Proceedings of the Tenth National Conference: The Ninth G. Gayle Stephens Lecture by Surgeon General David Satcher, MD, Ph.D.

David Satcher, MD, MPH, then Surgeon General of the United States, gave the G. Gayle Stephens Lecture at the 10th National Conference in Bethesda, Maryland, March 1999.

John Midtling, MD, MS, Associate Dean, University of Illinois, Rockford:

Good morning. I am John Midtling, from the University of Illinois. It is my pleasure to be able to lead off this plenary session, which will focus on the Ninth G. Gayle Stephens Lecture. The Stephens Lectures were the first of the peer reviewed lecture series to be established as part of the National Conferences on Primary Health Care Access.

The Stephens Lectures have been presented since 1991. Thus, at all but the first of the ten conferences we have had a Stephens Lecturer. Among the imminent leaders in the disciplines of family and conmunity medicine that have given this address, are Doctor Stephens himself, and Doctors Charles Odegaard, Marion Bishop and Lynn Carmichael.

Today’s speaker is a great friend of ours, and a great supporter. We are honored to have the Surgeon General of the United States here today to give the Ninth Stephens Lecture, with Doctor Stephens in attendance. I regard Gayle as the intellectual founder of the discipline of family medicine. His works on the intellectual basis of family medicine are unmatched and are an important contribution to American medicine. It is fitting that this lectureship is named after Gayle.

It is a special honor for me to be able to introduce Dr. Cornelius Hopper who will present Surgeon General Satcher. I have known Con Hopper for almost my entire academic career dating back to 1979, when I joined the faculty at the University of California, San Francisco. I remember making presentations to Dr. Hopper in the early 1980s when he was a member of the California Health Manpower Policy Commission and I was a lowly residency director seeking funding from that Commission.

Last Fall, I had the opportunity to speak at the Commission’s 25th anniversary and was delighted that Dr. Hopper still serves on it, and soon is expected to become its senior member. Dr. Hopper and his fellow Commissioners have played a very important role in increasing access to health care in the State of California through the Commission’s efforts to increase the production and geographic distribution of family physicians, physician assistants, and nurse practitioners.

But I think Dr. Hopper’s greatest achievements are in his leadership of the University of California, as Vice President for Health Affairs, where he has helped nudge the University of California system and its five medical schools in the direction of increasing the production and distribution of primary care providers into the community, into the geographical areas of greatest need, and in service to at-risk and underserved populations. Leading the California medical schools has not been an easy task, given some of the legislative proposals, such as the Isenberg bill, that have impacted academic medical policy direction in California.

In fact, changing the specialty mix in medical schools has been such a difficult task, that if I ever need anyone to do demolition work on academic medical centers, I will call on Con. But he has been crucial to the effort to bring about change, and has avoided the mine fields. In the process, he has moved the University of California system along in a very positive fashion.

Having myself been a former citizen of California for a decade or so, I believe the people of California are deeply indebted to Dr. Hopper. Californians are also in debt to our honored guest, Dr. Satcher, for efforts that he put forth in South Central Los Angeles when he was in California, which we will recognize later. I also want to note there seems to be a California thread running through this morning,s introductions.

But there is an Alabama thread also, since both Doctors Hopper and Satcher have Alabama ties. So, to introduce a lecture named after Dr. G. Gayle Stephens of Alabama, I will turn over the microphone to Dr. Hopper.

Cornelius Hopper, MD

Vice President for Health Affairs

University of California,

Office of the U. C. President, Oakland

Good morning. Doctor David Sundwall earlier this morning mentioned a very sad event – the untimely passing of Dr. Herbert Nickens of the American Association of Medical Colleges, who was really a role model for many of us and a giant in his own way. I do want to join you all later today at Dr. Nicken’ funeral.

I am pleased to have the opportunity this morning to introduce Dr. David Satcher, the Ninth G.Gayle Stephens Lecturer. But I first want to congratulate the sponsors of this annual event for having the wisdom nine years ago to name a lectureship after Dr. Gayle Stephens, one of the predominant people in primary care in this country, and an outstanding leader.

There is a personal note to that, because I had the privilege of having a ringside seat in Tuskegee, Alabama throughout most of the 1970s, as Gayle Stephens and Bill Willard battled the dragons of Birmingham to put family practice training and practice on the map in Alabama. I am delighted that they were successful.

Our Stephens lecturer today actually needs very little introduction. David is a native of Alabama. After graduating from Morehouse College, he entered Case Western Reserve University where he got both his MD and Ph.D. in 1970. His career has been marked by a steady progression of leadership roles.

Among these, and I think very appropriate for today’s event, he developed and chaired the first King-Drew Department of Family Medicine in Los Angeles, and from 1977 to 1979 he served as the Interim Dean of the Charles R. Drew Postgraduate Medical School. During that time he carried a professorship at UCLA and was successful in negotiating an affiliation agreement between UCLA and Charles Drew that led to a medical education program that is still alive and well.

In the eleven year span from 1982 to 1993, Dr. Satcher served as President of the Meharry Medical College. In 1993 he moved to the Directorship of the Centers for Disease Control in Atlanta. Among his many noteworthy contributions and accomplishments in that post, he spearheaded initiatives that increased childhood immunization from 55% in 1992 up to 78% in 1996, and he laid the groundwork for new early warning systems to detect and prevent food-borne illnesses.

In 1997, David was nominated by President Clinton for the position of Assistant Secretary for Health and for the Surgeon Generalship of the United States and was confirmed by the Senate in February of last year. He is the 16th Surgeon General in a line that goes back to the year 1871. This is perhaps the most visible position in government for the advocacy of health behaviors.

He is, in effect, our administrator of health, and in his one year on the job, he has made it perfectly clear that he plans to make full use of this “bully pulpit”. (laughter) He has been, and remains an outstanding role model for those of us who are committed to the re-integration of medicine and public health. I give you our Ninth Gayle Stephens Lecturer, Dr. David Satcher, Surgeon General of the United States.

David Satcher, MD, PhD,

Assistant Secretary for Health and Surgeon General,

United States Department of Health and Human Services

Thank you. [Standing Ovation] Thank you very much. Well, thank you very much, I am delighted to be here. I want to thank Dr. Hopper for that very kind introduction. I am deeply honored to be asked to give the Ninth G. Gayle Stephens Lecture, to join a series of really outstanding family physicians and health professionals, in this line of Stephens Lectures. It is a real honor.

It is also great to be here, because this is the kind of place where I just want to stop and stay awhile. And I say that because I go to a lot of places. I can’t tell you the number of places I have been, just in the last two weeks, because I can’t remember. [laughter] My schedule is managed by somebody else, I just do it. [laughter] But every once in awhile I get somewhere, where I would like to stay awhile. These are the people I’d like to spend some time with, and that’s how I feel this morning. It’s quite a feeling.

There are so many people in this room to whom I owe so much in terms of my own development, and I just want to say a collective thank you to all of those people who have influenced me along the way and have been so supportive. Of course, Ludlow “Barry” Creary, who is there in the back, stands out as a really good friend and colleague – a friend when I went through some really difficult times in my life and family. He has been consistently a good friend, but also a great colleague. We worked together at King-Drew. We took on some real challenges in that inner city community to develop family medicine and family practice. So it’s great to see Barry, to see his wife Ruth, and his son Adam, back there.

Also, to see Bill Burnett, back there in the back row. He is always in the back row, but really has been a solid supporter of the development of primary care and of family medicine and was very supportive of our efforts in California. So whenever Bill Burnett says to me he wants me to do anything, if I can do it, I will do it, because I appreciate that.

Of course, there was another guy out there in California, back in those days. I think his name was Ken Moritsugu [laughter] out there representing the Department of Health and Human Services in that region. Of course, in my great wisdom he is now Deputy Surgeon General. Ken, just in case anybody missed you, why don’t you stand up [applause].

It really means a lot to me to have Ken as Deputy Surgeon General. He has been, for a long time, for many years, working on improving health and health care of the American people. He has been part of the Public Health Service for many years – I won’t tell you how many, because you won’t believe it – but it is great having somebody like that supporting you. I feel really good that Ken agreed to leave the Federal prison system where he had managed the health care for several years, to join us as Deputy Surgeon General.

There are so many other people here. Marion Bishop, I saw last week when I was speaking to the American College of Preventive Medicine, but didn’t get a chance to speak to her or hug her, so I did that this morning. And I feel better, much better. It’s good to see you (laughter). But it’s great to be here. There’s a young family physician who many of you know, Jimmy Smith, who joined us. He was with the Academy and joined us in the Office of the Assistant Secretary for Health and Surgeon General. Jimmy why don’t you stand up [applause]. We were delighted to have Jimmy with us. So we have a lot to be grateful for in terms of friendship and support. That’s why it feels so great to be here.

I want to commend you for the work you have done over the last ten years. I go to a lot of places that are much older. We were in Philadelphia at the Philadelphia College of Physicians. They started in 1787. In fact, they provided the medical support for the Lewis and Clark Expedition. [laughter.] We spoke there in the last ten days, and then two days ago we were at Yale speaking at the Annual meeting of Christian Whitney Library, there at Yale which was started in the early part of the 1700’s.

So we’ve been a lot of places and have seen institutions that did a lot of things in the eighteenth century and are still doing great things. Your National Conferences started in 1990, so it’s good to know that we’re just not looking back at the past but that we’re also building today for the future. And it’s great to have the kind of history that we have in family medicine and certainly the kind of work that Gayle Stephens and others have done to lay the groundwork.

Let me just tell you a story. I tell a lot of stories, but I don’t tell this one much. Back in the early 1970’s when the King-Drew Medical Center started, there was no Department of Family Medicine. The hospital opened in March, 1972. I arrived there, in July of 1972, to work with Doctor Al Haynes as a fellow in the Department of Community Medicine. Doctor Ludlow Creary was working with Al Haynes in that department. It was an interesting time. We started a physician assistant program and several other programs, and then set out to develop family practice.

It was an interesting environment. People from that inner city community needed a lot of help. Before the development of the King hospital, many people had to catch three or four buses to get to the Los Angeles County Hospital. They would go there without a specific appointment. Once there, many of them had to wait from five to eight hours. You can imagine why people didn’t seek care until the pain was unbearable, or the disease was life threatening. When the King hospital opened, the emergency room was very busy, very busy.

I had come from Cleveland and Rochester, where I had a background in treating sickle cell disease. When I first got to South Central Los Angeles, there was nobody there who knew how to treat sickle cell disease, so I volunteered to be on call for the emergency room. I even had a phone next to my bed specifically for that purpose, and got called to the emergency room a lot. We also started a hypertension clinic because that was such a serious problem.

But one of the interesting things that we noticed was the amount of chronic diseases that we saw among the patients who came to the emergency room. About 40% of the patients had significantly elevated blood pressure. That was one of several indications that what was needed in South Central was primary care.

You know as in most emergency rooms, the majority of the patients that come in there are not emergencies. They are using the emergency room in the absence of a primary care provider, and that was certainly true in South Central. They had an emergency room for people who were true emergencies, for people who were bleeding or had life threatening symptoms. Then they had what they called the walk-in clinic.

None of the other academic departments wanted anything to do with the walk-in clinic. Those departments disliked assignments to the walk-in clinic because the people came there, not because they had emergencies, but because they had other needs.

So Dr. Haynes and Dr. Creary and I developed the strategy for our department. We volunteered to take over the walk-in clinic, on the logic that if we were going to develop a primary care program, the walk-in clinic would be a good base of patients for it. You think about that.

As part of that process, I went over to UCLA as a Robert Wood Johnson Scholar to try to get some skills in planning and evaluation. I made it very clear to them that I wanted to do my project in Watts and they only reluctantly agreed. Bob Brook had just come from John Hopkins to head the Robert Wood Johnson Scholar program. We fought throughout the whole year, but we decided that I would do my project in Watts.

We selected out of that 400,000 population of South Central Los Angeles, a representative sample of households in terms of race, gender, and income, etc. We decided that we would survey that representative sample of households to determine the need for family practice in an inner city community. And we did this by putting together objectives of family practice.

We looked at writings of Gayle Stephens and others (all that we could find in terms of what was the essence of family practice). I think we ended up with a list of about thirty-eight objectives. And of course over at UCLA, you can imagine what went on. We learned about reliability and validity testing. We learned how to do sampling, and piloting, field testing – all of those things. We worked for a long time putting together this survey that would be valid and reliable. Then I trained a few people and we went out into the community to do these household surveys.

I never will forget this first house. I knocked on the door, and an older African-American gentleman came to the door. I explained to him that I was doing a “needs assessment study”. He looked at me and said “Dr. Satcher, I don’t knows what you’s got, but we needs everything.” [Laughter]

It did get easier after that, but I have to confess, it took me twenty years to realize that that gentleman was right. You cannot put the needs of people in boxes. You cannot package them in terms of health, or income, or children’s problems. You have to deal with their needs comprehensively. What he was telling me was that sometimes our needs are overwhelming. Sometimes we are worrying about surviving. Sometimes we worry about living through the day or the night. That was what he was communicating to me, many years ago.

Well, as you know, we completed the survey, we even published it in the Journal of Family Practice. But more importantly than that, we used it as a basis for developing our residency program and our teaching program there. It has been critical for me throughout my career in terms of what we learned in that community.

Let me share with you, as the 16th Surgeon General of the United States, and the second person to be both the Assistant Secretary of Health and the Surgeon General, my perspectives on what should be the priorities of our Office of Public Health and Science. And in a sense, what should be the priorities of the nation in terms of the health of the American people.

We have been celebrating the 200th Anniversary of the Public Health Service since July of 1998. We were founded when President John Adams signed the Act of Congress in Philadelphia in 1798 for the Marine Hospital Service to take care of the Merchant Seaman. Then it evolved from Marine Hospitals to eight agencies beginning with the hygiene laboratory that would become the National Institute of Mental Health and all of the other agencies and several other programs.

Today, there are 50,000 employees in the Public Health Service, including 6,000 of Commission Corps who report to the Surgeon General. We have a budget of 400 billion dollars. We have some major challenges that we are facing in terms of the health of the American people. So, in struggling with that over the last year, we have tried to put together a set of priorities. How will we spend our time? Where will we try to influence the resources of this country? Let me share these three with you and to say that we need your help as we try to move forward with them.

One that we believe is critical is to help move this country toward a balanced community health system – a system which balances health promotion, disease prevention, early detection and universal access to care. Balance! You know we have the most sophisticated health care system in the world, and probably the best technology and probably the best trained people. Yet it lacks balance. We spend 1.5 trillion dollars a year in our health system, and we spend about 1.2% of that amount for population-based prevention. That came to about 12 billion dollars in 1995.

There are a lot of problems in terms of balance. We spend a lot of money treating people when they are seriously ill. A lot of time we don’t even make a diagnosis until people are suffering from complications of diabetes or hypertension or what have you. That’s the nature of our system. One of the real challenges we face is the need towards greater balance.

What are some of the things that we would expect a balanced community health system to do? One, I think it would assure that every child born in this country has the optimal chance for a healthy start in life. I don’t believe that any nation could justify not giving children a chance for a healthy life. Nor could any nation justify allowing children to be injured early in life.

Sometimes the environment of pregnancy is the site of injury – fetal alcohol syndrome, crack cocaine, tobacco, low-birth weight. A lot of children in this country are not getting a healthy start in life. I think that commitment is one we ought to make. Whatever it takes to get there, we ought to do it.

Then, when the child is born, we ought to work to make sure that they have safe and healthy environments – including breast feeding in the first year of life and sleeping on their backs. A healthy environment that is free from tobacco, which is the source of the onset of so much asthma in early childhood and which accounts for the growth of asthma in this country. A healthy environment means immunizations. It means nurturing as a child develops very early in life. If you miss that opportunity, the child never fully recovers. So right up front we ought to make that commitment.

We have done some things that are important. We have the Child’s Health Insurance Program. We have made a commitment to try to cover every child in this country. There are 43 million people within this country who are uninsured and 11 million of them are children. And so, two years ago, Congress passed legislation that was recommended by the President to provide insurance coverage to all of those children, over a period of time, and put forth 24 billion dollars for the next five years.

We have already determined that 4.5 million of those 11 million children are eligible for Medicaid, but not enrolled. Part of the challenge is to get them enrolled. I’ve seen some interesting strategies to do this. In Chicago when I was visited the public school system, it was explained to me that they the Chicago schools had made a commitment to identify children who were eligible for Medicaid but not enrolled. In the first month they had identified 171,000 children. They took me to one of the schools where they were helping the parents fill out the application.

Now that application was too long, it was about 28 pages and I told them that I had visited Louisiana where people, working with the business community, had reduced their application for Medicaid from 28 pages to two. So I said, I want you to get in touch with Louisiana. You would be surprised how those long applications prevents people from having access to care in this country.

In California, we are also dealing with other issues that some of you are familiar with. A lot of the Hispanic families are reluctant to enroll their children because even though the child may be a citizen, they are worried that later on should somebody else in the family go up for citizenship, they may find themselves liable for all the child’s benefits. We are working with the Immigration and Naturalization Service to try to deal with that problem.

I want you to understand that that a lot of barriers can stand in the way of children getting access to care. I wish that we would just go ahead and make the commitment to universal access, but it doesn’t seem that that will happen. But if we are going to piece-meal it, then children represent a good place to start.

I hope next we go to prenatal care. As an example, 35% of the women in the District of Columbia do not see a physician in the first trimester of pregnancy. There are a lot of reasons for that, but I wish we as a country would say, whatever barriers stand in the way of prenatal care, including financial, we are going to remove them as an investment in our future.

The second thing that a balanced community health system would do, would be to promote healthy lifestyles – including physical activity, good nutrition, avoidance of toxins like tobacco, and responsible sexual behaviors. By now, hopefully you have heard about the Surgeon General’s prescription. This is an idea that originated with my staff, after hearing me talking about all these things. My staff said, since you are a physician, you ought to have a pad of prescriptions for healthy lifestyles. So now I can write out prescriptions to whomever needs them. I think I have given one to each of the children here this morning. I want to tell you what is written on these prescriptions.

One, moderate physical activity, at least five days a week, 30 minutes a day. Remember that report out of CDC in 1996, on physical activity? Well, science has backed that up.

Two, eat at least five servings of fruits and vegetables a day. Today, as we speak, the Department of Agriculture is releasing new guidelines for nutrition. What do they say? The American diet needs more grains and more fruits, more vegetables, less fats and less sweets. And clearly that is true. Why is that clearly true? Because both childhood and adult obesity is at an all time high in this country. 36% of adults are overweight, 15% of children are overweight. Among African-Americans and Hispanics, over 50% are overweight. Obesity is an epidemic in this country. Physical activity and nutrition is something we ought to be prescribing for our patients and for our communities.

The next one is avoidance of toxins, including tobacco, illicit drugs and abusive alcohol. I know I don’t have to talk to this audience about tobacco. You know that over 430,000 people die every year from smoke related diseases in this country. Not all of them are smokers, by the way. You know we estimate 62,000 cardiovascular deaths from second hand smoke, and 300,000 lung cancer deaths from second hand smoke. How many children suffer because of other people’s smoking?

Why is it that inner city children are twice as likely to show up in the emergency room from asthma, or to be hospitalized. For one thing, they live in units where they are exposed to tobacco smoke, even if nobody in their own home smokes. Sometimes the smoker could be the person next door. Smoking is a problem that affects each of us right now, and not just in terms of our risk for lung cancer 30 years from now. Millions of peoples suffer every day from their own smoke and from other people’s smoke, so we need to be very serious about tobacco.

I mention the abuse of alcohol because it is increasing as a problem. On our college campuses, we estimate today that 42% of college students are binge drinking – that is, drinking five or more drinks in one sitting. You probably heard about my little debate with the Bureau of Alcohol and Firearms and Tobacco. It had to do with approving language about the health benefits of alcohol. The point I was trying to make was that when we say moderate drinking, there are some people who interpret that the way that they should -something like one or two glasses of wine a day.

But studies were conducted that found that there are other people who define “moderate drinking” as six drinks in any one sitting. People do not necessarily know what we mean when we say “moderate” So we have to be very careful.. Since 1991, there has been an increase in the percentage of pregnant women drinking.

One of my favorite stories, which I’m sure some of you have heard, Kay and I were at the Robert Wood Johnson Foundation about a month ago where I spoke to the Board of Trustees. We wanted to get back to Washington that night, so we rushed to the Trenton Station to catch the last train. We were standing around waiting, the train was late, and I was in my Surgeon General Uniform and a lot of people were walking around. One guy who was smoking, looked up and said, “Man, you look like the Surgeon General.” [Laughter.] And I said, there’s a reason for that. Then he started screaming to people, “The Surgeon General is here, the Surgeon General is here,” and people came running from everywhere.

The first guy who got there said, “Man, you mean you’re smoking in front of the Surgeon General?” He threw the cigarette down, he stomped it, and I wrote him a prescription. [Laughter.] His buddy got a kick out of that and started laughing. Then the first man said, “Well, you can’t laugh, you’re overweight.” So, I wrote him a prescription [Laughter.] Another guy came up and they said, “Well the way you play around, you’re going to get AIDS or something.” I wrote more than ten prescriptions that night.

But seriously, let me tell you why this is so important. Let’s just list some of the reasons. I mentioned that obesity is at an all time high. 3,000 new teenagers become smokers in this nation, every day. One half of them will be addicted before they are old enough to buy cigarettes legally. One third of them will die from smoke-related disease.

Only one state in the Union requires physical education Kindergarten through grade 12. Only 25% of teenagers take physical education. At a time in our history when more people spend more time in front of TVs, more time in front of computers, and where many streets are not safe to walk on, much less jog, our schools are not requiring physical education. That is one of the first things to go when schools have to cut their budgets.

Some people say because we promote physical activity and healthy lifestyles, our message is personal responsibility. Responsible sexual behavior is personal responsibility, yes, but our message is also community responsibility. We cannot separate personal responsibility from community responsibility. If we are not requiring our young people to take physical education, and making it attractive so that they develop lifetime physical activity habits, then we are failing community responsibility. If we don’t teach sex education, in the schools or in the homes, or in the churches, or in the community, we are failing.

One of my favorite people passed last year, Mary Calderon, whom some of you knew. She was 94 when she passed. She pushed this country in terms of sex education. You may think that Jocelyn Elders was the first to try to move us, but Mary Calderon tried for years. I remember when I was a student at Case Western University, she came and spent a week there. In fact, my advisor, Neil MacIntyre, had her there because they were trying to get us oriented to our role in sex education.

The thing that I remember most about Mary Calderon was that one day she said to us, “I want you to think about sex. Really think about it. And I want you to think about a four letter word for sexual relations, that ends in k, a four letter word that ends with k.” And we were all down in our seats and we waited, and we waited. And she said, “Talk, T-A-L-K. That’s where sexual relations ought to start.”

We talk about abstinence to our young people. The one point we try to make is that this is about relationships, human relationships and what that means. Relationships don’t start with sex. They don’t. If they do, they are destined to fail. So we ought to be talking to our teenagers about what is significant about relationships. Mary Calderon tried to make that point, but she also tried to move us as a nation to getting comfortable talking about sex and therefore, doing a better job with our children. We are not there yet. We have a lot to do.

Too few Americans consume five servings of fruits and vegetables per day. Too few persons will have high blood pressure diagnosed and treated. Too few have their blood pressures controlled, even today. Too few diabetics are diagnosed and adequately treated. Too few physicians are putting prevention into practice. There simply are too few healthy communities in this country. So we have some major challenges in this area.

The third thing that a balanced community health system should do is to provide an environment of caring and support for mental health. For too long, as many of you know, our attitude towards mental illness has been one of blame and stigmatization, as opposed to caring and support. It is time for us to make the point that just as things go wrong with the heart, the lung, the kidneys, and the liver, things go wrong with the brain.

There should be no shame in that. No family should have to hide because of that. Nobody should be reluctant to come forth to seek help because of that. Yet, we have created an environment where people are reluctant to seek help. We can and have to change that kind of environment.

We had a national conference on suicide prevention last October. We brought together our experts from CDC, and ADAMHA, and NIMH. We brought health policy experts and people who were practicing in this area. We also brought suicide survivors – people who have had intimate family members commit suicide, and people who themselves have attempted suicide. 750,000 people attempt suicide in this country every year. We estimate that there are 5 million Americans living who have attempted suicide. So we have a lot of survivors. And we all came together, people from these various perspectives.

We put different groups together to work on recommendations. These groups fought and argued. When it was all over they presented me some key recommendations which will be coming out very shortly as the Surgeon General’s Conference Report on Suicide Prevention. The recommendations all neatly under an acronym we call AIM. A-I-M.

“A” is for awareness. We need to increase the awareness of the American people about suicide and the early signs of suicide. Are you aware of the fact that most people in this country don’t know that over 40 million people a year in this country have some sort of mental illness that is incapacitating in terms of their day to day activities. We estimated 44 million for the last year for which we have information.

Awareness! We need to educate people about mental illness, so people don’t continue to look at it as something strange. The New York Times had an article recently pointing out that over half of the people who are homeless are not homeless because they are poor, but are homeless because of mental illness. There was a study done at UCLA, during the time I was a clinical scholar, showing that it was also true back then in Los Angeles.

“I” is for intervention, which we need to improve. We need to improve the early diagnosis of depression. It was pointed out at that conference, with very good data, that of the people who commit suicide, 70% had seen a physician within the last 30 to 60 days. And in most cases, they were not asked by the physician about depression. We do need to improve our level of suspicion, if you would, and index our suspicions so that we diagnose depression early enough to prevent suicide. We have a lot to do.

“M” is for methodology. We need to continue to do research, to come up with better indications, better ways of diagnosing, better ways of treating depression and anxiety and other forms of mental illness. We also need to deal with substance abuse. I know that there are a group of physicians, Lou Sullivan, Ed Brand, and others, and some of you, I think, who are involved in a program to try to get more attention paid to addiction medicine.

Addiction disorders are in many cases just as treatable as diabetes and hypertension, if not more so. But every day people are being sent off to prison, when they need to be sent to a treatment for addiction disorder. They come out of prison more addicted than when they went in. So we have a vicious circle. Now there are some people who go to prison – who are selling or whatever – that should be there. But there are a lot of others who are just addicted to drugs and they need to be treated. Addiction disorders are medical problems. That is a message!

The last thing the system should do is the one thing I know you have had a lot of discussion about – that is to improve access to quality health care. We need to find ways to eliminate all the barriers to universal access, whether the barriers are because people are uninsured or live in underserved communities. Many of you have spent years and years working on that problem.

There are other barriers, too, including the underrepresentation of African-Americans, Hispanics, American Indians and others in the health professions. There is a barrier to access when providers are not sensitive to the culture of the persons needing care, and when there is distrust by those persons of the system. How do we get more providers in underserved communities? How do we break down the barriers?

We had a very important study last year that I hope you are familiar with. It was the Tamoxifen study by the National Cancer Institute to show that Tamoxifen can prevent the development of breast cancer. Now whenever Congress decides to hold a hearing on some medical issue, they want the Surgeon General to be lead speaker. I can’t explain to you why that is, but they think that it gives the hearing more prestige. Because they asked me to be the lead speaker, I had to look into the Tamoxifen study. Well, one of the first things that I found was that only 2% of the women in the Tamoxifen study were minorities – only 2%. So, I asked, what is going on here, why only 2%. They said, “Well we tried. We tried.” And I am sure they did.

But until we have a community-based system that involves a diverse group of people in a provision of care, we are not going to succeed, whether it is getting minorities to participate in a Tamoxifen clinic trial or just getting basic care to people. We need a health care system that reflects our population, and the cultures and languages that comprise it. Language and culture should all be represented in our health care systems in such a way that people feel comfortable with it and trust it. There is a lot of distrust now.

I won’t go into all the concerns this administration is struggling with in terms of health access, but one notable goal is to change environment of hopelessness. There are several programs under way, in terms of raising income and reducing unemployment. Welfare reform, with all of its problems, has as its ideal the elimination of environments of hopelessness.

When I was President at Meharry, we were concerned about teenage pregnancy, especially in the housing projects around Nashville. I went to meet with David Hamburg at the Carnegie Corporation to request some money to work on teenage pregnancy. Well, I didn’t get very far the first time. The second time I went, I took Hank Foster with me. They were good friends, and I knew it, and I asked David Hamburg for funds again. He reluctantly said yes, and finally we got a grant from Carnegie to study teenage pregnancy.

Hank Foster pulled together a team of people, including clinical psychologists and social workers. The first thing the team did – very smart – was to go into the communities to interview the teenagers and their parents. Most households – 88% – were headed by single parents. And they asked them about the risk factors for teenage pregnancies.

The team reported back to the Carnegie Commission, “David, the problem is not teenage pregnancy. It is only a symptom, like violence and drug abuse. Teenage pregnancy is just another one of those symptoms. The attitude of a group of teenagers who don’t have a lot of hope for the future is that they are going to be dead by the time they are 25. Most of them think they will never get out of the housing project, because they haven’t seen enough people get out.”

So, we organized a program called “I Have a Future” to be our teenage pregnancy prevention program. We developed eleven kinds of programs where the housing projects are – tutorial programs after school, bringing kids onto the campus in the summer, giving them jobs, or “entrepreneurships”. I think Hank Foster said that within five years, that the number of males in Nashville’s major housing projects graduating and going to college had tripled. The programs gave them something else to do. I think it is a model for what needs to happen. When that man in South Central said to me, “We needs everything”, one of the things we need is hope for a better life for our children.

I can relate to that because I grew up in a situation where neither of my parents finished elementary school. But they created and environment of hope and high expectations of what we were to do. And that’s what we owe our children, HOPE.

Well, let me close, there are two other priorities. My talk has been about a balanced community, but this community is getting bigger every day. You have to look at public health as part of a global community. If you have my responsibility, as I do, of protecting the blood supply of the country, you have to be aware that it is a global blood supply. Whatever happens anywhere in the world can threaten the safety of the blood supply in this country. We didn’t even pick up Hepatitis C, which developed somewhere else in the world, until 1988.

Our food supply is a global supply. 60% of our seafood from outside of the country. 40% of our fruits, 8% of our vegetables. We live in a global community, and, of course, we send a lot of things out of this country, including tobacco to addict generations of children to smoking. So we live in a global community, and if we are going to be successful in public health in the future, it has got to be global.

The last priority which I want to mention to you and it’s very important to us is eliminating disparities in health on the basis of race and ethnicity. It’s a commitment that we have made at every level of government. It was almost two years ago that President Clinton in speaking at the commencement at the University of California, San Diego, talked about the race initiative.

The fact is that we are the most diverse nation in the world, so we should be providing leadership in dealing with diversity. He called upon the American people to engage in a dialogue about diversity in race and ethnicity. He appointed a national advisory council headed by John Hope Franklin. They met in several places throughout the country. There were debates. There was cynicism. They finally came out with the report and recommendations.

What some people missed, of course, was that each cabinet head was asked to develop some strategy to support the race initiative. In our Department of Health and Human Services, led by Secretary Donna Shalala, we made the commitment, after a lot of discussion and debate, to eliminate disparities in health by the year 2010. Now, I know that be we have been talking about reducing disparities ever since Julie Richmond in 1979 started “Healthy People”. We have been committed to reducing disparities through ten year planning cycles. We made some progress in some areas, but when you make the decision that you are going to eliminate disparities, you raise a lot of questions.

Number one you raise the question, is it realistic? Some people are very cynical about that. But also you say a lot about what you have to do. Those things that you know you can do, you make the commitment to do them. If they are access problems, you make the commitment to get rid of those problems. The areas where you don’t know how to do it, you make the commitment to do research to find out what it will to take to eliminate disparities. And that’s what we are trying to do.

We are trying to make sure that we make those basic commitments to move in that direction. Let me just give you some examples. We decided to take just six areas to focus on – (1) infant mortality, (2) the HIV/AIDS epidemic (which is increasingly becoming an epidemic of women and people of color), (3) childhood and adult immunizations, (4) diabetes, especially dealing with complications, (5) cancer screening and management, and (6) cardiovascular disease, focusing on risks. Those are the six areas that we decided to start with, not because those are the only problems, but because we felt that we had the data base for those and that they applied to so many different groups.

For example, a baby born to an African-American mother has more than twice the risk of dying in the first year of life than a white baby, an American Indian baby 1.5 the risk. A Vietnamese woman living in this country experiences cervical cancer at 5 times the rate of the majority of women.

African-American men, under the age 65, suffer prostrate cancer at twice the rates of whites. In fact, it is the highest rate of any group we know of in any country in the world. American Indians suffer from diabetes at nearly 3 to 5 times the rate of the majority of the population. In some of our American Indian tribes, it is the highest rate of diabetes seen anywhere in the world. Hispanics are twice as likely to be diabetic. African Americans are more likely to be diabetic. Breast cancer incidents are higher in white women, yet African American women are more likely to die from breast cancer.

The AIDS epidemic is interesting. When it was recognized in 1981, we thought it was an epidemic of white, gay men. All of our biases that relate to gay men came out, yet very clearly it was and always has been an epidemic of all people. Anything that transfers body fluids from one to the other, especially blood and semen, can transmit the AIDS virus. And so we saw that one half of the hemophiliac population in this country become infected with AIDS. By the middle of the 1980’s, we saw that people who got transfusions for surgery, like Arthur Ashe, become infected with AIDS. We saw the increase in heterosexual transmission. We saw injection drug use, especially where people shared dirty needles, become a major factor.

So whereas in 1986 only 8% of the people with AIDS in this country were women, 25% were African-American and 14% Hispanic. By the end of 1997, 23% of the people with AIDS reported to CDC were women, 45% African-Americans, 22% Hispanics. When we looked at that group between the ages of 13 and 24, 50% of the new AIDS cases in that group, 44% were female and 63% were African-Americans. So you see what is happening with this epidemic. This is a pandemic. It is probably the worst pandemic we’ve seen since the plague in the 14th century or the influenza pandemic of 1918.

But we know how to stop this problem. We know how to prevent the spread of AIDS, even though we don’t have a vaccine. We have made progress in pharmaceuticals so we can treat people with AIDS. We’ve seen a drop in death rates. We’ve seen a drop in full-blown AIDS. We can prevent the spread of this virus. We have made commitments to be very aggressive about prevention in the next few months and years.

You’ve seen us, I’m sure, going to the churches, and sometimes not being well received. It’s been gradual. You’ve seen Jesse Jackson get on board. You’ve seen our program two Sundays ago with him. We are very pleased with what’s happening with community leaders becoming involved with this epidemic and not just pointing fingers at sex and drugs, but pointing a finger at the disease. So we’re very pleased with what’s happening, but we have a long way to go.

I will end with what we are doing with diabetes. I visited an American Indian Hospital in North Dakota recently. It was amazing what I saw in terms of the number of people on dialysis for end-stage renal disease due to diabetes. I want to remind you that type 2 diabetes constitutes about 90 to 95% of the diabetes that we see. We can prevent the onset of more than 30% of type 2 diabetes with physical activity and nutrition. And if we diagnose people with diabetes early enough, we get them under control so as to prevent complications such as blindness, knee amputations, and the end-stage renal disease.

Those are things we can do to close the gaps. It’s not a zero-sum game. We wouldn’t have to take anything away from any group in order to improve the health status of another group.

I think we have proved that with the childhood immunization program at CDC. When it started, you heard that the childhood immunization rate nationally was 55%. What you didn’t hear was that in Detroit, Michigan it was 29%. On some American Indian reservations, it was less than 20%. So we targeted the most vulnerable groups, developed new strategies and public health partnerships that we never had before.

By 1975 almost 85% of the children of this country were immunized by the age of two, and no group – African-American, Hispanic, American Indian – was below 70%. So we have come a long way towards closing the gap in that area. Everybody benefited – white children, black children, American Indian. Everybody benefited from the effort to improve immunizations here. That is what is going to happen with the effort to eliminate disparities.

We are going to have a better public health system in this country. We are going to have better health care – everybody’s going to benefit. We need, as Con Hopper said, a new partnership between public health and medicine. As Donna Shalala said in Chicago in 1996, “Public health and medicine are like two trains running parallel. On one side, medicine looks out the window and often sees the individual patient and a disease. On the other side, public health looks out and sees a community, the population, and thinks prevention. But it’s the same community.”

The bridge is family practice. And that goes all the way back to the Millis Report in 1966 which asked, what is primary care? The four “C’s”. It is “Comprehensive care” where the physician is trained to take care of the overwhelming majority, 90% plus of the problems seen. It is first contact care for the undifferentiated patient. It is “Continuity of care” and “Coordination of care” in this very complex system. But what else did they say it was? It was “Community leadership”. Community leadership was the fourth C.

Family physicians are expected to provide community leadership. That’s the bridge that exists between public health and medicine as we know it, because family physicians take responsibilities, not just for their individual patients, but for their patients? families, and their communities. That’s where we need to be in this country, and I hope we get there soon.

We don’t have a lot of time as in that old poem “God’s Minute” says: “I have only just a minute, Only sixty seconds in it, Forced upon me, Didn’t seek it, didn’t choose it, Yet it’s up to me to use it, I must suffer if I lose it, Give account if I abuse it, Just a tiny little minute, And yet eternity is in it.” Thank you. [Standing Ovation.]

Midtling: I know that Dr. Satcher has indicated a willingness to take questions, but I also know that he is under a tight timeline and I’d like to take the moderator’s perogrative, since we are going to recognize him for work that he did at King/Drew and work that he has done nationally to advance health care for inner city populations, I’d like to take the prerogative to hold the questions so as to allow him to meet his scheduling obligations.

I’d just like to say that it was great to see you again, David. I think that the last time you came to the conference was in 1993, just about six years ago, and that you have been the embodiment of what this conference has been all about – primary care, access to care, and prevention. I certainly think you have used your minute, your sixty seconds, to have a major impact. Hopefully, you will have sixty minutes because, you’ve had a major impact and you’ll continue to have a major impact. It’s great to see you again, and we’re appreciative that you took time out to be here today with your friends and your supporters. We thank you.

Last Updated (29 January 2005 16:37)

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