A MOMENT OF OPPORTUNITY

BY

        C, EVERETT KOOP, MD

  DEPUTY ASSISTANT SECRETARY FOR HEALTH

        AND SURGEON GENERAL

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

KEYNOTE ADDRESS TO THE FIRST MEETING OF THE

   SOCIETY OF HANDICAPPED PHYSICIANS

        WASHINGTON, D,C,

         AUGUST 20, 1982


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(GREETINGS TO HOSTS, GUESTS, ETC.1

  IT IS ALWAYS AN HONOR TO BE INVITED TO DELIVER THE KEYNOTE ADDRESS

FOR ONE MEETING OR ANOTHER, BUT THIS AFTERNOON, I FEEL ESPECIALLY

PRIVILEGED TO SPEAK WITH A GROUP OF PHYSICIANS WHO NOT ONLY HAVE PARTI-

CULAR PERSONAL AND PROFESSIONAL NEEDS BUT ALSO HAVE SPECIFIC SKILLS AND

PERCEPTIONS TO OFFER THE AMERICAN PEOPLE,

  AS MANY OF YOU KNOW THROUGH FIRST-HAND EXPERIENCE, DR, SPENCER B.

LEWIS WAS THAT KIND OF PHYSICIAN -- TRUE TO HIS PROFESSION, TO HIMSELF,

TO HIS FAMILY, AND TO THE PEOPLE HE SERVED,   HIS SUDDEN DEATH LAST

APRIL WAS A SEVERE BLOW TO US ALL,  HIS WIDOW, MRS, MARY LEWIS, CALLED

HER LATE HUSBAND "A MAN OF COURAGE AND GREAT DETERMINATION AND COMPAS-

SION, 'I  THOSE QUALITIES ARE ALWAYS IN SHORT SUPPLY, AND SO WE MOURN

THE LOSS OF ANY PERSON WHO HAS DEMONSTRATED THEM IN THE WAY DR. LEWIS

DID WHEN HE WAS ALIVE AND PRACTICING MEDICINE, THIS YEAR WILL BE

REMEMBERED AS THE LAST ONE IN WHICH OUR SOCIETY WAS ENRICHED BY THE

PRESENCE OF DR, SPENCER B, LEWIS.


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  COINCIDENTALLY, 1982 HAS BEEN PROCLAIMED BY PRESIDENT REAGAN AS

THE "NATIONAL YEAR OF DISABLED PERSONS." IT IS OUR FOLLOW-UP OF THE

"INTERNATIONAL YEAR OF DISABLED PERSONS," SPONSORED THROUGHOUT 1981 BY

THE 158-MEMBER WORLD HEALTH ORGANIZATION, DURING THE CURRENT TWELVE

MONTHS, OUR COUNTRY WILL EXAMINE ITS RECORD OF CARE SO FAR AND TRY TO

MAKE THE NECESSARY ADJUSTMENTS AND IMPROVEMENTS, FOR THIS, AS WELL AS

FOR OTHER MORE PRESSING REASONS, I BELIEVE YOUR MEETING HERE TODAY AND

TOMORROW IS PARTICULARLY APPROPRIATE AND TIMELY.

  LET ME BEGIN MY REMARKS THIS AFTERNOON WITH A DISCLAIMER: I DO NOT

SPEAK AS A PHYSICIAN WHO HAS HIMSELF EXPERIENCED ANY PHYSICAL DIS-

ABILITY, RATHER, I AM HERE AS A SURGEON WHO HAS SPENT NEARLY ALL HIS

PROFESSIONAL LIFE DEALING WITH THE INTRICATE DISABILITIES OF THE NEW-

BORN AND THE PROFOUND EFFECTS FELT BY THEIR PARENTS AND FAMILIES, BUT

I'VE ALSO WATCHED MANY OF MY FORMER PATIENTS GROW FROM INFANCY INTO

ADULTHOOD, SOME ARE NOW IN THEIR LATE 30s AND EARLY 40s. IT HAS GIVEN

ME THE UNIQUE CHANCE TO OBSERVE THE LONGITUDINAL DEVELOPMENT OF PERSONS

WITH MILD TO SEVERE DISABILITIES,

  IN MY PRESENT POSITION AS SURGEON GENERAL, HOWEVER, I HAVE THE

CHANCE TO DIRECT ATTENTION TO DISABLED PERSONS EVERYWHERE, REGARDLESS

OF THEIR AGE OR OCCUPATION OR STATUS,  IT IS MY FERVENT HOPE THAT,


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THROUGH ME, THE FEDERAL GOVERNMENT AND THE MEDICAL PROFESSION ITSELF
MAY BECOME MORE SENSITIZED TO THE ISSUES RAISED BY ADVOCATES FOR THE
DISABLED AND THAT WE WILL NOT ONLY TALK ABOUT THEM., .BUT DJ SOMETHING
fOJ THEM,

  THIS IS AN ISSUE GROWING IN IMPORTANCE EVERY DAY, AND IT IS
PECULIARLY MEDICINE'S ISSUE, SINCE MANY OF OUR PROBLEMS -- AS WELL AS

OUR OPPORTUNITIES -- SPRING FROM THE VICTORIES OF CONTEMPORARY MEDI-

CINE AND THE BIOMEDICAL SCIENCES.  LET ME ILLUSTRATE THIS WITH A BRIEF

LOOK AT SOME RECENT HISTORY.

  DURING THE DECADE FROM 1969 THROUGH 1980, THE UNITED STATES
EXPERIENCED A DECLINE IN THE MORTALITY RATES ASSOCIATED WITH CERTAIN
LEADING DISABLING DISEASES AND TRAUMA. FOR EXAMPLE, THE DEATH RATE
FOR HEART DISEASE DROPPED NEARLY 20 PERCENTmFOR STROKE, ABOUT 30

PERCENT,, . AND FOR ACCIDENTS, THERE WAS A DROP OF 18 PERCENT,  I THINK

THESE STATISTICS INDICATE THE KIND OF PROGRESS WE HAVE BEEN MAKING IN
THE DEVELOPMENT OF EMERGENCY MEDICAL SERVICES AND SYSTEMS, IN THE WIDE-
SPREAD USE OF INTENSIVE CARE TECHNOLOGIES, AND IN THE APPEARANCE OF
NEW LIFE-SAVING DRUG THERAPIES AND SURGICAL PROCEDURES DURING THIS

PERIOD OF TIME,


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  MANY OF THE NEW SURVIVORS OF THE PAST DECADE NOW SHOW UP IN

ANOTHER CATEGORY: THEY ARE PERSONS WHO ARE LIMITED -- BY ONE OR

ANOTHER CHRONIC CONDITION -- FROM CARRYING OUT ACTIVITIES NORMAL FOR

PEOPLE THEIR AGE OR SEX, THEY INCLUDE THE,,,

16.5 MILLION MEN AND WOMEN WHO SUFFER FROM A CHRONIC HEART

CONDITION,

THE 9.9 MILLION SUFFERING FROM HYPERTENSION,

THE 4.5 MILLION WHO ARE VISUALLY IMPAIRED -- PARTIALLY OR TOTALLY

BLIND,

THE 2.4 MILLION WHO HAVE A HEARING IMPAIRMENT -- PARTIALLY OR

TOTALLY DEAF,

AND THE 5.4 MILLION WITH IMPAIRMENTS OF THE BACK, SPINE, HIPS,

ARMS, AND LEGS,


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  IN 1969 APPROXIMATELY 23 MILLION AMERICANS WERE LIMITED BY ONE OR
MORE CHRONIC CONDITIONS,  HOWEVER, BY 1980 MORE THAN 31 MILLION

AMERICANS WERE IN THIS CATEGORY.  THE PERCENTAGE OF THE POPULATION
THEY REPRESENTED ALSO CREPT UP FROM 1116 PERCENT IN 1969 TO 14.4

PERCENT IN 1980,

  IN OTHER WORDS, ABOUT 1 IN EVERY 7 AMERICANS IS DISABLED AS A
RESULT OF A CHRONIC CONDITION -- OR OF SEVERAL CONDITIONS AT ONCE --
AND MUST LIMIT HIS OR HER WAY OF LIFE,,,LIVING A LIFE THAT IS
DIFFERENT FROM THAT OF PERSONS THE SAME AGE AND SEX,

  BUT EVEN HERE WE ENCOUNTER SOME TROUBLE, WE STILL HAVE NOT AGREED
ON WHAT A "DISABILITY" OR A "HANDICAP" REALLY IS IN PRECISE LEGAL OR

MEDICAL TERMS.  THIS POINT WAS RECENTLY MADE IN A REPORT TITLED HEALTH
CARE IN A CONTEXT OF CIVIL RIGHTS, PRODUCED BY THE INSTITUTE OF MEDI-
CINE OF THE NATIONAL ACADEMY OF SCIENCES, THE REPORT OBSERVES THAT
THE GOVERNMENT HAS USED 16 DIFFERENT MEANINGS FOR "HANDICAPPED" OR
"DISABLED" IN THE COURSE OF CARRYING OUT 66 DIFFERENT FEDERAL PROGRAMS,


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  THE REPORT BY THE INSTITUTE OF MEDICINE ALSO MAKES THE FOLLOWING

IMPORTANT OBSERVATION:

"THE NEEDS OF HANDICAPPED PERSONS FREQUENTLY ARE FOR SERVICES NOT
PROPERLY CALLED 'MEDICAL,' BUT RATHER ARE SOCIAL, PSYCHOLOGICAL,

AND/OR REHABILITATIVE,  THUS, THE QUESTION OF ADEQUACY OF SERVICES
FOR HANDICAPPED PERSONS IS NOT ONLY A QUESTION OF WHETHER THEY RE-
CEIVE THE NEEDED AMOUNT OF MEDICAL SERVICES BUT ALSO WHETHER THEY
RECEIVE THE APPROPRIATE TYPE OF SERVICES."

  THE REPORT WAS PREPARED BY A SPECIAL COMMITTEE TO STUDY THE
PATTERNS OF HEALTH CARE SERVING RACIAL AND ETHNIC MINORITIES AND HANDI-

CAPPED PERSONS,  CHAIRING THIS INSTITUTE OF MEDICINE COMMITTEE WAS A
FORMER COLLEAGUE OF MINE, DR. ROSEMARY STEVENS, PROFESSOR OF HISTORY
AND THE SOCIOLOGY OF SCIENCE AT THE UNIVERSITY OF PENNSYLVANIA. SHE
AND THE MEMBERS OF THAT PRESTIGIOUS COMMITTEE REPRESENT MANY THOUSANDS
OF PROFESSIONALS WHO REMAIN CONCERNED ABOUT EQUITY AND FAIRNESS IN

AMERICAN HEALTH CARE,


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  AS A NATION, WE NEED THIS KIND OF IN-DEPTH UNDERSTANDING, THE
UNITED STATES, AFTER ALL, IS ONLY JUST BEGINNING TO GRAPPLE WITH THE
MORAL, ETHICAL, AND FISCAL ISSUES SURROUNDING THE LIVES OF ITS DIS-
ABLED CITIZENS,  I WOULD HOPE THAT YOU, AS MEMBERS OF THIS NEW SOCIETY
OF HANDICAPPED PHYSICIANS, WOULD ALSO BEGIN TO LOOK AT THESE ISSUES,
THE PRACTICE OF MEDICINE IN TODAY'S WORLD CAN BENEFIT FROM EYESIGHT,,,
BUT IT WILL BENEFIT EVEN MORE FROM YOUR INSIGHT,

  THERE ARE ANY NUMBER OF QUESTIONS THAT CRY OUT FOR ANSWERS, BUT,
AT THIS TIME, LET ME SHARE WITH YOU SOME QUESTIONS THAT WE, AS PHYSI-
CIANS AND AS AMERICANS, MUST ADDRESS RIGHT NOW. I LIST THEM IN NO
SPECIAL RANK ORDER: TO ME, THEY ARE u VERY IMPORTANT,

FIRST, WE NEED TO REVISE MANY OF OUR RESEARCH AND SERVICE
STRATEGIES.  THEY HAVE USUALLY BEEN STRUCTURED ON A DISEASE-BY-DISEASE
OR DISABILITY-BY-DISABILITY BASIS,  BUT, ACCORDING TO SOME ESTIMATES,
AS MANY AS A THIRD OF OUR DISABLED MAY SUFFER FROM MULTIPLE CHRONIC

CONDITIONS,  SOME JUDGMENTS HAVE TO BE MADE AS TO THE LEVEL OF EFFORT
TO BE EXPENDED ON ONE OR ANOTHER CONDITION, RELATIVE TO ITS EFFECT ON
AN INDIVIDUAL WITH ONE OR MORE OTHER CONDITIONS,


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  THIS WON'T BE EASY, SINCE WE ARE CONDITIONED TO COME AS CLOSE AS
WE CAN TO PUTTING FORTH A 100 PERCENT EFFORT -- INCLUDING FUNDS -- IN
ORDER TO OVERCOME EACH DISABILITY, TODAY THAT'S NOT ONLY IMPOSSIBLE,
IT'S NO LONGER EVEN USEFUL AS A REALISTIC RESEARCH AND SERVICE

STRATEGY.

SECOND, WE'VE GOT TO CLARIFY JUST WHO IT IS WHO PAYS WHAT COSTS FOR
CHRONIC ILLNESS AND DISABILITY. THUS FAR, WE HAVE BEEN WILLING TO LET
MOST OF THE FINANCIAL BURDEN FALL UPON DISABLED PERSONS THEMSELVES AND

THEIR FAMILIES.  IN ADDITION, I SUSPECT THAT SOCIETY'S RELATIVELY SMALL
CONTRIBUTION VERY LIKELY HAS ITS ROOTS IN THE HISTORIC NOTION THAT SUCH
PAYMENT IS A COMPENSATION FOR THE DISABLING CONDITION, THERE'S A
LITTLE HINT OF GUILT IN MANY PROGRAMS OF PUBLIC SUPPORT, AND I SUPPOSE
THAT'S ONLY HUMAN NATURE.  BUT UNFORTUNATELY IT DOES TEND,TO PLACE
SOCIETY'S FOCUS ALMOST ENTIRELY UPON THE CONDITION -- HOW MUCH IS IT

WORTH? -- AND ONLY INCIDENTALLY UPON THE PERSON WHO HAS THE
CONDITION,

  I BELIEVE THAT SUCH A FOCUS IS NOT USEFUL IN OUR KIND OF SOCIETY,
WE SET GREAT STORE BY THE PARTICIPATION OF ALL MEMBERS OF SOCIETY IN
OUR POLITICAL, SOCIAL, AND ECONOMIC PROCESSES, OUR NATION HAS DRAWN
ITS STRENGTH FROM THIS VERY IDEA TH4T THE COUNTRY BELONGS TO EVERYONE
-- AND, THEREFORE, THE CONDUCT OF ITS BUSINESS IS EVERYONE'S RESPONSI-

BILITY,


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  BUT THAT WILL CONTINUE TO BE ONLY RHETORIC, IF WE`FORGET THAT SOME

PERSONS JUST DON'T HAVE THE MATERIAL WHEREWITHAL TO PARTICIPATE IN THE

FULL LIFE OF THE NATION.   THEREFORE, I BELIEVE THAT THE AMERICAN

DOCTRINE OF "FAIRNESS' DICTATES THAT WE OUGHT TO DO MORE TO CONTRIBUTE

TO A PERSON'S CAPACITY FOR PARTICIPATION IN OUR SOCIETY, AND THAT WE

SHOULD PUT INTO A MORE BALANCED PERSPECTIVE THE WAY WE COMPENSATE A

PERSON FOR ENDURING A SPECIFIC CONDITION OR DISABILITY,

PHRASED ANOTHER WAY, OUR QUESTIONS MIGHT BE:

"DO WE CONTINUE TO HELP SUPPORT SOMEONE BECAUSE HE OR SHE IS A

PARAPLEGIC.,. OR BECAUSE THE SUPPORT IS NEEDED TO GET THAT

PARAPLEGIC TO AND FROM WORK?"

"DO WE PROVIDE A DISABILITY PAYMENT TO A HANDICAPPED PHYSICIAN,

FOR EXAMPLE, BUT PREVENT THAT PHYSICIAN FROM OBTAINING A LICENSE

RENEWAL, HOSPITAL PRIVILEGES, OR PATIENT REFERRALS?"

I THINK WE HAVE TO FACE SUCH QUESTIONS AND GIVE THEM FRESH, NEW

ANSWERS,


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  THIRD, AND RELATED TO THE "FAIRNESS" ISSUE I JUST RAISED, IS THE
WHOLE RE-EVALUATION NOW GOING ON CONCERNING THE ROLE OF INSTITUTIONS OF

CARE AND OF THE ALTERNATIVES TO INSTITUTIONALIZATION,

  THERE'S NO QUESTION BUT THAT THE PENDULUM IS SWINGING THE OTHER

WAY, AGAINST INSTITUTIONALIZATION AND IN FAVOR OF THE RE-ABSORPTION OF

DISABLED PERSONS BY FAMILY AND COMMUNITY, AND THAT IS CERTAINLY THE

IDEAL WAY TO MOVE, TO MY WAY OF THINKING, BUT THE WALLS OUTSIDE AN
INSTITUTION MAY BE JUST AS HIGH AND AS IMPENETRABLE AS THE WALLS INSIDE

AN INSTITUTION,  PUBLIC FACILITIES MAY HAVE NEEDLESS BARRIERS, OCCUPA-

TIONS MAY HAVE OUTMODED REQUIREMENTS, AND IGNORANCE AND PREJUDICE MAY

STILL BE ACCEPTED BEHAVIOR AMONG TOO MANY SO-CALLED ABLE-BODIED OR

SIGHTED PERSONS.

  I'M THINKING NOW ESPECIALLY OF OUR ELDERLY CITIZENS. NOT LONG AGO

I W4S DISCUSSING THEIR PROBLEMS WITH A VERY PERCEPTIVE SOCIAL SERVICE

WORKER WHO DESCRIBED THE PLIGHT OF MANY ELDERLY HOMEMAKERS, NOW IN


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THEIR LATE 60s OR 7Os, WHO MAY HAVE A BRIEF PERIOD OF IN-PATIENT CARE

AND THEN ARE SENT BACK TO THEIR NEIGHBORHOODS AND THEIR HOMES, WHEN

THEY RETURN HOME, THEY ACTUALLY MAY BE LESS CAPABLE OF INDEPENDENT

LIVING, YET THEY MAY NO LONGER HAVE THE HUMAN RESOURCES TO SUPPLY THE

HELP THEY NEED IN THEIR TINY APARTMENTS OR OUT AMONG THEIR NEIGHBORS.

  THERE IS ALSO THE PHENOMENON OF THE AGED PARENT WHO HAS OUTLIVED

HIS OR HER CHILDREN, WHO HAS SURVIVED STROKE AND HEART DISEASE THROUGH

THE MIRACLE OF MODERN MEDICINE, BUT WHO CANNOT SURVIVE THE ORDINARY

STRESSES OF LIVING IN AN EMPTY HOME -- EMPTY OF HELP AND EMPTY OF HOPE,

  THIS IS ANOTHER PROBLEM THAT WILL NOT GO AWAY, IN FACT, THERE IS

EVERY INDICATION IT WILL BECOME AGGRAVATED AS THE AMERICAN SENIOR

CITIZEN POPULATION BEGINS TO EXPAND DRAMATICALLY OVER THE NEXT THREE

DECADES.  THIS GROUP WILL INCLUDE NOT ONLY THOSE PERSONS WHO WERE

DISABLED IN THEIR MIDDLE ADULT YEARS, BUT ALSO THOSE PERSONS NEW TO

THE WORLD OF DISABILITY WHO CANNOT COPE VERY WELL WITH DAILY PROBLEMS

OF A HANDICAPPED LIFE,


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  FOR A FEW, THE ANSWER MAY STILL BE THE PROTECTION AND THE SERVICE

OF AN INSTITUTION, BUT FOR MOST OTHERS, THE ANSWER OUGHT TO BE A

HIGHER LEVEL OF CARE AND INTEREST BY RESPONSIVE FAMILIES AND COMMUNI-

TIES,  BOTH ANSWERS, HOWEVER, NEED TO BE UNDERSTOOD AND NURTURED BY OUR

SOCIETY,

  I CAN TELL YOU THAT THIS ISSUE IS OF MAJOR CONCERN TO MANY OTHER

SOCIETIES AS WELL.  I JUST RETURNED FROM THE WORLD ASSEMBLY ON AGING,

HELD IN VIENNA, WHERE OUR UNITED STATES DELEGATION JOINED 110 OTHERS

IN DELIBERATING THE MERITS OF INSTITUTIONAL CARE FOR THE ELDERLY, ON

ONE POINT WE ALL AGREED, AND THAT IS,..WE CAN'T AFFORD TO LEAVE THE

MATTER TO CHANCE BECAUSE EXPERIENCE TELLS US THAT THE CONSEQUENCES FOR

THE ELDERLY CAN BE SEVERE,  IT IS NOT A MATTER TO BE DECIDED BY

DEFAULT,

  MY FOURTH AND FINAL QUESTION BRINGS US BACK TO A POINT I MADE

EARLIER,  SOCIETY AS A WHOLE IS NOT LIKELY TO MAKE VERY MUCH PROGRESS

TOWARD ANSWERING THE QUESTIONS I'VE RAISED TODAY, UNLESS THE DISABLED

COMMUNITY ITSELF PARTICIPATES FULLY IN THE DECISION-MAKING PROCESSES,

IT MUST BECOME MORE DEEPLY INVOLVED IN THE DEVELOPMENT OF PUBLIC POLICY

AND IN THE FULFILLMENT OF PUBLIC PROMISES, AND WHO BETTER THAN DIS-

ABLED PHYSICIANS, WITH THEIR DOUBLE KNOWLEDGE OF CAUSE AND EFFECT, CAN

PROVIDE THAT VERY NECESSARY LEADERSHIP?


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  DISABLED PERSONS HAVE HAD POWERFUL ADVOCATES IN THE PAST AND
CERTAIN GROUPS CONTINUE TO MAINTAIN HIGH VISIBILITY AND INFLUENCE, MY
FOURTH POINT, THEREFORE, SHOULD NOT BE INTERPRETED AS A CRITICISM,
RATHER, IT IS A PLEA THAT YOU PURSUE YOUR GOALS AND MAKE ADJUSTMENTS
ALONG THE WAY, ACCORDING TO VICTORIES AND SETBACKS AS THEY APPEAR,

  DISABLED PHYSICIANS AND OTHERS WITH LIMITING CONDITIONS WHO PROVIDE
HEALTH CARE DO FACE A DOUBLE CHALLENGE: FIRST, YOU HAVE ALL THE HANDI-
CAPS INDISCRIMINATELY PLACED UPON YOU BY THE ABLE-BODIED MAJORITY,
SECOND, YOU HAVE THE HANDICAPS IMPOSED BY YOUR ABLE-BODIED COLLEAGUES
IN MEDICINE AND BY YOUR POTENTIAL PATIENTS.  IT'S A "DOUBLE WHAMMY,"

AS L'IL ABNER USED TO SAY.

  BUT THE BEST POSSIBLE RESPONSE IS THE ONE MADE BY THE DISABLED

PHYSICIAN,  IT HAS THE RING OF CANDOR AND AUTHORITY, AND IT REPRESENTS
FOR THESE
YOUR CHARACTER AND YOUR STRENGTH AS HEALTH PROFESSIONALS,
REASONS I FULLY SUPPORT THE NEW SOCIETY OF HANDICAPPED PHYSICIANS, I
THINK IT COMES AT A SPECIAL MOMENT OF GREAT OPPORTUNITY,  I WISH THE
ORGANIZATION A LONG AND SUCCESSFUL LIFE WITHIN THE FAMILY OF PROFES-

SIONAL MEDICAL SOCIETIES,  AND I HOPE EACH OF YOU WILL EXERCISE MAXIMUM
PARTICIPATION IN THE LIFE OF AMERICAN MEDICINE IN PARTICULAR -- AND IN

AMERICAN SOCIETY IN GENERAL,

THANK YOU.

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