DFRSPECTIVES ON THE FUTURE OF HEALTH CARE BY C. EVERETT KOOP, MD SURGEON GENERAL AND DEPUTY ASSISTANT SECRETARY FOR HEALTH KEYNOTE ADDRESS PRESENTED TO THE FIFTH ANNUAL MEDICAL CONFERENCEOF THE MEDICAL ASSOCIATION OF THE BRITISH VIRGIN ISLANDS TORTOLA, BALI. FEBRUARY 5, 1983 -l- (GREETINGS TO HOSTS, GUESTS> `\ \ I'M DELIGHTED TO JOIN YOU TH;S MORNING TO ADD MY "PERSPECTIVES ON HEALTH CARE" TO THOSE ALREADY OFFERED FROM THIS PODIUM. WHEN MINISTER O'NEAL AND DR, BLOCKSMA EXTENDED THEIR GRACIOUS INVITATION TO ME TO SPEAK AT THIS CONFERENCE, THEY ENCLOSED THE PROGRAM. IT IS VERY IMPRESSIVE AND, AT FIRST READING, A BIT INTIMIDATING, ALSO. I SAW THAT, BY THIS TIME IN THE PROGRAM, YOU WILL HAVE HAD MORE THAN THREE DAYS OF INTENSIVE, SUBSTANTIVE PRESENTATIONS BY EXCELLENT FACULTY, THE INVITATION PRESENTED-ME, THEREFORE, WITH AN EXQUISITE CHALLENGE. WERE I NOT A SURGEON, I DOUBT THAT I COULD STAND UP TO IT, HOWEVER, AFTER MORE THAN 35 YEARS AS A SURGEON AND, FOR THESE PAST TWO YEARS, A "SURGEON GENERAL," I DECIDED TO RISE TO YOUR CHALLENGE, I HAPPILY ACCEPTED YOUR INVITATION TO COME HERE AND SPEAK OF THE FUTURE IN HEALTH CARE, I SHOULD BEGIN, HOWEVER, WITH THE ACKNOWLEDGEMENT THAT THE FUTURE OF HEALTH CARE IN ANY COUNTRY DEPENDS TO A VERY GREAT EXTENT ON ITS GENERAL ECONOMIC, SOCIAL, AND POLITICAL HEALTH. -2- THAT IS NOT ONLY TRUE FOR EACH NATION, BUT FOR ALL THE NATIONS IN THIS HEMISPHERE AS A SINGLE COMMUNITY OF NATIONS, WHEN JOHN ADAMS WAS PRESIDENT OF THE UNITED STATES, AT THE TURN OF THE 19TH CENTURY, HE WAS -- AND MANY OF HIS COLLEAGUES WERE AT THAT TIME -- VERY MUCH AWARE OF THE OTHER EMERGING SOCIETIES AND NATIONS IN THE WESTERN HEMISPHERE. HE OBSERVED, "THEY CAN NEITHER DO \JITHOUT US NOR US WITHOUT THEM," AN OBSERVATION THAT HAS REMAINED TRUE FOR 180 YEARS, AND IT WAS IN THAT SPIRIT THAT PRESIDENT.REAGAN PRESENTED HIS "CARIBBEAN BASIN INITIATIVE" TO THE ORGANIZATION OF AMERICAN STATES A YEAR AGO THIS MONTH, "WHAT HAPPENS ANY!dHERE IN THE AMERICAS AFFECTS US IN THIS COUNTRY," HE SAID, ADDING, "WE SHARE A COMMON DESTINY.. . IN THE COMMITMENT TO FREEDOM AND INDEPENDENCE, THE PEOPLE OF THIS HEMISPHERE ARE ONE, IN THIS PROFOUND SENSE, WE ARE ALL AMERICANS a" OF COURSE, PEOPLE TALK OF THE "GIANT TO THE NORTH," AND I PRESUME THEY STILL MEAN THE UNITED STATES AND NOT CANADA, BUT I LIKE TO RECALL THE SIMPLE LINE BY JOSE MARTI, THE GREAT PATRIOT OF THE AMERICA'S, WHO DRILY NOTED THAT "THIS IS THE AGE IN WHICH HILLS CAN LOOK DOWN UPON THE MOUNTAINS," HE WAS RIGHT THEN, AND HE IS RIGHT TODAY, TOO. -3- I AM PLEASED TO BE HERE, THEN, AS AN AMERICAN AMONG FELLOW AMERICANS WHO ARE ENGAGED IN THE PURSUIT OF GOOD HEALTH AND WELL- BEING FOR ALL PEOPLES. OF COURSE, I MUST SPEAK FROM THE UNITED STATES PERSPECTIVE, NEVERTHELESS, WHILE OUR EXPERIENCES MAY BE DIFFERENT FROM YOURS IN THEIR DETAILS, I BELIEVE THE OVERALL CHALLENGES ARE QUITE SIMI ILAR, FOR EXAMPLE, IN THE NEXT SEVERAL DECADES.., ALL OF US wILL BE SERVING THE HEALTH NEEDS OF A DEMOGRAPHICALLY DIFFERENT PoPuLATroN IN AGE, IN FAMILY STRUCTURE, AND IN WORK AND IN LIFE EXPERIENCES.,. WE 1IILL MOST CERTAINLY BE PRACTICING 1$lUCH MORE PREVENTIVE MEDICINE, WHILE OUR CURATIVE AND REPARATIVE MEDICINE WILL BE RADICALLY CHANGED BY NEW RESEARCH RESULTS, SUCH AS THE APPLICATION OF THE NEW HYBRIDOMA TECHNOLOGIES AND NON-INVASIVE DIAGNOSTIC TECHNOLOGIES.. . AND I THINK THE FUNDAMENTAL RELATIONSHIPS BETWEEN PATIENTS AND PHYSICIANS WILL BE MORE OPEN, MORE INFORMED, MORE SENSITIVE, AND, AS A RESULT, THEY OUGHT TO BE MORE ROUTINELY SUCCESSFUL, -4- I WILL GRANT YOU THAT THE NUMBERS ASSOCIATED WITH THESE CHANGES MAY BE DIFFERENT FROM COUNTRY TO COUNTRY -- THE ORDERS OF MAGNITUDE, FOR EXAMPLE -- BUT, IN MOST CASES, ALL OF US IN HEALTH AND MEDICAL CARE PERCEIVE THE HEALTH PROBLEMS OF THE WORLD THROUGH SIMILAR SETS OF LENSES. LET ME BEGIN, THEREFORE, WITH THAT FIRST POINT I MADE A MOMENT AGO, THE ONE CONCERNING THE DEMOGRAPHY OF CARE. I BELIEVE IT IS ESSENTIAL FOR EACH OF US, WHEREVER WE PRACTICE, TO UNDERSTAND HOW OUR POPULATIONS ARE CHANGING, THIS IS A MAJOR CHALLENGE TO ANYONE IN HEALTH CARE. THE OLD WAYS OF DOING THINGS -- NO MATTER HOW SUCCESSFUL THEY'VE BEEN -- WILL PROBABLY NOT BE ADEQUATE FOR THE FUTURE, YOU MAY HAVE COME UPON POPULAR MAGAZINE ARTICLES ABOUT THE "GRAYING OF AMERICA." AND THEY'RE ALL TRUE. THE POST-WORLD WAR II "BABY BOOM" GENERATION IS NOW OUR ADULT WORK-FORCE, IT IS THE BEST EDUCATED ADULT COHORT IN OUR HISTORY. IT RUNS OUR FACTORIES AND FARMS, DOMINATES OUR POLITICAL LIFE, AND IS AT THE CORE OF OUR NATIONAL VITALITY, DURING THIS DECADE AND THE 199Os, THIS AGE GROUP iJILL REPRESENT 40 PERCENT OF OUR TOTAL POPULATION, AS ITS MEMBERS MOVE UP AND DOMINATE THE U.S. POPULATION AGE PYRAMID, -5- THIS GENERATION IS LIVING BETTER AND WILL BE LIVING LONGER BECAUSE IT IS THE BENEFICIARY OF ABOUT 30 YEARS OF SUCCESSFUL RESEARCH ON THE DETECTION AND TREATMENT OF SOCIETY'S MAJOR KILLERS: FIRST ON ANYONE'S LIST IS HEART DISEASE,,.SINCE 1950 WE'VE BEEN ABLE TO REDUCE THE MORTALITY RATE FROM THIS DISEASE BY OVER 30 PERCENT. OF COURSE, THAT MEANS REDUCING THE NUMBER OF PREMATURE DEATHS AMONG THE "BABY BOOM" GENERATION, NEXT IS CANCER. ,a MANKIND'S MOST PERSISTENT SCOURGE, PRODUCING THE SECOND HIGHEST NUMBER OF PREMATURE DEATHS IN OUR SOCIETY, WE HAVEN'T SOLVED THE PUZZLE OF CANCER, BUT WE HAVE NEVERTHELESS BEEN ABLE TO DROP THE DEATH RATE FROM CANCER BY 33 PERCENT AMONG PERSONS UNDER THE AGE OF 45 -- THE "BABY BOOM" GENERATION AGAIN, AND THEN THERE IS STROKE,, . A COMPLEX DISEASE THAT IS SO CLOSELY COUPLED TO AN INDIVIDUAL'S PHYSICAL, MENTAL, AND EMOTIONAL HEALTH, IN THE PAST 30 YEARS, WE WERE ABLE TO REDUCE THE DEATH RATE FROM STROKE BY 49 PERCENT, THE FIRST GROUP OF AMERICANS TO BENEFIT FROM THIS EXTRAORDINARY ADVANCE IN MEDICINE HAS BEEN THAT SAME "BABY BOOM" GENERATION. -6- ONE RESULT OF ALL THIS PROGRESS APPEARS TO BE A FEW MORE YEARS OF LIFE FOR THE PEOPLE IN THIS GENERATION, THEREFORE, WE CAN EXPECT THAT SHORTLY AFTER THE TURN OF THE CENTURY -- AROUND THE YEAR 2010 -- APPROXIMATELY 1 IN EVERY 5 AMERICANS WILL BE A SENIOR CITIZEN. AT THAT TIME THERE WILL BE SOMETHING LIKE 50 MILLION PERSONS OVER THE AGE OF 65, COMPARED TO ABOUT 25 MILLION THAT AGE TODAY, I SHOULD ALSO POINT OUT THAT THE MEDIAN AGE IN THE UNITED STATES TODAY 1s 28 YEARS AND lo MONTHS, BUT IN THE YEAR 2010 WE EXPECT THE MEDIAN AGE TO BE 35 YEARS AND 7 MONTHS, MANY PERSONS AND ORGANIZATIONS THAT DELIVER HEALTH AND MEDICAL CARE HAVE SEEN THIS KIND OF NUMBER-WRITING ON THE WALL, THEY ARE BEGINNING TO ADJUST THEIR MIX OF SERVICES TO ACCOMMODATE THE GROWTH IN OUR AGED POPULATION. THEY ARE ALSO RE-EVALUATING THEIR PLANS FOR INSTITUTIONALIZING THE INFIRM ELDERLY, INSTEAD, THEY ARE EflPHASIZING HOME HEALTH CARE SERVICES FOR INDIVIDUALS AND FAMILIES, IN FACT, I 14OULD GO SO FAR AS TO SAY THAT MANY OF THE MAJOR DEVELOPMENTS IN MEDICAL AND HEALTH CARE TECHNOLOGY IN THE NEXT SEVERAL DECADES WILL BE IN THIS VERY AREA OF HOME CARE OR FAMILY-CENTERED CARE, -7- I WISH I COULD STOP THERE, BUT I CAN'T, THE FACT OF THE MATTER IS THAT THE "GRAYING OF AMERICA," AS SIGNIFICANT AS IT MAY BE, IS ONLY HALF THE STORY. THIS AGING "BABY BOOM" GENERATION IS HAVING BABIES OF ITS OWN, IN FACT, THE UNITED STATES IS EXPERIENCING !JHAT IS CALLED AN "ECHO EFFECT," LET ME EXPLAIN HOW THAT IS WORKING. THE FERTILITY RATE IN 1980 AMONG "BABY BOOM" WOMEN -- THAT IS, CHILD-BEARING WOMEN IN THEIR TbiENTIES AND THIRTIES -- \JAS 68.4, OUR MOST CURRENT STATISTIC. THE RATE FOR THEIR MOTHERS, THE CHILD-BEARING WOMEN IN THE 1950s AND EARLY 60s HIT A RECORD HIGH OF 122.7 IN 1957, NEARLY TWICE THE CUR- RENT FERTILITY RATE. BUT WHILE THAT EARLIER GE~~ERATION HAD, IN 1957, ABOUT 4,3 MILLION LIVE BIRTHS, THE WOMEN IN 1980 HAD 3.6 MILLION LIVE BIRTHS -- OR ONLY 16 PERCENT FEWER BIRTHS THAN THEIR MOTHERS' GENERATION. LETME PUT IT ANOTHER WAY: IF THE UNITED STATES FERTILITY RATE WERE THE SAME TODAY AS IT WAS 25 YEARS AGO, THEN, INSTEAD OF AN ESTIMATED THREE AND A HALF MILLION BABIES TO BE BORN THIS YEAR, 1JE WOULD HAVE SOMETHING LIKE 7 MILLION BABIES, NEARLY TWICE THE NUMBER BORN IN OUR ALL-TIME "BABY BOOM" YEAR, -8- BUT THERE IS YET ANOTHER FACTOR: MORE OF TODAY'S BABIES ARE SURVIVING. IN 1957 THE UNITED STATES HAD AN INFANT MORTALITY RATE OF 26, OUR LATEST ESTIMATE IS AN INFANT MORTALITY RATE OF 11,3 INFANT DEATHS FOR EVERY 1,000 LIVE BIRTHS, so IN JUST ONE GENERA- TION, WE REDUCED THE INFANT MORTALITY RATE BY MORE THAN HALF, DURING THIS SAME PERIOD, BY THE WAY, WE ALSO REDUCED THE DEATH RATE FOR CHILDREN AGES 1 THROUGH 14 BY NEARLY HALF, THAT'S WHY I BELIEVE WE CAN DRAW ONLY ONE CONCLUSION FROM ALL THIS: WE MAY BE IN THE MIDST OF YET ANOTHER -- AND ONLY sL IGHTLY LESS DRAMATIC -- "BABY BOOM, u WHAT DOES ALL THIS MEAN FOR PERSONS SUCH AS OURSELVES, PEOPLE WHO ORGANIZE AND DELIVER HEALTH AND MEDICAL CARE TO INDIVIDUALS AND FAMILIES. IT'S MY BEST GUESS THAT, OVER THE NEXT 25 YEARS OR SO, 1JE ARE GOING TO HAVE THE UNUSUAL TASK OF PROVIDING QUALITY GERIATRIC AND QUALITY PEDIATRIC HEALTH CARE AT THE SAME TIME. WILL WE IN THE UNITED STATES BE ABLE TO DO IT? I THINK WE WILL, BUT I AM NOT AT ALL SURE j-lOJ WE WILL DO IT, WE HAVE NO EXPERIENCE FOR SUCH AN HISTORIC SET OF CIRCUMSTANCES, AND NO OTHER COUNTRY HAS HAD THAT KIND OF EXPERIENCE EITHER, -9- IF WE HAVE ANY MAJOR HURDLES TO OVERCOME, THEY WOULD BE THE HURDLES OF TOO LITTLE TIME AND NOT ENOUGH 'MONEY, AND I GUESS EVERY- ONE IN THIS ROOM HAS HEARD THAT BEFORE, I DON'T PRETEND THAT I'VE DISCOVERED ANYTHING UNIQUE, NEVERTHELESS, I THINK THESE PRESSURES ARE ESPECIALLY SEVERE IN THE CURRENT PERIOD, IN THE PAST WE'VE H.AD AT LEAST A FEW YEARS TO MAKE SOME ADJUST- MENTS, BUT WE REALLY DON'T HAVE THE LUXURY OF TIME ANYMORE, I SUSPECT WE HAVE A DECADE OR TWO -- AT BEST -- TO PREPARE OUR PHYSICIANS AND NURSES, OUR DENTISTS AND THERAPISTS, OUR TECHNICIANS, ADMINISTRATORS, TRUSTEES, AND SOCIAL SERVICE WORKERS TO DEAL WITH A NATION WITH MANY MILLIONS 0F THE AGED AND MANY MILLIONS OF CHILDREN -- AND A LOT OF OTHER PEOPLE OF ALL AGES SCATTERED IN BETWEEN, AS FOR MONEY -- PARTICULAR NEW MONEY TO BUY MORE SERVICES FOR OUR.EXPANDING POPULATION -- THAT ALSO IS IN SHORT SUPPLY RIGHT NOW. THE UNITED STATES, LIKE MANY OF ITS NEIGHBORS IN THIS HEMISPHERE AND 1~s FRIENDS IN EUROPE, Is FOCUSING ITS ATTENTION 0N WAYS To SHIFT PRIORITIES, TO BREAK OLD AND COSTLY HABITS, AND TO DO WHATEVER ELSE -lO- MAY BE NECESSARY TO MAINTAIN OUR RECORD IN FIGHTING DISEASE AND DISABILITY AND STILL, WHEREVER WE CAN, RAISE THE LEVEL OF HEALTH AND MEDICAL CARE IN THE UNITED STATES, THESE OBJECTIVES REQUIRE THAT WE TAKE A CLOSER AND MORE CRITICAL LOOK AT THE llAY WE PROVIDE HEALTH AND MEDICAL SERVICE IN THE UNITED STATES, THE TRADITIONAL WAY HAS BEEN TO CURE OR REPAIR OUR PATIENTS AFTER THEY HAVE COME DOWN WITH SOMETHING, THAT IS A VERY COSTLY APPROACH FOR THE PATIENT AND FOR SOCIETY AS A WHOLE. UNDER THE CIR- CUMSTANCES, IT IS LESS THAN AN ADEQUATE APPROACH FOR MEETING THE HEALTH NEEDS OF TOMORROW. WHAT WE ARE DOING, THEREFORE, IS SIGNIFICANTLY RAISING THE LEVEL OF INTEREST AND EFFORT IN THE PROMOTION OF GOOD HEALTH AND THE PRE- VENTION OF DISEASE AND DISABILITY, SUCH AN APPROACH EMPHASIZES SELF- CARE AS A \JAY TO AVERT "THE FOUR D's": DISCOMFORT, DISEASE, DIS- ABILITY, AND DEATH, IT IS MUCH CHEAPER FOR THE INDIVIDUAL AND FOR SOCIETY. PREVENTION ALSO TENDS TO PRODUCE POSITIVE, LONG-TERM, GENERATIONAL EFFECTS, I DO \JANT TO EMPHASIZE, HOWEVER, THAT WE HAVE NO INTENTION OF ABANDONING OR COMPROMISING TRADITIONAL CURATIVE AND REPARATIVE MEDICINE, FAR FROM- IT, RATHER, OUR GOAL IS TO ESTABLISH A NEW AND MORE EFFECTIVE BALANCE BET\IEEN PREVENTIVE AND CURATIVE MEDICINE, -ll- WHILE THIS ADMINISTRATION HAS MADE PREVENTION AND HEALTH PROMO- TION THE KEYSTONE OF NATIONAL HEALTH POLICY, I MUST BE CANDID AND TELL YOU THAT THERE IS NOTHING REALLY NEW ABOUT IT, YOU CAN GO BACK TO THE DEDUCTIVE GENIUS OF DR, JOHN SNOW DURING THE GREAT LONDON CHOLERA EPIDEMIC OF 1854. YOU WILL RECALL THAT DR. SNOW TOOK THE HANDLE OFF THE COMMUNITY WATER PUMP AT BROAD STREET AND -- WITH THAT SIMPLE PREVENTIVE MEASURE -- HE INTERRUPTED THE TRANSMISSION OF CHOLERA AMONG THE LONDON POOR. SINCE THEN, GIE'VE ADVANCED THE NOTION OF PREVENTION QUITE A BIT, STILL, WE OUGHT NOT TO GET CARRIED AWAY BY IT, IT IS GOOD TO REMEMBER THE HOMELY EXAMPLE OF DR, SNOW OR, NOW AND THEN, TO RECITE THE BLUNT OPINION OF THE PHILOSOPHER, JEAN-JACQUES ROUSSEAU, WHO SAID THAT "HYGIENE WAS LESS A SCIENCE THAN A VIRTUE,' AND I SUPPOSE HE'S RIGHT. BUT 1JHETHER YOU SUBSCRIBE TO "SCIENCE' OR TO 'VIRTUE,' I BELIEVE YOU'LL BE INTERESTED IN TWO BASIC DOCUMENTS PRODUCED BY THE U,S, ?UBLIC HEALTH SERVICE. THE FIRST IS TITLED HEALTHY PEOPLE, THE SURGEON GENERAL'S REPORT ON HEALTH PROMOTION AND DISEASE PREVENTION. THE SECOND IS CALLED OBJECTIVES FOR THE NATION, AND IT SPELLS OUT IN -12- SOME DETAIL HOW WE HOPE TO ACHIEVE BETTER HEALTH STATUS AND A REDUCED LEVEL OF DISEASE AND DISABILITY AMONG THE PEOPLE OF THE UNITED STATES, THESE TWO SLIM VOLUMES WERE PREPARED WITH THE HELP OF ABOUT 2,000 NON-GOVERNMENTAL EXPERTS ACROSS A BROAD SPECTRUM OF DISCI- PLINES. I STRONGLY COMMEND THEM TO YOU. IN THE OBJECTIVES, FOR EXAMPLE, WE REVIEW 15 DIFFERENT PRIORITY AREAS SUCH AS ACCIDENT PREVENTION, NUTRITION, TOXIC AGENT AND RADIATION CONTROL, DRUG ABUSE, AND SO ON. THIS INFORMATION IS THEN TRANSLATED INTO GOALS WE BELIEVE WE CAN ACHIEVE BY THE YEAR 1990. PERSONALLY, I THINK IT IS ONE OF THE MOST AMBITIOUS PUBLIC HEALTH PROGRAMS IN RECENT MEMORY. WE HAVE ALREADY STARTED ALONG THE ROAD LEADING TO THOSE OBJECT- IVES, IN PARTNERSHIP WITH STATE AND LOCAL HEALTH AGENCIES, PRIVATE PROFESSIONAL AND VOLUNTARY ASSOCIATIONS, AND WITH THE ACTIVE SUPPORT OF BUSINESS AND INDUSTRY. IN ADDITION, WITHIN OUR OWN DEPARTMENT OF HEALTH Af'JD HUMAN SERVICES, b/E HAVE A WIDE-RANGING "HEALTH PROMOTION STRATEGY" \lITH SPECIFIC TASKS FOR THE SOCIAL SECURITY ADMINISTRATION, MEDICARE AND MEDICAID, AND, OF COURSE, THE PUBLIC HEALTH SERVICE, -13- THE KINDS OF OBJECTIVES WE HAVE IN MIND ARE FAIRLY SPECIFIC AND MEASURABLE, FOR EXAMPLE, CJE LOOK FORWARD TO ACHIEVING.,, 9 FULL IMMUNIZATION FOR AT LEAST 95 PERCENT OF ALL SCHOOL-AGE CHILDREN BY THE YEAR 1990,., it A DECLINE IN THE INFANT MORTALITY RATE FROM THE PRESENT 11,3 DEATHS PER 1,000 LIVE BIRTHS DOWN TO 9 DEATHS PER l,!)OO,.. 0 WE'D LIKE TO ACHIEVE LONG-TERM BLOOD PRESSURE CONTROL FOR AT LEAST GO PERCENT OF THE POPULATION WITH DEFINITE HYPERTENSION, THAT IS, \dITH A READING OF 160 OVER 95 OR HIGHER,.. 9 1JE HOPE TO SEE A DROP IN THE NUMBER OF ADULTS SMOKING CIGARETTES FROM THE CURRENT 1 IN 3 DOWN TO 1 IN 4,. . -14- AND A REDUCTION IN THE MOTOR VEHICLE FATALITY RATE FROM ITS PRESENT LEVEL OF ABOUT 24 PER 100,000 POPULATION TO A LEVEL OF 18 -- OR EVEN LOWER. * THESE ARE NOT ALL OF THEM, THERE ARE MULTIPLE OBJECTIVES AMONG THOSE 15 DIFFERENT HEALTH AREAS, BUT I HOPE YOU ARE STIMULATED BY MY FEW REMARKS TO READ BOTH REPORTS, SINCE THEY DO PROVIDE THE AMERICAN PEOPLE AND THE PROFESSIONAL HEALTH COMMUNITY WITH A KIND OF ROADMAP OF WHERE WE'RE HEADED AND HOW WE HOPE TO GET THERE. THE BASIC ROUTE WE NEED TO FOLLOW TAKES US DEEP INTO THE BEHAVIORS OF BOTH PATIENTS AND PHYSICIANS, AS AN EXAMPLE OF WHAT LIES AHEAD OF US, I WILL RETURN FOR A MOMENT TO THAT DEMOGRAPHIC PHENOMENON I MENTIONED EARLIERmTHE ONE CALLED "THE GRAYING OF AMERICA." LET ME OFFER THREE VIGNETTES OF PATIENT BEHAVIOR AND PHYSICIAN RESPONSE. THE FIRST CONCERNS SMOKING, IT SHOULD COME AS NO SURPRISE THAT I WOULD RAISE THIS ISSUE SOMEWHERE IN MY REMARKS THIS MORI'UNG. AFTER ALL, IF I WERE NOT HERE I WOULD BE BACK IN WASHINGTON STAMPING MY LITTLE MESSAGE ON EVERY PACK OF CIGARETTES. -15- THE CAUSAL RELATIONSHIP BETWEEN SMOKING AND CANCER AND CARDIOVASCU- LAR AND RESPIRATORY DISEASES HAS BEEN WELL DOCUMENTED, WE ALSO KNOW THAT, ONCE A PERSON STOPS SMOKING, HE OR SHE CAN SLOWLY REGAIN CARDIO- RESPIRATORY HEALTH. IT MAY TAKE 5, 10, OR 20 YEARS, DEPENDING ON THE INDIVIDUAL AND THE DEGREE OF DAMAGE DONE, BUT WE KNOW THAT THE BODY WILL RESPOND AND TRY TO REPAIR ITSELF. BUT WHAT ABOUT THE PERSON WHO IS, SAY, 60 YEARS OLD AND HAS SMOKED FOR THE PAST 40 YEARS? SHOULD A PHYSICIAN ADVISE THAT PERSON TO STOP SMOKING, TOO? I WOULD CERTAINLY HOPE SO, BUT I HAVE TO TELL YOU THAT WE HAVE VERY LITTLE EVIDENCE SHOWING PHYSICIANS AND OTHER HEALTH WORKERS GIVING SUCH ADVICE TO THEIR OLDER PATIENTS. THEY DON'T SEEM AWARE THAT, BY THE END OF THIS CENTURY, ABOUT 10 PERCENT OF OUR POPULA- TION WILL BE 75 YEARS OLD OR OLDER,, . AND THEY ARE THE VERY PEOPLE WHO ARE TODAY'S 60-YEAR-OLD% IN OTHER WORDS, THE SIMPLE PREVENTIVE COUNSEL -- "STOP SMOKING" -- OUGHT TO BE GIVEN TO PERSONS OF ALL AGES, WE MUST ELIMINATE ANY FEELINGS THAT, FOR SOME OLDER PEOPLE, A CHANGE OF HABIT MAY BE "TOO LATE.M FOR THOSE ELDERLY PATIENTS -- AND FOR THEIR FRIENDS AND FAMILY, TOO -- THE ADVICE MUST BE OFFERED VIGOROUSLY AND REPEATEDLY: DON'T SMOKE. -16- MY SECOND EXAMPLE INVOLVES PHYSICAL FITNESS AND EXERCISE, I CON- FESS THAT I AM JUST DELIGHTED TO SEE SO MANY YOUNG NURSES AND PHYSI- CIANS JOGGING AND HIKING AND PLAYING HANDBALL OR SQUASH. GOOD FOR THEM. BUT I WONDER IF THEY ADVISE THEIR OLDER PATIENTS TO KEEP PHYSICALLY FIT, ALSO, THEY MIGHT NOT ADVISE HANDBALL AND SQUASH OR EVEN JOGGING, BUT WE'RE REALLY AT NO LOSS FOR GOOD ALTERNATIVES. THE POINT TO REMEMBER IS THAT ELDERLY PEOPLE NEED TO MAINTAIN THEIR MUSCLE STRENGTH, ~00, IN ORDER To LIVE FULL AND ACTIVE LIVES, THERE IS A REAL DANGER THAT, THROUGH INACTIVITY, THEY MAY BEGIN TO GAIN WEIGHT, WHICH ADDS STRESS TO THE HEART THEY MAY ALSO LOSE THE ESSENTIAL "TONE" OF THEIR MUSCLES. THAT POSSIBILITY REFLECTS THE OLD SAYING, ,,AND YOU'VE ALL PROBABLY HEARD IT.,,"YOU DON'T STOOP BECAUSE YOU'RE OLD, YOU'RE OLD BECAUSE YOU STOOP," IT'S TRUE THAT OLDER PEOPLE WHO KEEP GOOD POSTURE QJ LOOK AMD ACT YOUNGER THAN THEIR CHRONOLOGICAL AGE. THE PRESIDENT'S COUNCIL ON PHYSICAL FITNESS AND SPORTS, WHICH IS PART OF THE U.S, PUBLIC HEALTH SERVICE, HAS DEVELOPED SEVERAL EXCELLENT GUIDES ON EXERCISE FOR PERSONS AGE 65 AND OLDER. THE COUNCIL HAD BEEN ORIGINALLY CALLED THE "PRESIDENT'S COUNCIL ON YOUTH FITNESS," BUT SUCH A TITLE WAS TOO LIMITING. WORKING ADULTS AND SENIOR CITIZENS NEEDED HELP IN THIS AREA, Too, AND so THE WORD "YOUTH" WAS TAKEN OUT, -17- MY THIRD AND LAST EXAMPLE IS NUTRITION. WE KNOW THAT OLDER PEOPLE DO NOT METABOLIZE FATS AND CARBODHYDRATES AS EFFICIENTLY AS YOUNGER PEOPLE DO, THEY NEED TO REDUCE THEIR INTAKE OF FATS, IN ORDER TO MAIN- TAIN HEALTHY BODY WEIGHT AND AVOID OBESITY, THIS GOES RIGHT ALONG WITH THE COMMENTS I JUST MADE ABOUT EXERCISE, GOOD NUTRITION IS ALSO A PREVENTIVE MEASURE AGAINST HEART DISEASE AND STROKE.. . IT CAN FURTHER ASSURE BASIC DENTAL HEALTH,, #AND IT MAY EVEN HELP PREVENT THE OCCURRENCE OF SOME CANCERS, SUCH AS COLONIC CANCER, I MIGHT POINT OUT THAT THE "BABY BOOM" GENERATION -- AS IT BEGINS TO REALLY SHOCJ ITS AGE AT THE TURN OF THE CENTURY -- WILL BE MORE KNOWLEDGEABLE ABOUT HEALTH THAN YESTERDAY'S OR EVEN TODAY'S SENIOR CITIZENS, AS I SAID EARLIER, THE MEMBERS OF THE "BABY BOOM" GENERA- TION ARE NOW IN THEIR PRIME, LIVING THEIR MOST PRODUCTIVE, ACTIVE, AND INQUISITIVE YEARS. AND BECAUSE THEY ARE A BETTER EDUCATED GENERATION, I THINK WE WILL SEE MANY CHANGES IN THEIR HEALTH BEHAVIOR -- THE SO-CALLED "LIFESTYLE" CHANGES THAT CAN BE AN IMPORTANT DEFENSE AGAINST DISEASE, DISABILITY, AND PREMATURE DEATH. -18- OF COURSE, WE MUST DO BETTER THAN OPERATE 0~ GOOD INSTINCTS IN THIS MATTER OF HEALTH PROMOTION AND DISEASE PREVENTION. IF WE WANT TO KEEP PEOPLE OUT OF INSTITUTIONS AND HELP THEM ADOPT HEALTHFUL LIFE- STYLES, WE'REGOING TO NEED A MUCH BETTER KNOWLEDGE BASE, A GREAT DEAL OF PRFEVENTION INFORMATION STILL NEEDS TO BE GENERATED AND APPLIED TO PATIENT CARE IN THE YEARS AHEAD, WE HOPE TO UNDERSTAND A LITTLE BETTER WHICH KINDS OF PHYSICIAN INTERVENTIONS WORK WITH PATIENTS COMING IN FOR ROUTINE CARE, AND WE NEED TO KNOW WHY SOME PEOPLE CAN BE MORE EASILY INFLUENCED THAN OTHERS TO CHANGE THEIR HEALTH BEHAVIORS FOR THEIR OWN GOOD, IN A WORD, WE HAVE QUITE A FAR-REACHING AGENDA OF BIOMEDICAL AND BEHAVIORAL RESEARCH TO ACCOMPLISH. THE NATIONAL INSTITUTES OF HEALTH, FOR EXAMPLE, ARE SUPPORTING A NUMBER OF PROJECTS THAT COULD LEAD TO NEW VACCINES, NEW PROTECTIVE AND PREVENTIVE PHARMACEUTICALS, AND NEW DIAGNOSTIC AGENTS AND PROCEDURES. THERE ARE MANY OTHER RESEARCH EFFORTS ACROSS THE WHOLE SPECTRUM OF PREVENTION,,, IN GENETICS AND NEUROBIOLOGY, .,IN THE USES OF THE NEW HYBRIDOMA TECHNOLOGY... IN CONTAINING THE SEXUALLY TRANSMITTED DISEASES -19 ,, JN THE CONTROL OF TOXIC AGENTS IN THE ENVIRONMENT,,,IN THE FIELD OF IMMUNOLOGY AND THE DEVELOPMENT OF NEW VACCINES,.,IN THE ROLE PLAYED BY NUTRITION AND DIET.,, IN STRESS CONTROL, DENTAL CARIES, AND IN THE ETIOLOGY OF THE MAJOR METABOLIC DISEASES, I'D SAY WE ARE NOT LACKING FOR RESEARCH CHALLENGES IN THIS PART OF MEDICINE, THIS, THEN, IS A KIND OF SYNOPSIS OF THE CURRENT PUBLIC HEALTH PERSPECTIVES IN THE UNITED STATES. I SAID AT THE BEGINNIMG OF MY REMARKS THAT MANY OF YOU UNDOUBTEDLY SHARE THE SAME OR A VERY SIMILAR VISION OF THE FUTURE OF HEALTH AND MEDICAL CARE FOR YOUR OWN COMMUNITIES, I THINK IT CAN BE SAID GENERALLY FOR YOUR SOCIETIES AS WELL AS FOR OURS THAT.,, FEWER BABIES ARE DYING... THAT EVEN WITH LOWER BIRTH RATES, THERE ARE MORE PEOPLE AROUND... AND THEY ARE LIVING A LITTLE LONGER, WITH A BETTER CHANCE FOR MISS1 FIG -- OR RECOVERING FROM -- THE MAJOR DISEASES OF MANKIND,, . AND THAT BY AND LARGE THE QUALITY 0F LIFE Irs ONE's TWILIGHT YEARS IS GRADUALLY IMPROVING, -2o- THAT'S GOT TO ADD UP TO PROGRESS, EVEN GIVEN THE MANY KINDS OF RESTRAINTS -- FISCAL, SOCIAL -- UNDER WHICH WE MUST FUNCTION. IN ANY CASE, I TEND TO BE AN OPTIMIST MAINLY BECAUSE THE UNITED STATES REMAINS A NATION WITH AN UNENDING SENSE OF ADVENTURE AND A VIGOROUS TRADITION OF FREE INQUIRY, AS A PEOPLE, I BELIEVE WE SHARE THE VIEW HELD BY ALBERT EINSTEIN, WHO WROTE THAT "THE ETERNAL MYSTERY OF THE WORLD IS THAT IT IS COPlPREHENSIBLE. u LIKE HIM, WE ARE INTRIGUED BY THE FUTURE, WE ARE IMPATIENT FOR IT TO ARRIVE, AND WE ARE ABSOLUTELY POSITIVE WE WILL UNDERSTAND IT. WE MAY NOT ALL HANDLE THE FUTURE AS WELL AS DR, EINSTEIN, BUT WE NEVERTHELESS SHARE HIS OPTIMISM AND ENTHUSIASM, AND, IF I HAVE RELAYED THOSE FEELINGS TO YOU AS WELL, I WILL COUNT MY APPEARANCE HERE IN TORTOLA AS HAVING BEEN A GREAT SUCCESS, THANK YOU, ?###I##