PROFOUNDLY INFLUENCED BY TECHNOLOGY,

  TECHNOLOGY HAS ALSO RAISED TO A CONSIDERABLE DEGREE THE

PUBLIC'S EXPECTATIONS OF MEDICINE AND HEALTH CARE, IN FACT, THE

PUBLIC TENDS TO EQUATE MEDICAL TECHNOLOGY WITH THE MIRACULOUS,

AND SOME PEOPLE IN MEDICINE HAVE BEEN UNWISE ENOUGH TO PROMOTE

THAT KIND OF REVERENCE,


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  BUT CIILL TECHNOLOGY ALWAYS BE CONSIDERED BENEFICENTLY

"MIRACULOUS"? TWENTY OR EVEN 10 YEARS AGO I WOULD HAVE SAID

"YES" WITHOUT ANY HESITATION, BUT TODAY I HESITATE, AND TEN

YEARS FROM TODAY, WE MIGHT ALL BE SAYING "NO" mu, "NO" TO HIGH-

TECH MEDICINE,

  \IHY SUCH A CHANGE? SEVERAL REASONS, INCREASINGLY -- AND

WITH FEW EXCEPTIONS -- OUR NEW MEDICAL TECHNOLOGIES RESPOND TO

NARROWER AND NARROWER HUMAN NEEDS, THEY ARE IMPORTANT -- PLEASE

DON'T MISUNDERSTAND ME -- BUT THEY ARE FURTHER AND FURTHER

REMOVED FROM BROAD PUBLIC EXPERIENCE,


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  THE HIGH-TECHNOLOGY FRONTIERS YESTERDAY LAY WITH THE MAJOR

INFECTIOUS DISEASES, FOR EXAMPLE, WHICH WOULD AFFECT THE LIVES OF

TENS OF MILLIONS OF PEOPLE EACH YEAR, THE FRONTIERS OF

TOMORROW, HOWEVER, LIE IN THE AREA OF MAJOR SYSTEMIC OR

DEVELOPMENTAL ANOMALIES WHICH AFFECT THE LIVES OF HUNDREDS OF

THOUSANDS OF PEOPLE EACH YEAR,

IT'S QUITE A DIFFERENT ORDER OF MAGNITUDE,

  IN ADDITION TO THIS GRADUAL NARROWING OF THE FOCUS OF

BIOMEDICAL RESEARCH AND MEDICAL HIGH-TECH, I BELIEVE THE PUBLIC

HAS TWO ADDITIONAL PROBLEMS:


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FIRST, THE PUBLIC SEES AS A MIXED BLESSING -- AT BEST -- THE
ABILITY OF TECHNOLOGY TO PROLONG LIFE ,,a OR, IN MANY
SITUATIONS, TO PROLONG THE ACT OF DYING, IN FACT, BOTH THE

LAY PUBLIC AND THE MEDICAL PROFESSION ARE NOW ENGAGED IN A

VERY DIFFICULT DEBATE OVER THE USE OF SO-CALLED

"EXTRAORDINARY" MEASURES TO SAVE OR PROLONG THE LIVES OF

PERSONS PROFOUNDLY TRAUMATIZED OR TERMINALLY ILL,

FOR MANY PEOPLE FACED WITH DECISIONS TO MAKE ON BEHALF OF

LOVED ONES, HIGH-TECH MEDICINE SOMETIMES LOOKS LIKE A

FRIEND 1,. AND SOMETIMES IT LOOKS LIKE THE ENEMY,


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PEOPLE ARE TURNING TO LEGAL INSTRUMENTS LIKE THE SO-CALLED

"LIVING WILL" AND THE "PERMANENT POWER OF ATTORNEY" TO

PROTECT THEMSELVES FROM RUNAWAY MEDICAL TECHNOLOGY,

THAT'S NEW, BUT, UNFORTUNATELY, I THINK WE'RE STUCK WITH

THAT AMBIVALENCE FOR THE FORESEEABLE FUTURE,

AND THE SECOND PROBLEM OF PUBLIC PERCEPTION IS ONE THAT

MEDIC I NE AND PUBLIC HEALTH HAVE THEMSELVES SYSTEMAT I CALLY

BROUGHT ABOUT, WE'VE BEEN SAYING OVER AND OVER AGAIN THAT

TECHNOLOGY IS NOT THE ANSWER TO NEARLY ALL OF THE MAJOR

HEALTH PROBLEMS OF OUR SOCIETY: HEART DISEASE, STROKE,

ACCIDENTS, AND EVEN CANCER,


INSTEAD, WE SAY THAT PEOPLE THEMSELVES CAN AND MUST TAKE

CHARGE OF THEIR OWN HEALTH STATUS , , , THOSE b/HO SHOULD, MUST

STAY AWAY FROM HARMFUL FOODS, LIKE FATTY MEATS, AND "SAY

NO" TO HARMFUL DRUGS, LIKE ALCOHOL AND NICOTINE,

AND WE'RE RIGHT, OF COURSE, BUT TELLING PEOPLE, FOR
EXAMPLE, THAT THE BEST WAY TO BEAT HEART DISEASE IS THROUGH

ROUTINE EXERCISE IS ANOTHER WAY OF TELLING THEM, "DON'T RELY

ON HIGH TECHNOLOGY TO SAVE YOUR LIFE/'

THAT'S REALLY WHAT WE'RE SAYING ,a, AND WHAT WE'LL CONTINUE

TO SAY WELL INTO THE NEXT CENTURY,


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  HENCE, I BELIEVE -- FOR THESE SEVERAL REASONS -- THAT ONE OF

THE MAJOR SHIFTS ON MEDICINE AND PUBLIC HEALTH IN THE NEXT

CENTURY WILL BE A REDUCTION IN OUR FAITH IN -- AND RELIANCE UPON

-- HIGH TECHNOLOGY AND A GREATER RELIANCE UPON THE RELATIVELY

"LOW-TECH" EXPERIENCE OF PERSONAL DECISION-MAKING IN REGARD TO

HEALTH,

WE KNOW IT WILL BE CHEAPER AND IT MAY EVEN BE MORE EFFECTIVE

OVER THE LONG TERM,

WHAT'S THE SECOND BIG CHANGE ON THE HORIZON?


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IT WILL BE THE CONTINUATION OF THE CHANGING RELATIONSHIP

BETWEEN THE PUBLIC AND THE HEALTH CARE SYSTEM ITSELF,

  MANY FACTORS ARE BRINGING ABOUT THIS CHANGE, ONE IS THE

INCREASED MOBILITY OF THE AMERICAN PEOPLE, WE MOVE AROUND SO

MUCH THAT IT'S BECOMING HIGHLY UNLIKELY THAT THE AVERAGE PATIENT

WILL BE KNOWN AND SERVED BY THE SAME PHYSICIAN AND SAME HOSPITAL

STAFF THROUGHOUT HIS OR HER LIFETIME,

  THAT WAS THE NORM IN OUR SOCIETY FOR ALMOST THREE

CENTURIES, BUT NOT ANY MORE, THE DOCTOR-PATIENT RELATIONSHIP IS

A RELATIONSHIP BETWEEN STRANGERS.


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  ANOTHER FACTOR IS THE RISE IN PRE-PAID PRACTICES, THESE

PLANS, WHILE MORE COST-EFFICIENT, TEND TO ATOMIZE AND SUB-

DIVIDE PATIENT CARE,

  I'M NOT SAYING THAT THE RESULTS ARE EITHER GOOD OR BAD,  I'M

ONLY SAYING THEY'RE VERY DIFFERENT, BUT THAT DIFFERENCE IS QUITE

SIGNIFICANT IN HELPING TO RE-SHAPE THE LONG-TERM RELATIONSHIP

BETWEEN HEALTH CARE AND THE PUBLIC,

  A THIRD FACTOR CHANGING THE RELATIONSHIP BETWEEN THE PUBLIC

AND THEIR SYSTEM OF HEALTH CARE IS THE WELL-ADVERTISED AND WELL-

DISCUSSED SHIFT IN THE DEMOGRAPHY OF OUR COUNTRY,


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  WE KNOW THIS PHENOMENON BEST BY THE TAGS WE GIVE THEM: THE

"BABY BOOMERS" NOW FORMING THEIR OWN FAMILIES, AND THEIR PARENTS,

WHO ARE NOW "GRAYING IN AMERICA?

  THERE'S A BITTER IRONY HERE, FOR MANY YEARS WE'VE BEEN

EXTOLLING THE VIRTUES OF "CONTINUITY OF CARE," BUT WE'VE ALSO

BECOME RESIGNED TO THE FACT THAT THE AVERAGE INDIVIDUAL, IN THE

COURSE OF HIS OR HER LIFETIME, IS PASSED FROM PEDIATRICS TO

FAMILY MEDICINE AND FINALLY TO GERIATRIC MEDICINE a,, AND TO

MANY SPECIALISTS AND TECHNICIANS IN BETWEEN,


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   I'M AFRAID WE STILL BASE MUCH OF OUR HEALTH PLANNING -- AND

FINANCING, TOO -- ON A DISAPPEARING PATIENT-TO-SYSTEM RELATION-

SHIP THAT EXISTS MORE IN OUR MEMORY THAN IN ACTUAL DAILY

PRACTICE, AND, CONSISTENT WITH THE EINSTEINIAN CONCEPT OF

ENTROPY, THAT FORMER RELATIONSHIP IS DISAPPEARING AT GREATER AND

GREATER SPEED,

   BUT NATURE HATES A VACUUM -- IN HEALTH CARE AS ANYWHERE ELSE

-- AND FILLING MUCH OF THE GAP IN PUBLIC HEALTH IS A NEW AND VERY

FAST-GROWING PHENOMENON CALLED "SELF-HELP,"


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  NOT LONG I WAS GIVEN AN ESTIMATE OF 15 MILLION AMERICANS WHO

ARE NOW INVOLVED IN THE SELF-HELP MOVEMENT, BUT I'D SAY THAT

PROBABLY WAS A GROSS UNDERCOUNT,

  THE SELF-HELP MOVEMENT IS RESPONDING TO A PUBLIC NEED FOR

DIRECTION IN THESE AREAS OF PREVENTING DISEASE AND DISABILITY ,a,

OF PROMOTING AND MAINTAINING GOOD HEALTH 11, AND OF OBTAINING

ADVICE AND GOOD COUNSEL FOR THE BUSINESS OF COPING,


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  THE SELF-HELP MOVEMENT EMBRACES ALCOHOLICS ANONYMOUS AND THE

MANY, MANY GROUPS DEDICATED TO HELPING SMOKERS QUIT THEIR HABIT,

AND THERE ARE ALSO GROUPS SUCH AS PARENTS WITHOUT PARTNERS AND

THE GRAY PANTHERS mm, LA LECHE LEAGUE AND OVEREATERS ANONYMOUS




I I I BROTHER TO BROTHER AND MY SISTER'S PLACE ,.a THE AMERICAN

SCHIZOPHRENIA ASSOCIATION AND THE EPILEPSY FOUNDATION mAND SO

ON,

   THE DISEASES AND DISORDERS DEALT WITH BY THESE SELF-HELP

GROUPS ARE AMONG THE MOST SERIOUS PUBLIC HEALTH PROBLEMS WE FACE

TODAY: SUBSTANCE ABUSE, INCLUDING CIGARETTES .,a THE EPIDEMICS OF

SEXUALLY TRANSMITTED DISEASES, SUCH AS SYPHILIS, HERPES,

GONORRHEA, AND AIDS #urn AND THE THREE MAJOR KILLERS OF OUR

PEOPLE: HEART DISEASE, CANCER, AND STROKE,


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  I'M AMAZED AT THE EXTRAORDINARY DEGREE TO WHICH AVERAGE

AMERICANS ENGAGED IN THESE "DO-IT-YOURSELF' HEALTH PROGRAMS ARE

TRULY HELPED BY THEM, THEY ARE NOT FALSE PALLIATIVES, THESE

PROGRAMS REALLY WORK,

  AS A TRAINED SURGEON WHO PRACTICED FOR NEARLY A HALF-CENTURY

IN A UNIVERSITY SPECIALTY HOSPITAL, I'M NATURALLY UNCOMFORTABLE

ADMITTING THIS, NEVERTHELESS, THERE IT IS,

   MY ONLY CONCERN -- AND IT'S A MAJOR CONCERN -- IS THAT SOME

PEOPLE WHO NEED THE HELP OF TRADITIONAL, MEDICALLY TRAINED

EXPERTS AREN'T GOING TO GET IT OR THEY'LL BE ABLE TO AVOID IT BY

TURNING TO THE SELF-HELP MOVEMENT, CONSEQUENTLY THEIR HEALTH --

AND POSSIBLY THEIR LIVES -- MAY BE IN DEEP PERIL,


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  BUT SELF-HELP CAME ON THE SCENE PRECISELY BECAUSE THE

PUBLTC PERCEIVED THAT TRADITIONAL MEDICAL PRACTICE WAS NOT

RESPONDING TO CONTEMPORARY HEALTH PROBLEMS, AND, UNLESS GREAT

UNIVERSITIES LIKE YESHIVA AND GREAT MEDICAL SCHOOLS LIKE ALBERT

EINSTEIN DO SOMETHING TO UPDATE MEDICAL PRACTICE, I'M AFRAID THIS

DEVELOPMENT WILL ACCELERATE IN THE YEARS AHEAD,

  I DON'T THINK THE SEPARATION IS GOOD FOR MEDICINE ,a, GOOD

FOR THE SELF-HELP MOVEMENT mm u OR GOOD FOR THE AMERICAN PEOPLE,

I THINK BOTH SIDES -- MEDICINE AND SELF-HELP -- NEED TO PUT ASIDE

THEIR MUTUAL ATTITUDES OF SUSPICION AND DISPARAGEMENT AND TRY,

INSTEAD, TO FORGE A PARTNERSHIP OF HEALTH, HELP, AND CARING,


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  THAT'S WHAT THE AMERICAN PEOPLE WANT, THEY WANT SERVICE,

NOT NAME-CALLING AND BACKBITING AMONG THEIR SERVICE PROVIDERS,

  BUT FRANKLY, WHETHER TRADITIONAL MEDICINE AND PUBLIC HEALTH

DO OR DO NOT GET INVOLVED, I BELIEVE THE SELF-HELP MOVEMENT WILL

CONTINUE TO GROW ON INTO THE NEXT CENTURY 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 DJSABILITY PREVENTION,


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  AND THAT LEADS ME TO THE THIRD AND FINAL ISSUE I WANT TO

TOUCH ON THIS AFTERNOON,  IT'S THE RELATED ISSUE OF COMMUNITY

VALUES AND PUBLIC SUPPORT, RELATIVE TO MEDICINE AND PUBLIC

HEALTH,

  I MENTION IT BECAUSE, IN THE COURSE OF MY INVOLVEMENT WITH

THE AIDS EPIDEMIC, I'VE SEEN THE OUTLINES OF THIS ISSUE BEGINNING

TO FORM, ALSO, IT'S SOMETHING OF A COROLLARY TO THE TWO ISSUES

I'VE DISCUSSED SO FAR,


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  LET ME BEGIN WITH A DISCLAIMER, OF ALL THINGS, BUT I DO WANT

TO STATE VERY CLEARLY THAT I BELIEVE THE AMERICAN PEOPLE ARE

COMPASSIONATE AND 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 THE AMERICAN PEOPLE CAN ALSO BE IMPATIENT, FOR

EXAMPLE, MOST AMERICANS DO NOT SMOKE, AND THESE NON-SMOKERS

GENERALLY DISAPPROVE OF SMOKING AND WOULD LIKE TO SEE ALL SMOKERS

STOP, AND EVERY DAY, MANY A& STOPPING , , , BUT IT'S HAPPENING

VERY SLOWLY,


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  HENCE, THE NON-SMOKING PUBLIC IS DEMANDING -- AND GETTING --

NEW AND STRONGER LAWS AT ALL LEVELS OF GOVERNMENT TO CURB

CIGARETTE SMOKING IN THE WORKPLACE, IN ALL MODES OF TRANSPORTA-

TION, AND IN ALL PUBLIC GOVERNMENTAL AND COMMERCIAL BUILDINGS

  BUT PUBLIC DISPLEASURE DOES NOT STOP WITH SMOKERS, IT IS

BEING EXERCISED AGAINST OTHERS AS WELL, WHO WILFULLY BEHAVE IN A

HIGH-RISK MANNER: DRUNK DRIVERS, CHILD MOLESTERS, WIFE BEATERS,

DRUNK DRIVERS, DRUG ADDICTS, PROMISCUOUS AND PREGNANT TEEN-AGERS,

AND OTHERS WHO DEVIATE -- OR WHO ARE PERCEIVED AS DEVIATING --

FROM THE COMMUNITY'S STANDARD OF NORMATIVE BEHAVIOR,


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  AS I INDICATED EARLIER, THE AMERICAN PEOPLE ARE GENEROUS AND

FORGIVING, THEY DQ BELIEVE IN -- AND WILL CONTINUE TO SUPPORT --

PUBLIC HEALTH PROGRAMS THAT PROMISE REDEMPTION,

  BUT AMERICANS ARE NOT PUSH-OVER!?, AND IT'S POSSIBLE THAT

THE AMERICAN PEOPLE -- ALREADY TAKING A CONTENTIOUS APPROACH

TOWARD BACKSLIDERS -- MAY DEMONSTRATE THEIR IMPATIENCE AND

DISPLEASURE ON A GRANDER SCALE, ADDING A STRONG FOOTNOTE OF

DISAPPROVAL TO THE EXISTING BODY OF AMERICAN PUBLIC HEALTH LAW,


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  UNFORTUNATELY, WE'RE SEEING SOME OF THAT CONTENTION DEVELOP

IN REGARD TO PERSONS WITH AIDS,  IN THE MINDS OF SOME AMERICANS,

THE MOST WILLFUL MISCREANTS IN OUR SOCIETY TODAY ARE PEOPLE WITH

AIDS,

   NINE OF EVERY 10 PERSONS WITH THE DISEASE BECAME INFECTED BY

DOING WHAT THE COMMUNITY REGARDS AS AN UNSAVORY ACT: SOMETHING

THAT MOST PEOPLE DO NOT DO AND DO NOT APPROVE OF OTHERS DOING

EITHER,


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  I BELIEVE THIS REACTION BY A RELATIVELY HEALTHY AND HEALTH-

CONSCIOUS MAJORITY TOWARD A HTGH-RISK MINORITY IS AN ISSUE FOR

AMERICANS IN THE COMING YEARS, I THINK WE HAVE TO RECOGNIZE THIS

POSSIBILITY AND TRY TO CHANNEL IT INTO MORE POSITIVE, MORE

TOLERANT RESPONSES m 8, RESPONSES MORE IN KEEPING WITH OUR

NATIONAL HI STORY AND VALUES

  LET ME CLOSE, THEN, BY SAYING THAT I ANTICIPATE CERTAIN

MAJOR CHANGES IN AMERICAN HEALTH CARE OVER THE NEXT SEVERAL

DECADES SOME OF THESE CHANGES WILL BE EASIER TO EXPERIENCE THAN

OTHERS


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  BUT, ON BALANCE, I BELIEVE THEY WILL CONTRIBUTE TO A

STRONGER, MORE CONTEMPORARY, MORE RESPONSIVE SYSTEM OF HEALTH

CARE FOR THE NEXT AND SUCCEEDING GENERATIONS OF AMERICANS,

THANK YOU,

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