ADDRESS

BY

C, EVERETT KOOP, M,D,, Sc,D,

    SURGEON GENERAL

         OF THE

     UA PUBLIC HEALTH SERVICE

LLS, DEPARTMENT OF HEALTH AND HUMAN SERVICES

PRESENTED TO THE UNIVERSITY OF NEW MEXICO MEDICAL CENTER

         ALBUQUERQUE, NEW MEXICO
           FEBRUARY 10, 1989

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

I WANT TO THANK YOU VERY MUCH FOR THE WARM RECEPTION YOU'VE

GIVEN ME TODAY IN YOUR GRACTOUS CITY,

  I'M ALSO DELIGHTED TO BE PART OF YOUR CENTENPIIAL CELEBRA-

TION AND THE SILVER ANNIVERSARY OF YOUR SCHOOL OF MEDICINE,  I

REMEMBER THAT ESPECIALLY BECAUSE YOUR SCHOOL HAS BEEN AORUND AS

LONG AS THE SURGEON GENERSAL'S REPORTS TO CONGRESS ON SMOKING AND

HEALTH,

  A CENTURY IS JUST A SNAP OF THE FINGERS, RELATIVE TO ALL

HUMAN HISTORY, BUT TO US MORTALS, IT IS A LONG PERIOD OF TIME,

TN WHICH SOCIETIES MAY CHANGE -- FOR BETTER OR FOR \/ORSE -- AND

THE ENVIRONMENT MAY CHANGE -- ALSO, FOR BETTER OR FOR WORSE,


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   SOMETIMES IT'S USEFUL TO REMEMBER WHAT THE WORLD WAS LIKE AS

FAR BACK AS 100 YEARS AGO, SO THAT WE CAN TRULY APPRECIATE WHAT

MEDICINE, FOR EXAMPLE, HAS BEEN TRYING TO ACHIEVE SINCE THEN,

   IN THE 1880s AND 1890s MOST HOMES AND HOSPITALS WERE STILL

LIT BY GAS OR OIL LAMPS ELECTRICITY WAS RARE, EXCEPT FOR THE

FEW MAJOR CITIES IN THE INDUSTRIAL NORTHEAST,

YOU GOT AROUND BY FOOT OR BY HORSE OR BY BICYCLE, EMERGENCY

MEDICINE WAS AN OXYMORON, IN FACT, THERE WAS NO SUCH THING,


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  EVEN A STEADY SUPPLY OF BOILING HOT WATER WAS ALSO A RARITY,
STERILIZATION AND ANTISEPSIS WERE RELATIVELY NEW CONCEPTS,

RECOMMENDED FOR SOME -- BUT OBVIOUSLY NOT FOR ALL -- ASPECTS OF

MEDICAL PRACTICE, IT WAS SIMPLY IMPRACTICAL,

  TELEPHONES WERE JUST GETTING POPULAR, ALTHOUGH THEY WERE NOT
GENERALLY AVAILABLE, COMMUNICATIONS IN GENERAL WERE BASICALLY OF

THE FACE-TO-FACE OR PAPER-AND-PENCIL VARIETY,

EFFECTIVE, MAYBE, BUT NOT VERY EFFICIENT,


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  THE FOOD FOR YOUR DINNER HAD TO HAVE BEEN PURCHASED -- OR

PICKED a,, OR SHOT -- SOMETIME EARLIER THAT SAME DAY, COMMERCIAL

REFRIGERATION WOULD NOT BE AVAILABLE FOR ALMOST 50 YEARS, THERE

WERE MANY REASONS WHY PEER REVIEW DIDN'T EXIST,

  BUT THEN, PROFESSIONAL STANDARD-SETTING WAS A VERY NEW AND

REVOLUTIONARY IDEA, IF YOU WANTED SOME KIND OF PERSONAL,

PROFESSIONAL SERVICE, YOU ASKED A FRIEND OR RELATIVE FOR A

RECOMMENDATION,


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  FOR EXAMPLE, IF YOU WANTED THE NAME OF A GOOD DOCTOR, YOU

WENT TO SOMEONE WHO HAD BEEN SICK, HAD BEEN TREATED, YET WAS

STILL ALIVE, THAT PERSON WAS YOUR BEST -- AND PROBABLY YOUR

ONLY -- REFERENCE FOR A DOCTOR,

A HUNDRED YEARS AGO, THAT WAS THE ENVIRONMENT IN WHICH THIS

UNIVERSITY WAS FOUNDED,

  AT ABOUT THE SAME TIME, THE FIRST GOVERNMENT EFFORTS AT

BIOMEDICAL RESEARCH WERE BEGUN ,,a EFFORTS WHICH 100 YEARS LATER

WE KNOW AS THE "NATIONAL INSTITUTES OF HEALTH,"


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AND ABOUT THIS TIME, A CENTURY AGO, PRESIDENT GROVER

CLEVELAND GAVE ANOTHER BOOST TO THE "MARINE HOSPITAL SERVICE," IN

EFFECT ESTABLISHING THE UNIFORMED COMMISSIONED CORPS OF THE US,

PUBLIC HEALTH SERVICE AND PUTTING A SURGEON GENERAL IN CHARGE,

IN THE 1890s AND ON INTO THE 20TH CENTURY A GREAT SURGE OF

PROGRESS TOOK PLACE ACROSS MANY FRONTS:

+

     CITIES AND STATES DECIDED TO ESTABLISH PUBLIC

DEPARTMENTS OF HEALTH AND HYGIENE TO ENSURE THAT THEIR DRINKING

WATER WAS SAFE AND COMMERCIAL MILK SUPPLIES WERE NOT

CONTAM I NATED,


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*

      THE UrnSa GOVERNMENT DECIDED IT WAS TIME TO SET A

MINIMUM STANDARD FOR MEATS AND MEDICINES THAT WERE SHIPPED IN

INTERSTATE COMMERCE,

+

AND ABRAHAM FLEXNER PRODUCED A REPORT ON MEDICAL

EDUCATION THAT CHANGED OUR FIELD FOR THE BETTER 11, AND FOREVER,

  YES, OF COURSE, THERE WERE MANY NEW BREAKTHROUGHS IN

SCIENCE, ALSO, THE WORK OF ROBERT KOCH AND LOUIS PASTEUR AND

BELA SCHICK AND PAUL EHRLICH AND MANY OTHERS, THEIR DISCOVERIES

CHANGED MEDICAL PRACTICE FOREVER,


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  BUT I SOMETIMES THINK THAT THE POOR CONDITION OF SO MUCH OF

MANKIND tarn THE DIFFICULTIES OF DAY-TO-DAY LIVING FOR SO MANY

MILLIONS OF PEOPLE, EVEN PEOPLE LIVING IN THE SO-CALLED

INDUSTRIALIZED AND CIVILIZED WEST , m, THAT THOSE HARD CONDITIONS

OF LIFE WERE WHAT PROMPTED MANY DISCOVERIES TO BE MADE AND TO BE

QUICKLY AND UNIVERSALLY EMBRACED,

AND THAT'S BEEN THE CASE TIME AFTER TIME, HASN'T IT?


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NUTRITION AND VITAMINS EMERGED AS A BRAVE NEW SCIENCE

DURING THE DEPRESSION AND THE HUNGER OF THE 193Osm

ANTIBIOTICS APPEARED DURING THE SECOND WORLD WAR, WHEN

WE DESPERATELY NEEDED THEM TO SAVE THE LIVES OF OUR

WOUNDED SOLD I ERS,

AND THE ORAL CONTRACEPTIVE CAME ALONG DURING THE PEAK

YEARS OF THE POST-WAR "BABY BOOM,"

  IN OTHER WORDS, HEALTH AND MEDICINE DO NOT EVOLVE IN A

VACUUM, THEY AFFECT -- AND ARE AFFECTED BY -- WHATEVER ELSE IS

GOING ON IN SOCIETY AT THE TIME 11. AND IN THE ENVIRONMENT IN

GENERAL,


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  ALL THIS HAS BEEN IN MY MIND LATELY, BECAUSE I WANTED TO

COME HERE TO TALK NOT ABOUT THE PAST HUNDRED YEARS BUT ABOUT THE

NEXT HUNDRED YEARS am, OR AT LEAST THE NEXT 20,

  FOR ECONOMY'S SAKE, I'LL LIMIT MY CRYSTAL-BALL GAZING TO

JUST THREE AREAS BUT THEY ARE BIG ONES .m, AREAS IN WHICH I

BELIEVE WE'LL SEE SOME CHANGES AHEAD mnm CHANGES WHICH WILL

REQUIRE A RESPONSE FROM PEOPLE SUCH AS YOURSELVES, THE DOCTORS

AND NURSES AND PUBLIC HEALTH PERSONNEL OF THE FUTURE,

   THE FIRST OF THESE THREE AREAS CONCERNS TECHNOLOGY,  I

BELIEVE THAT A PROFOUND CHANGE IS OCCURRING IN THE RELATIONSHIP

BETWEEN TECHNOLOGY AND THE HEALTH OF THE AMERICAN PEOPLE,  I

ALSO THINK THIS CHANGE WILL ACCELERATE IN THE YEARS AHEAD,


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  FOR OUR PURPOSES TODAY, LET'S DEFINE TECHNOLOGY AS THE

APPLICATION OF NEW SCIENTIFIC KNOWLEDGE TO REAL EVENTS, IF WE

CAN ACCEPT THAT SIMPLE DEFINITION, THEN IT'S OBVIOUS THE WAY

TECHNOLOGY HAS INFLUENCED HEALTH CARE IN OUR SOCIETY,

   WE'VE GONE THROUGH A "GOLDEN AGE OF SURGERY" 10, AND A

"GOLDEN AGE OF DRUG THERAPY" 11, WE'RE IN THE MIDST OF A "GOLDEN

AGE OF ORGAN TRANSPLANTATION" a,, AND SO ON,

   I DON'T THINK THAT IT'S ALL HYPERBOLE, EITHER, I THINK IT'S

TRUE THAT WE'VE MADE SOME EXTRAORDINARY PROGRESS IN HEALTH CARE

TECHNOLOGIES OF EVERY KIND,


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  BUT FOR THOSE OF US IN MEDICINE, I THINK ALL THAT WELL-

ADVERTISED PROGRESS HAS BEEN A MIXED BLESSING,  IN THE COURSE OF

TIME, THESE NEW TECHNOLOGIES HAVE RAISED TO A CONSIDERABLE

DEGREE THE PUBLIC'S EXPECTATIONS OF WHAT MEDICINE AND HEALTH

CARE ARE ABLE TO ACCOMPLISH,

AND SO THE PUBLIC, I'M SORRY TO SAY, OFTEN EQUATES MEDICAL

TECHNOLOGY WITH THE MIRACULOUS AND THE NEAR-MIRACULOUS

   I WILL ADMIT -- ALBEIT UNHAPPILY -- THAT SOME OF MY

COLLEAGUES IN MEDICINE HAVE UNWISELY PROMOTED THAT KIND OF

REVERENCE FOR TECHNOLOGY n Is AND REVERENCE FOR THEMSELVES IN THE

BARGAIN,


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BUT WHAT ARE THE CHANCES THAT TECHNOLOGY WILL ALWAYS BE

CONS I DERED BENEF ICENTLY "MIRACULOUS"?

  TWENTY OR EVEN 10 YEARS AGO I'D HAVE SAID -- WITHOUT ANY

HESITATION -- THAT THE CHANCES ARE EXCELLENT, BUT TODAY I QQ

HESITATE, I'M REALLY NOT THAT SURE,

  AND TEN YEARS HENCE, WE MIGHT ALL BE SAYING "NO, THE

CHANCES ARE NOT GOOD, BECAUSE TECHNOLOGY IS NOT THE TOTAL

BLESSING WE'VE THOUGHT IT WAS/'


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WHY SUCH A CHANGE? I THINK THERE ARE SEVERAL REASONS, BUT

I'LL JUST TOUCH UPON TWO,

FIRST, THE PUBLIC SEES AS A MIXED BLESSING -- AT BEST -- THE

ABILITY OF TECHNOLOGY TO PROLONG LIFE ,a. OR, IN MANY

SITUATIONS, MERELY TO PROLONG THE ACT OF DYING,

  AS MOST OF YOU KNOW, 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,


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  FOR MANY PEOPLE WHO MUST DECIDE THE FATE OF LOVED ONES,

HIGH-TECH MEDICINE SOMETIMES ACTS LIKE A FRIEND ,I. AND

SOMETIMES IT ACTS LIKE AN ENEMY,

  HENCE, SOME PEOPLE ARE TURNING TO LEGAL INSTRUMENTS LIKE THE

SO-CALLED "LIVING WILL" AND THE "DURABLE POWER OF ATTORNEY" TO

PROTECT THEMSELVES FROM RUNAWAY MEDICAL TECHNOLOGY, IF -- AT SOME

FUTURE DATE -- THEY THEMSELVES HAVE A TERMINAL ILLNESS flR

CONDITION,

   SO THE FIRST REASON FOR PUBLIC SKEPTICISM ABOUT TECHNOLOGY

IS THE FACT THAT, IN MANY REAL-LIFE SITUATIONS, TECHNOLOGY IS A

MIXED BLESSING n a w AT BEST m, a AND CAN BE A CURSE, AT THE WORST,


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AND THE SECOND REASON GOES BACK TO THE FACT THAT MEDICINE

AND PUBLIC HEALTH HAVE THEMSELVES BEEN PREACHING OVER AND

OVER AGAIN THAT PEOPLE THEMSELVES CAN AND MUST TAKE CHARGE

OF THEIR OWN HEALTH STATUS,

  THE EXAMPLES ARE ALL AROUND US, THE PUBLIC IS EXHORTED TO

STAY AWAY FROM HARMFUL FOODS, LIKE FATTY MEATS, AND TO "SAY NO"

TO HARMFUL DRUGS, LIKE ALCOHOL AND NICOTINE,

  YOU KNOW THIS AS WELL AS I DO, BY VIRTUE OF THE ACTIVITY OF

"HEALTHNET" HERE IN NEW MEXICO AND ITS CURRENT STATEWIDE CAMPAIGN

CALLED "EAT RIGHT/STAY FIT,"


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  IT LOOKS LIKE "HEALTHNET" IS A VERY EFFECTIVE APPROACH TO

GETTING THE PEOPLE OF NEW MEXICO TO TAKE CHARGE OF THEIR OWN

HEALTH, I'M IMPRESSED WITH WHAT YOU'RE DOING AND THE

EXTRAORDINARY DEGREE OF PARTICIPATION YOU HAVE FROM BOTH THE

PUBLIC AND PRIVATE SECTORS,

   I'M ALSO IMPRESSED BY THE HIGH DEGREE TO WHICH THE MEDICAL

AND PUBLIC HEALTH COMMUNITIES OF NEW MEXICO, INCLUDING PERSONNEL

FROM OUR OWN INDIAN HEALTH SERVICE, ARE ALL CONTRIBUTING TO THE

SUCCESS OF THIS PROGRAM.


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  OF COURSE, TELLING PEOPLE THAT THE BEST WAY TO BEAT HEART

DISEASE IS THROUGH ROUTINE EXERCISE AND GOOD DIET IS ANOTHER WAY

OF TELLING PEOPLE, "DON'T RELY ON MEDICINE'S HIGH TECHNOLOGY TO

SAVE YOUR LIFE/'

THAT'S REALLY WHAT WE'RE SAYING 11, AND I BELIEVE WE'LL

CONTINUE TO SAY IT WELL INTO THE NEXT CENTURY,

   AND OUR ADVICE WILL CONTINUE TO BE ABOUT MORE THAN JUST

HEART DISEASE, WE'LL ADVISE PEOPLE ON WAYS TO TAKE

RESPONSIBILITY AND PREVENT STROKE, CANCER, FETAL ALCOHOL

SYNDROME, HIGHWAY TRAUMA, OCCUPATIONAL SAFETY, HOME ACCIDENTS,

AND SO ON,


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I DON'T SEE ANY SHORTAGE OF MESSAGES,

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

THE MAJOR SHIFTS IN MEDICINE AND PUBLIC HEALTH IN THE NEXT

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

UPON -- HIGH TECHNOLOGY,

  INSTEAD, I ENVISION A GREATER RELIANCE UPON THE RELATIVELY

"LOW-TECH" DECISION-MAKING ONE ENGAGES IN AFFECTING ONE'S OWN

HEALTH AND WELL-BEING,

   IT'S CERTAINLY CHEAPER a,, AND IN MANY CASES IT'S MORE

EFFECTIVE OVER THE LONG TERM, NOW, IF WE COULD ONLY MAKE IT

GLAMOROUS! BUT I'M AFRAID THERE'S STILL NOTHING VERY "GLITZY"

ABOUT LOW-TECH MEDIC I NE,


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WHAT'S THE SECOND BIG CHANGE ON THE HORIZON?

IT'S A PROCESS THAT HAS ALREADY BEGUN, BUT WE HAVEN'T BEEN

PAYING TOO MUCH ATTENTION TO IT, I THINK WE OUGHT TO,

IT'S THE CHANGING RELATIONSHIP BETWEEN THE PUBLIC AND THE

HEALTH CARE SYSTEM ITSELF,

   THIS IS ESPECIALLY IMPORTANT RIGHT NOW TO THOSE OF YOU IN

THE HEALTH PROFESSIONS, HOWEVER, THE REASONS FOR THE CHANGE ARE

FAR-REACHING AND APPLY TO MANY OTHER PROFESSIONS AS WELL,


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FOR EXAMPLE, ONE REASON FOR THE CHANGE IN RELATIONSHIPS 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,

  I'M SURE THIS IS NOT NEWS TO YOU, SINCE THE STATE OF NEW

MEXICO HAS GROWN SO IN THE LAST FEW YEARS, DRAWING PEOPLE OF ALL

AGES FROM ALL POINTS OF THE COMPASS . . ,  MOST OF THEM COMING HERE

WITHOUT THEIR MEDICAL HISTORIES,


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  THOSE HISTORIES ARE USUALLY LEFT BEHIND WITH THE CLOTHES

THAT NO LONGER FIT AND THE PHOTOGRAPHS OF PEOPLE NO LONGER

REMEMBERED,

FOR ALMOST THREE CENTURIES IT WAS THE NORM IN OUR SOCIETY TO

LIVE AND DIE WHERE WE WERE BORN AND, HENCE, TO BE CARED FOR BY --

AT MOST -- TWO DIFFERENT PHYSICIANS,

  BUT TIMES HAVE CHANGED, THE DOCTOR-PATIENT RELATIONSHIP --

NOW AND IN THE FUTURE -- IS A RELATIONSHIP BETWEEN STRANGERS

AND THAT IS A KEY REASON WHY THE RELATIONSHIP BETWEEN THE

INDIVIDUAL AND THE HEALTH SYSTEM IN GENERAL IS UNDERGOING A

PROFOUND CHANGE,

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

THESE PLANS SEEM TO BE MORE COST-EFFICIENT, THAT'S TRUE, BUT

THEY ALSO TEND TO ATOMIZE AND SUB-DIVIDE PATIENT CARE,  I THINK

THAT'S TRUE, TOO,

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

BAD, I'M ONLY SAYING THAT THEY'RE DIFFERENT, AND THAT

DIFFERENCE IS HELPING SIGNIFICANTLY TO RE-SHAPE THE LONG-TERM

RELATIONSHIP BETWEEN THE HEALTH CARE SYSTEM AND THE PUBLIC IT

SERVES,


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   A THIRD FACTOR CHANGING THE RELATIONSHIP BETWEEN THE PUBLIC

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

DISCUSSED SHIFT IN THE DEMOGRAPHY OF OUR COUNTRY,

WE KNOW THIS PHENOMENON BEST BY THE TAGS WE'VE GIVEN IT: THE

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

BOOMERS' OWN PARENTS, WHO ARE NOW "GRAYING IN AMERICA,"

THERE'S A BITTER IRONY IN ALL THIS CHANGE, THE MORE YOU

THINK ABOUT IT,


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  FOR MANY YEARS WE'VE BEEN EXTOLLING THE VIRTUES OF THE

"CONTINUITY OF CARE,"  BUT WE'VE ALSO BECOME RESIGNED TO THE FACT

THAT THE AVERAGE INDIVIDUAL, IN THE COURSE OF HIS OR HER LIFE-

TIME, IS PASSED FROM THE HANDS OF A PEDIATRICIAN TO THOSE OF A

FAMILY PHYSICIAN AND THEN TO A SPECIALIST OF SOME KIND -- A

CARDIOLOGIST, PERHAPS, OR AN EAR-NOSE-AND-THROAT SPECIALIST --

AND FINALLY WE SETTLE DOWN WITH A SPECIALIST IN GERIATRIC

MEDICINE,

  ALL THIS MOVEMENT IN THE SYSTEM TENDS TO THROW THE

INDIVIDUAL PATIENT -- "THE CONSUMER," AS IT WERE -- BACK ON

HIS OR HER OWN DEVICES


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  HENCE, ANOTHER ELEMENT HELPING TO CHANGE THE RELATIONSHIP

BETWEEN SYSTEM AND PATIENT IS THE RISE OF THE

SO-CALLED "SELF-HELP" MOVEMENT.

  NOT LONG AGO I WAS TOLD THAT AN ESTIMATED 15 MILLION

AMERICANS ARE NOW INVOLVED IN SOME FORM OF SELF-HELP HEALTH

CARE, BUT IN MY OPINION 15 MILLION IS A GROSS UNDERCOUNT,

  THE SELF-HELP MOVEMENT IS RESPONDING TO THE PUBLIC'S NEED

FOR DIRECTION IN PREVENTING DISEASE AND DISABILITY ,a. IN

PROMOTING AND MAINTAINlNG GOOD HEALTH e,, AND IN THE DAY-TO-DAY

BUSINESS OF COPING,


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THE SELF-HELP MOVEMENT INCLUDES ALCOHOLICS ANONYMOUS AND THE

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

   THERE ARE ALSO GROUPS SUCH AS PARENTS WITHOUT PARTNERS AND

THE GRAY PANTHERS amn 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 ,,,AND SO

ON.

   THIS IS NOT "MARGINAL MEDICINE" BY ANY MEANS, THESE SELF-

HELP GROUPS ARE DEALING WITH CONTEMPORARY SOCIETY'S MOST SERIOUS

AND MOST PERVASIVE DISEASES AND DISORDERS:


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SUBSTANCE ABUSE, INCLUDING CIGARETTES ,a, THE EPIDEMICS OF

SEXUALLY TRANSMITTED DISEASES, SUCH AS SYPHILIS, HERPES,

GONORRHEA, AND AIDS 11, AND THOSE THREE MAJOR KILLERS OF

THAT I MENTIONED A MOMENT AGO: HEART DISEASE, CANCER, AND

STROKE,

  I'M AMAZED AT THE EXTRAORDINARY DEGREE TO WHICH AVERAGE

AMERICANS TURN TO THESE "DO-IT-YOURSELF" HEALTH PROGRAMS AND ARE

TRULY HELPED BY THEM, THEY ARE NOT FALSE PALLIATIVE% THESE

PROGRAMS REALLY WORK,

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

PROGRAMS MAY NOT BE GOOD IN THE SAME WAY FOR EVERYONE, SOME

PEOPLE STILL DO NEED THE HELP OF TRADITIONAL, MEDICALLY TRAINED

EXPERTS, INSTEAD, THEY MAY CHOOSE NOT TO GET THAT HELP, BUT

WILL TURN EXCLUSIVELY TO THE SELF-HELP MOVEMENT,

   I DON'T THINK SUCH A SEPARATION IS GOOD FOR MEDICINE aa,

GOOD FOR THE SELF-HELP MOVEMENT , . , OR GOOD FOR THE AMERICAN

PEOPLE,  I THINK BOTH SIDES -- MEDICINE AND SELF-HELP -- NEED TO

SHED THEIR MUTUAL ATTITUDES OF DISPARAGEMENT AND DISTRUST AND

TRY, INSTEAD, TO FORGE A NEW PARTNERSHIP OF HEALTH, HELP, AND

CARING,


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TO ME, THAT WOULD BE A VERY EXCITING DEVELOPMENT FOR

MEDICINE IN THE 21ST CENTURY,

  BUT FRANKLY, WHETHER TRADITIONAL MEDICINE AND PUBLIC HEALTH

DO OR DO NOT GET INVOLVED, I BELIEVE THE SELF-HELP MOVEMENT WILL
CONTINUE TO GROW IN THE YEARS AHEAD AND WILL 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 AREA I WANT TO

TOUCH ON THIS AFTERNOON,  IT'S THE QUESTION OF COMMUNITY VALUES

AND PUBLIC SUPPORT, RELATIVE TO MEDICINE AND PUBLIC HEALTH,


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  I'M BRINGING UP THIS QUESTION BECAUSE, IN THE COURSE OF MY

INVOLVEMENT WITH THE AIDS EPIDEMIC, I'VE SEEN THE OUTLINES OF

THIS ISSUE BEGINNING TO TAKE SHAPE, ALSO, IT'S SOMETHING OF A

COROLLARY TO THE OTHER ISSUES I'VE DISCUSSED SO FAR m mu THE

TECHNOLOGY ISSUE AND THE ISSUE OF RELATIONSHIPS

   LET ME BEGIN BY STATING VERY CLEARLY THAT 1 BELIEVE THE

AMERICAN PEOPLE ARE COMPASSIONATE AND GENEROUS TO A FAULT,

THROUGH TAXES AND THROUGH PERSONAL, OUT-OF-POCKET CHARITABLE

DONATIONS THEY WANT TO HELP EVERYONE IN OUR SOCIETY ACHIEVE GOOD

HEALTH AND THE GOOD LIFE THAT COMES WITH GOOD HEALTH,


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BUT THE AMERICAN PEOPLE CAN ALSO BE IMPATIENT,

  FOR EXAMPLE, MOST AMERICANS DO NOT SMOKE, AND THIS NON-

SMOKING MAJORITY GENERALLY DISAPPROVES OF SMOKING AND SIOULD LIKE

TO SEE ALL SMOKERS STOP,

  AND EVERY DAY, MANY SMOKERS ARE STOPPING , a, BUT CIGARETTES

ARE ADDICTIVE AND SO THE CHANGE IS HAPPENING VERY SLO\JLYn


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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 SPACES, REGARDLESS OF WHO OWNS THEM,

  BUT PUBLIC DISPLEASURE DOES NOT STOP WITH SMOKERS, IT IS

BEING EXERCISED AGAINST OTHERS AS WELL 1,. PEOPLE WHO WILFULLY

BEHAVE IN A HIGH-RISK MANNER: DRUNK DRIVERS, CHILD MOLESTERS,

WIFE BEATERS, DRUG ADDICTS, PROMISCUOUS AND PREGNANT TEEN-AGERS,

AND ANYBODY ELSE WHO DEVIATES -- OR WHO IS 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 jlJ BELIEVE IN -- AND WILL CONTINUE TO SUPPORT --

PUBLIC HEALTH PROGRAMS THAT PROM I SE REDEMPTION,

   BUT AMERICANS ARE NOT PUSH-OVER% AND IT'S POSSIBLE THAT

THE AMERICAN PEOPLE -- ALREADY TAKING A CONTENTIOUS APPROACH

TOWARD SOME BACKSLIDERS -- MAY DEMONSTRATE THEIR IMPATIENCE AND

DISPLEASURE ON A GRANDER SCALE, ADDING A STRONG FOOTNOTE OF HIGH

DUDGEON 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 THE COUNTRY ARE PEOPLE WITH AIDS,

  NINE OF EVERY 10 PERSONS WITH THE DISEASE BECAME INFECTED BY

DOING WHAT THE MAJORITY OF THE COMMUNITY REGARDS AS AN UNSAVORY

ACT: THAT IS, THEY ENGAGED IN SODOMY OR INTRAVENOUS DRUG ABUSE,

  TRAGICALLY, ONCE YOU BECOME INFECTED THIS WAY, YOU CAN'T

BECOME UNINFECTED, HENCE, THERE'S NO REDEMPTION IN THE USUAL

SENSE tn. THERE'S NO REWARD FOR YOU IF YOU CHANGE YOUR BEHAVIOR,


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  NEVERTHELESS, WE MUST CONVINCE PERSONS WITH AIDS TO CHANGE

THEIR BEHAVIOR ANYWAY, IN ORDER TO STOP THE SPREAD OF THE VIRUS

AND THAT IS A REWARD OF SORTS FOR SOCIETY, AT THE VERY LEAST,

  AND WE NEED TO MAINTAIN STRONG PUBLIC SUPPORT FOR PROGRAMS

THAT PROVIDE INFORMATION TO PEOPLE AT RISK OF GETTING AIDS am. OR

PROGRAMS THAT PROVIDE MEDICAL SERVICES FOR THOSE WHO NEVER DID

GET THE MESSAGE -- AND ARE DYING,

  THIS IS THE MOST EXTREME EXAMPLE OF A PROBLEM WE HAVE, BUT

THERE IT IS NEVERTHELESS, IN ANY CASE, WE HAVE MANY EXAMPLES NOW

OF HOW A RELATIVELY HEALTHY AND HEALTH-CONSCIOUS MAJORITY OF

AMERICANS REACTS TOWARD A HIGH-RISK MINORITY,


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  HENCE, I WOULD SUGGEST THAT THE MORE THE MAJORITY BELIEVES

IN -- AND PRACTICES -- THE PRINCIPLES OF PREVENTION AND SELF-

HELP, THE LESS WILL BE ITS PATIENCE WITH THE MINORITY WHO DOES

NOT PRACTICE THESE VIRTUES,

AND THAT, I BELIEVE, IS AN ISSUE FOR AMERICANS IN THE

COMING YEARS

  AS I INDICATED AT THE BEGINNING OF MY REMARKS, I'M NOT SURE

THESE TRENDS AND CHANGES WILL OCCUR THROUGHOUT THE NEXT CENTURY,

BUT I'D GUESS THEY WILL BE AROUND FOR THE NEXT 20 YEARS OR SO

ANYWAY,


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  I SUSPECT THAT SOME OF THESE CHANGES WILL BE EASIER TO

EXPERIENCE THAN OTHERS, SOME WILL BE CHANGES IN THE WAY EACH OF

US BEHAVES n 1, TOWARD OURSELVES AND TOWARD OUR NEIGHBORS.

  AND SOME CHANGES WILL BE SYSTEMIC ,a, THAT IS, THE HEALTH

DELIVERY SYSTEM ITSELF WILL RESPOND IN NEW WAYS TO SHIFTING

PUBLIC ATTITUDES, SHIFTING DEMOGRAPHY, AND SHIFTING ARRANGEMENTS

WITHIN THE SYSTEM ITSELF,


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  BUT, ON BALANCE, I BELIEVE A STRONGER, MORE CONTEMPORARY,

MORE COMPASSIONATE, AND MORE RESPONSIVE SYSTEM OF HEALTH CARE

WILL EVOLVE TO SERVE THE NEXT AND SUCCEEDING GENERATIONS OF

AMERICANS ,.a THAT IS TO SAY, YOUR CHILDREN AND GRANDCHILDREN,

AND THAT'S THE BEST PREDICTION OF ALL,

THANK YOU,

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