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Commentary

Health and Health Care for the 21st Century: For All the People

Everett Koop Institute, Dartmouth College, Dartmouth Medical School, Hanover, New Hampshire, USA

	INTRODUCTION

Top Introduction Acknowledgments References C. Everett Koop Footnotes

 
As I reflect on my more than 6 decades of public health service, I am awed at what has been achieved and shocked at what has not. We can prevent and treat diseases formerly considered capricious death sentences. Yet many proven strategies for preventing disease and disability sit on the shelves. The gaping holes in our health care coverage net leave approximately 47 million Americans without coverage [1]. Our capability to prevent and treat disease seems to exceed our willingness to apply our interventions.

Through most of history, medicine could really cure very little, and the concept of science-driven public health did not exist. By the early 20th century, the so-called medical miracles to prevent and treat disease began to emerge at an increasing pace. Average life spans in the United States increased by nearly 30 years, allowing most people to live into their 80s and some of us substantially longer [2]. Services to enable people to spend those additional years free of disability, disease, and pain have not advanced proportionately.

Obesity and its associated problems, including diabetes, cardiovascular disease, and orthopedic injury, are largely preventable; unintended pregnancies are too frequent, and many result in abortions that could have been avoided by stronger efforts to guide and assist our young; and we are not adequately prepared for potential influenza pandemics, bioterrorism, or the next global epidemic that, like HIV/AIDS, is unexpected, incurable, and unusual in many aspects of its transmission.

As you read this commentary, transplant patients are waiting for organs that could be provided by a better system of distribution; millions of people are crying out because of inadequately treated pain; an aging person is suffering a debilitating hip fracture because no one told her how to get up from a chair; someone will be injured or killed on the highway by the abuser of an addictive drug that will most likely be alcohol; and drug-addicted people seeking help will be told to wait for a treatment slot to open.

Four of my own areas of special interest illustrate the promise, peril, and unrealized potential that public health professionals should consider in charting a course for the 21st century.

Pediatric Medicine and Surgery
When I focused on pediatric surgery in the 1940s, the specialty was in its infancy. Patients were lost because doctors treated them as though they were small adults. Other patients died with no intervention because doctors thought the procedures were more risky than the diagnoses. General anesthesia in small infants was akin to Russian roulette [3].

Yet pediatric medicine specialists' dedication to the unique needs of the young, respect for their humanity, and perseverance in the face of many obstacles brought achievements beyond the dreams many of us envisioned in the 1940s. I was fortunate to play a role in that revolution. As I reflect on my career, my contributions in this area—particularly in neonatal surgery—give me a sense of fulfillment that I carry with me every day.

HIV/AIDS
The HIV/AIDS public health bombshell struck during my early days as surgeon general. The enormity of the medical challenge was compounded by fear of and outright disrespect for many of the afflicted. Early on, public health and medical intervention took back seats as stigma, fear, and politics seemed to rule. Yet we quickly determined the main modalities of transmission. I used national television to tell people how to avoid the disease, including promoting the use of condoms. I was criticized by those who argued that people who had become infected through illicit drug use, sex out of marriage, or sex between same-sex individuals did not merit assistance and that my comments might further such behavior. My response was simple: I was surgeon general for all Americans.

I worked with the National Institutes of Health to advance research, with the Centers for Disease Control and Prevention to implement prevention, with the Food and Drug Administration to expedite treatment approval, with the pharmaceutical industry to develop treatment, with philanthropies to fill gaps in funding, and with advocacy organizations to help keep us all on track. A remarkable coalescence of leadership helped transform this mysterious death sentence of the early 1980s into a preventable and treatable disease by the 1990s, with many afflicted now living productive and fulfilling lives.

Even as progress continues, HIV transmission grows in some populations, probably because of gaps in education and health care. The virus is on a rampage in many nations, and the health of those populations is in the hands of leaders—theirs and ours—to provide science-based prevention and treatment. There is no reason that HIV in the 21st century could not go the way of smallpox in the 20th century. Such an accomplishment is eminently feasible, but leaders here and abroad must put health, well-being, and respect for all people as the highest goals.

Tobacco
Tobacco is a deadly and addictive substance that accounts for nearly 1 in 5 deaths in the United States, with a 50% risk of premature mortality in cigarette smokers who do not successfully quit [4, 5]. In the early 1980s I predicted that lung cancer mortality in women would exceed breast cancer mortality by 1990. This grim milestone was reached around 1987, and lung cancer among women continues to climb [6].

Evidence-based treatment [7] helps people quit smoking, thereby reducing illness, time away from work, and problem pregnancies and supports tobacco prevention efforts with our children. For tobacco addiction, as with other addictions, we must work to make treatment as accessible as the addicting substance, but we have a long way to go to achieve this [8, 9].

A special challenge is that the death and destruction by tobacco are spread by corporations that put greed and profit above health, ethics, and decency [10]. Virtually unchecked by regulatory oversight, tobacco companies continue to modify their products to make them even more addictive and attractive, often with allusions to health benefits through misleading labels such as "light" and "low tar." [11] An international treaty to control such practices entered into force in 2005 and has been ratified by more than 130 nations—but not ours [12]. We should ratify the treaty and work to make tobacco-related disease as rare as it was in the 19th century when doctors would travel just to witness the rare cancer of the lung.

Health Care Reform
In the early 1990s, I worked with President Clinton and First Lady Hillary Clinton on what I hoped could be a bipartisan effort to reform health care. At a White House meeting, I remarked, "Our health care system may function with compassion, with competence, at times with sheer excellence. But not for enough Americans. For too many Americans, our health care system is a tyranny, and that means for them it is more a curse than it is a blessing." [13] Party politics overwhelmed and killed that effort and offered little in its place. The number of Americans without health insurance has continued to grow and impede our nation's health and productivity, diverting hospital emergency care resources to what should have been routine medical care and threatening the economic viability of corporations big and small.

Health Care as a Moral Right
I know that in this land of chaotic claims to rights, there is no evidence, in the documents that America's founding fathers passed on, that suggests a right to health care, unless one assumes that it is implied by the "unalienable Rights. [to] Life, Liberty and the pursuit of Happiness" in the Declaration of Independence. Nevertheless, in poll after poll, people voice their belief that health care should be a right. I propose that we accept it as a moral right.

Core Principles
Following are the core principles that I believe are required to transform this unacceptable state of health and health care:

1. We must clearly affirm a fundamental moral right of all people to the highest standard of health through preventive care and, when disease and disability do develop, appropriate medical intervention.
   
2. Disparities in health care, be they on the basis of age, gender, ethnicity, sexuality, disability, or other characteristics, are unacceptable and at odds with the moral right.
   
3. The highest priority of health care providers—public and private—and health-related agencies including the Centers for Disease Control and Prevention, National Institutes of Health, and Food and Drug Administration, must be the improvement of the health and well-being of all people through disease prevention and treatment, with disease prevention assuming a larger role than it has in the past.
   

A Path for the 21^st Century
I believe that the incredible progress in public health and medical intervention of the 20th century will pale in comparison to what will happen in the 21st century. I am concerned, however, that the difference between the "haves" and the "have-nots" will worsen. It is in vogue to blame problems on the victims of disease and disability, on laziness, on immigration, on those who hold opposing political points of view, or even—and perhaps most incredibly in this most wealthy of all nations—on lack of resources. Consider just 2 telling facts: 80% of people without health insurance are from working families [14] and nearly 20% of them are children [1]. Can we blame their lack of access to health care on them?

Disparities in health care must be addressed with urgency. They threaten more than the physical well-being of our people. Failure to provide fundamental resources, be they clean air and water, education, or health care, are not consistent with what I believe is the essence of America. We should set a goal to reduce disparities significantly and provide health care for all within this first decade of the 21st century. Achieving this goal will take radical transformation of health care—not election-cycle Band-Aids. I do not intend to make this a partisan issue or the primary province of one as opposed to another branch of government. That would be neither productive nor true to history. Politics should serve health, not the other way around.

I am convinced that our growing health care crisis can be resolved only with the concerted efforts of both major political parties. I urge the president to work with leaders of Congress to appoint a bipartisan commission with input from major health organizations, public and private, to develop a plan toward fulfillment of the goals I have articulated. I urge health professionals and their professional organizations, foundations, and the private sector to support efforts that look at the 21st century from beginning to end as an opportunity for better health for all. Finally, I urge that as we focus on health care issues in the United States, we also consider the global context of our actions and participate more actively to raise the standards of health and health care globally. By contributing to world health, we not only demonstrate benevolence and leadership, we contribute to a healthier America.

I am constantly asked for the answer to our challenges as though a simple or foreseeable answer was sitting on the shelf along with underutilized health interventions. There are no simple answers. We must enter a process, guided by these core principles and driven by a commitment to health for all people. Then, I am convinced that answers will come, and they will probably include more than one surprise—surprises that will transform health care as we know it now. I look forward to doing my part to foster surprise, to implement change, and to see a better day for health worldwide.

	ACKNOWLEDGMENTS

Top Introduction Acknowledgments References C. Everett Koop Footnotes

 
I am grateful for the assistance of Jack E. Henningfield and Michael C. Fiore in the preparation of this article. Their efforts were supported by the Robert Wood Johnson Foundation, Innovators Awards Program at the Johns Hopkins University School of Medicine, Baltimore, Md (grants 46910 and 49532).

	REFERENCES

Top Introduction Acknowledgments References C. Everett Koop Footnotes

 

1. Center on Budget and Policy Priorities. The number of uninsured Americans is at an all-time high. Available at: www.cbpp.org/8-29-06health.htm. Accessed September 18, 2006.
2. National Center for Health Statistics. Health United States, 2005. Hyattsville, Md, 2005.
3. Koop CE. Koop: The Memoirs of America's Family Doctor. New York, NY: Random House, 1991.
4. McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA 1993;270:2207–2212; [Abstract].[Abstract/Free Full Text]
5. Peto R, Lopez AD. In: Boyle P, Gray N, Henningfield J, Seffrin J, Zatonski W, eds. Tobacco and Public Health: Science and Policy. The future worldwide health effects of current smoking patterns. Oxford: Oxford University Press, 2004.
6. US Dept of Health and Human Services. Women and Smoking: a Report of the Surgeon General. Rockville, Md: US Dept of Health and Human Services, Public Health Service, Office of the Surgeon General, 2001.
7. Fiore MC, Bailey WC, Cohen SJ et al. Treating Tobacco Use and Dependence. Clinical Practice Guideline. Rockville, Md: US Dept of Health and Human Services, Public Health Service, 2000.
8. Koop CE. Tobacco addiction: accomplishments and challenges in science, health, and policy. Nicotine Tob Res. 2003;5:613–619; [CrossRef][ISI][Medline].[Free Full Text]
9. Koop CE. Drug addiction in America: challenges and opportunities. Mil Med. 2003;168:viii–xvi; [Medline].[Medline]
10. Koop CE. The tobacco scandal: where is the outrage? Tob Control. 1998;7:393–396; [Free Full Text].[Free Full Text]
11. Henningfield JE, Benowitz NL, Connolly GN, Davis RM, Myers ML, Zeller M. Reducing tobacco addiction through tobacco product regulation. Tob Control. 2004;13:132–135; [Abstract/Free Full Text].[Abstract/Free Full Text]
12. World Health Organization. WHO Framework Convention on Tobacco Control. 2005, WHO Document Production Services, Geneva, Switzerland, Available at: www.who.int/tobacco/framework/en. Accessed June 8, 2006.
13. Koop CE, Remarks to physicians and supporters, The White House, September 20, 1993. Available at:www.ibiblio.org/darlene/sept.html. Accessed June 8, 2006.
14. Committee on the Consequences of Uninsurance, Board on Health Care Services, Institute of Medicine. Coverage Matters: Insurance and Health Care. Washington, DC: National Academy Press, 2001.

Editor's Note

	C. Everett Koop

Top Introduction Acknowledgments References C. Everett Koop Footnotes

From 1948 to 1981, Dr. Koop was also Surgeon-in-Chief at the Children's Hospital of Philadelphia. There he became a pioneer in the field of pediatric surgery and established one of the best departments in the field in the country, including the nation's first neonatal intensive care nursery. He also helped to establish the American Academy of Pediatric Surgeons and its journal.

In February 1981, President Reagan appointed Dr. Koop as Deputy Assistant Secretary for Health with the promise that he would be nominated as Surgeon General. Opposition to Dr. Koop's appointment, especially by those concerned that he would use the position of Surgeon General as a platform for his anti-abortion views, delayed the confirmation process. But he was finally confirmed by the Senate on November 16, 1981, and officially sworn in as Surgeon General on January 21, 1982.

Dr. Koop proved to be an outspoken advocate on public health issues. The problem of tobacco was one that he attacked particularly vigorously, calling for "A Smoke-Free Society by the Year 2000." Although the Public Health Service (PHS) had been calling attention to the danger of tobacco smoking since the 1964 Surgeon General's report on smoking and health, its anti-tobacco campaign was relatively low-key until invigorated by Dr. Koop's persistent efforts to speak out on the subject. The 1986 Surgeon General's report on the dangers of passive smoking was also an important milestone in the fight against smoking.

C. Everett Koop, M.D., Sc.D.

As the nation began to recognize AIDS as a new and deadly disease, Dr. Koop eventually became the chief federal spokesperson on AIDS. After remaining silent on AIDS for several years, President Reagan asked Dr. Koop to prepare a report on AIDS early in 1986. For the next 9 months, Dr. Koop worked on this report, writing much of it himself. The report, released on October 22, 1986, was explicit, nonjudgmental, controversial, and popular. It contributed significantly to providing accurate, comprehensive information on this frightening disease. Dr. Koop also personally penned "Understanding AIDS," the PHS brochure based on Centers for Disease Control guidelines that was sent to all 107 million households in the United States in 1988, the largest public health mailing ever done. Dr. Koop's frank statements about AIDS and his treatment of it as a public health rather than a moral issue won him many admirers, but his approach was not welcomed in all circles and he lost the support of many who had originally backed his appointment.

Dr. Koop also did much to revitalize the PHS Commissioned Corps and oversaw its centennial celebration in 1989. Dr. Koop's high-profile positions on topics such as tobacco, AIDS, organ transplantation, and the rights of the disabled also made the office of Surgeon General probably as prominent as it has ever been. He resigned as Surgeon General on October 1, 1989, but continues to educate the public about health issues through his writings and the electronic media. Dr. Koop also serves as Senior Scholar of the C. Everett Koop Institute at Dartmouth University and is chair or a member of various boards of health-related groups.

	FOOTNOTES

 
The following article was reprinted with permission from the American Public Health Association, from Am J Public Health, 2006;96:2090–2092. ©2006 American Public Health Association.

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