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David Satcher, U.S. Surgeon General
Landon Lecture
Thursday, September 20, 2001


To the Landon patrons, the university officials, members of the faculty and students, community, and to all of you distinguished people, I'm delighted to be here. I bring you greetings from Washington, D.C. It's not easy to get from there to here, especially at this time of year with all the things that are going on, but we had a very safe trip yesterday.

I'm delighted to be here today and certainly to be a part of this outstanding Landon Lecture Series. Clearly Gov. Alf Landon was truly a remarkable person and a legendary leader, and I consider it a distinct honor to deliver the lecture that bears his name, and certainly following his impressive leadership. Of course, his daughter, Nancy Kassebaum Baker, did an outstanding job as senator. She has certainly been one of my favorite people because of the spirit of civility and bipartisan productivity that she brought to the Senate, something that was so greatly needed, and is still greatly needed today. So I'm delighted to be here.

These are difficult times and all of our hearts go out to those who lost their lives or were injured in the terrorist attack that took place last Tuesday. I was on my way to the Union Station, I was to lecture at Princeton Tuesday afternoon and then catch a plane to South America to help Uruguay launch their Healthy People 2010 when the news came of the attacks of the World Trade Center. And as Surgeon General I immediately activated the Commission Corps Readiness Force.

Now, most people understand the role of the Surgeon General when it comes to the responsibility to communicate directly with the American people on issues related to their health and the health of family and community. Probably less well understood is the role of the Surgeon General as the commander of the Commission Corps of the Public Health Service. But we have about 5,600 members of the Commission Corps. For the most part they're health professionals. We also have engineers in the Commission Corps. Veterinarians play a tremendous role in the Commission Corps in a lot of our investigations, but the Commission Corps is a group of people on call 24 hours a day, seven days a week, to respond to any threat or emergency impacting the health of the American people. So we called them to active duty one week ago and they have played a tremendous role in rescue operations in New York City, at the Pentagon and in Pennsylvania, including members of the team who are now making a major effort to identify bodies.

But the thing that's really impressed me so is that there are about 800 members of the Commission Corps Readiness Force, people who are highly trained and highly skilled, and we put them on notice that a minimum of them would be called up. And we've had a lot of people calling the last few days complaining that they were not called yet. It's amazing the spirit with which people are responding to this disaster.

It sort of reminds me of a story, which Andrew Attaway shared in the Guidepost a few years ago. It was about his daughter, Elizabeth, at the time she was 2 1/2 years old, and Andrew Attaway wrote about his daughter and how her favorite thing was to have her dad read to her. Her favorite book was book given to her by her grandmother. And in that book her favorite story was The Good Samaritan.

And Andrew Attaway has read this story to his daughter many times, and so he decided to quiz her. And so he asked her about the story - you know the story, the man was on his way from Jerusalem to Jericho and fell among thieves, was robbed and beaten severely, left bleeding to die, and of course along came a priest who was on his way to church, and looked over at the man and decided that he was running late and so he couldn't stop to help him. And then another man passed by, a Levite, he was not late, but he asked the question that many of us ask, he said, "This is a very dangerous period and what will happen to me if I stop to help this man?" And so he went on.

And then a man came by who nobody expected to stop, a Samaritan, he was on his horse, looked over and he asked a different question, "What will happen to this man if I don't stop to help him?" So he got down off his horse and stopped the bleeding, bound up the wounds, took the man into town and left him for care and said, "I'll pay you whatever it costs."

So Andrew Attaway read the story to his daughter Elizabeth and then he quizzes her, "Where was the man going?" She remembered he was on his way from Jerusalem to Jericho. He asked, "What happened to the man?" And she described that he was beaten and was bleeding. And then he says, "Elizabeth, did the priest stop?" And Elizabeth said, "Yes, the priest stopped to help."

So Andrew Attaway reads the story again to Elizabeth, and he asks the same question, "Did the priest stop?" And she said, "Yes." And after awhile he gets really frustrated, he says, "Now, Elizabeth, I've read the story to you many, many times and every time I ask you if the priest stopped you say yes." And Elizabeth sad, "But, Daddy, I want the priest to stop. I want the story to be different."

Well, I don't know about you, but I sort of feel that way about last Tuesday. Sometimes I keep hoping that I am going to wake up and find out that it didn't really happen, that it was just a dream. But I think - we're not children, we know that we can't change the past, but I think together we can certainly shape the future.

And I want to talk about one aspect of that future, and that is the health of the American people and our role in terms of the global health. Since 1979 we have been involved in a process in this country called Healthy People. In fact, it was Julius Richmond, Dr. Julius Richmond, the only other person who served as both Surgeon General and Assistant Secretary for Health, who released the Surgeon General's report in 1979 called Health Promotion and Disease Prevention, and in that report he recommended that the nation embark upon a process of planning for the health of the American people on a 10-year basis, and we would set goals and objectives, measurable objectives.

And the first Healthy People program was released in 1980 and it was called Healthy People 1990, because that was the date at which it would end and be evaluated. And then in 1990 we released Healthy People 2000. When I came on as Surgeon General we were coming to the end of Healthy People 2000, and we looked very critically at what we had done. We traveled all over the country to get input as to what should be the major thrust of Healthy People 2010. And in January of 2000, Donna Shalala, who was then secretary, and I released Healthy People 2010.

There are two goals for Healthy People 2010. One goal is sort of a response to the fact that we as a nation are aging. There are now in this country over 35 million people over 65 years of age, and we're estimating that by 2030 there could be 70 million people over 65 years of age. In fact, the fastest growing group of people in America today are people over 85. So we have made a lot of progress improving the years of life that people live.

So the first goal of Healthy People 2010 is to wok to improve the quality as well as the years of healthy life. And it focuses on areas such as chronic pain and depression, Alzheimer's, Parkinson's, lower back pain, all of those areas where we see a lot of problems in terms of the elderly.

But it's not just concern about quality of life from the perspective of the elderly. We believe that quality of life begins at birth or at conception. For example, whether or not a baby's breast-fed has a lot to do with the quality of life. Certainly whether or not a child receives immunizations on time. A child who is abused early in life suffers an impact on quality of life for the rest of his or her life. A child who suffers from asthma and who cannot predict when the next asthma attack is going to come on suffers a diminished quality of life.

So the quality of life goal is one that involves a lot of objectives relating to on the one hand improving the independence of older American and dealing with the problems that older Americans face, but also looking at every step in life as to how we can improve the quality of life throughout life.

The second goal of Healthy People 2010 is a goal which acknowledges that we as a nation are becoming more diverse. In fact, diversity is one of the striking characteristics of our country, and should be one of our major strengths as a nation. In the area of health we have been concerned about disparities in health among different racial and ethnic groups in this country. So one of the goals of Healthy People 2010 is to work toward the elimination of disparities in health.

We began by focusing on six major areas of disparities, infant mortality; cardiovascular disease, including stroke; cancer, and especially cancer morbidity and mortality; diabetes, which is a really interesting area because it's one of the areas where we've seen a dramatic increase in the last ten years in this country; the HIV AIDS epidemic; and finally immunizations, childhood immunizations, where we've made so much progress in the last 10 years, but also adult immunizations, the influenza vaccine, the pneumococcal vaccines, that could really save so many lives in this country if we could get me adults over 65 immunized.

But there are disparities in each of these areas. For example, today in this country an African American baby born is two and-a-half times as likely to die in the first year of life as a majority baby. An American Indian baby is about twice as likely to die in the first year of life. In the area of cardiovascular disease, there are major disparities among different racial and ethnic groups, including the Asian pacific islanders at increased risk, African American males especially and females, at increased risk of heart disease and stroke.

In the area of cancer there are dramatic disparities. White women in this country have the greatest risk for breast cancer of any group. African American women have the greatest mortality rate. Now, we have made significant progress in the last 10 years, and really for the first time in the last 10 years, at reducing cancer mortality, especially cancer of the breast, where the reduction has been more than 20 percent. We've got to keep that going, and I think we will, as well as some other areas of cancer mortality.

But there are disparities. Asian Americans suffer disproportionately cancer of the liver, and most of that is related to hepatitis, and many Asian Americans who come to this country have experienced hepatitis. Of course, a lot of Americans suffer hepatitis, but it's disproportionately seen in Asian Americans, and so that goes on in many cases to cancer of the liver, so there is a disproportionate impact.

I think diabetes is one of the most interesting problems we're facing in this country today, for many reasons. For one thing, of course, we've seen a dramatic increase in the number of Americans who suffer diabetes, I think it was about four and-a-half percent about 20 years ago and we're now up to around seven percent of Americans experiencing Type II diabetes, that type that's related to overweight and obesity especially.

There are disparities. Native Americans or American Indians are at the greatest risk for Type II diabetes, and they suffer it at least three to five times the risk as the majority of the population. And it's interesting, because while we see that in this country, if you look at the same populations or certainly relatives of them in parts of Mexico, we don't see the same rates of Type II diabetes.

Hispanics in this country are at least twice as likely to suffer Type II diabetes, and diabetes, of course, often goes on to cause complications, such as blindness and the need for lower limb amputation and end stage renal disease. So there are a lot of people throughout the country on renal dialysis. As I visit reservations, for example, even in some of our smallest hospitals you see many people on dialysis with end stage renal disease. African Americans have an unusually high mortality rate from diabetes, because it often comes together with hypertension, and they both, of course, work on the kidneys and cause end stage renal disease as well as other cardiovascular diseases.

But again, one of the most striking things about diabetes, of course, and we're learning more every day, is the tremendous ability that we have to prevent Type II diabetes through programs of Health Promotion and Disease Prevention, which I'll mention later. But it's one of those areas where attacking life-style, if you will, is critical.

There are disparities in the AIDS epidemic, an epidemic which started as primarily an epidemic of white gay men in this country and has evolved over the years to affect disproportionately minorities and the poor. And so all of the recent reports to the CDC show a disproportionate impact on Hispanic and African Americans in terms of HIV AIDS. Those are just examples of disparities that we're facing in health.

Now, in Healthy People 2010 we have a lot of objectives. In fact, we have over 400, and one of my concerns, of course, was how do you communicate 400 plus objectives to the American people? You can't do it. Now, I want to assure you that there's somebody who's interested in every one of those objectives, there's some group that really focuses on area objectives.

For example, for the first time in Healthy People 2010 we have areas dealing with hearing and visual disorders. We didn't have that before. We have health communication for the first time. In all of these areas there are agencies within the government and there are community organization that are focusing - the American Heart Association, for example, focuses on objectives dealing with cardiovascular disease and stroke. The American Cancer Society, they join the National Cancer Institute. So all of these objectives have a lot of people and resources behind them.

But the question is, how do you as Surgeon General communicate Healthy People 2010 to the American people when you're dealing with 467 objectives. We decided that it couldn't be done. So what we decided to do, working with the Institute of Medicine, was to try to identify a small set of leading health indicators that would capture the essence of Healthy People 2010, and that we could communicate to the American people.

So we worked with the Institute of Medicine, we used regression analysis to try to conceptualize the major areas, and we ended up with 10 leading health indicators that we felt captured the essence of Healthy People 2010, and I want to leave those with you.

Of those 10 leading health indicators, five of them relate to the health system, beginning with access to care, because there are major disparities in accessing. We still have over 40 million American people who are uninsured. Hispanics, of course, are most likely to be uninsured. More than one out of three Hispanics. But it goes beyond that. If you ask Hispanics if they have a person physician, then as high as 46 to 50 percent report that they do not. One in four African Americans in this country are uninsured, but if you ask them about whether they have a physician, almost 40 percent report that they do not. So it becomes a problem at the outset in terms of are people really getting comprehensive health care? Especially primary care, where problems are discovered early, where providers have the opportunity to communicate about things you can do to improve your health. And so we decided that access to care, especially for prenatal care, should be one of the major targets for Healthy People 2010.

In the area of the health systems, another major area that I've dealt with and many of you are interest in, of course, from your work, is mental health. In December of 1999 I released the first ever Surgeon General's report on mental health, and in that report we said, among other things, that mental health is fundamental to overall health and well-being, that the mental disorders are real in the sense that they are, in fact, physical disorders. They have bases in the brain. We’ve studied the brain now intensively, and over the last 25 to 30 years it's very clear that most mental disorders can be traced to changes in the neurons of the brain or the secretions, the connections. And so mental disorders are real, and not only that, mental disorders are treatable. 80 to 90 percent of the time today we can treat people with mental illness and return them to productive lives and positive relationships.

And that was the good news in that Surgeon General's report, we can treat people, we can return them to productive lives, positive relationships. The bad news in that report was that of the one in five Americans who suffer a mental disorder each year, about 20 percent, 44 million people, of that number less than half even seek treatment. And you say, "Well, why is that?" Because of the stigma that still surrounds mental illness in this country. And I should say stigma and discrimination because there's still people who won't hire people who have a history of mental illness. There are still people how don't promote people who have a history of mental illness.

So we have a problem, and not just we America, it's a major global problem, in that this very real health problem, which is diagnosable and treatable, is still surrounded by an aura of stigma and discrimination. So people are not comfortable.

People who have children with mental disorders often hesitate to take them for care. They don't want other people to know, and so what it does is it adds to the problem and we end up seeing the products of our mental health problems in the homeless populations on our streets in many cases, and also in many cases in our jails and prisons.

So our strategy here is to really try to remove the stigma surrounding mental illness, and to improve the health system, so that there is comparative access for mental health problems. And I think we're making some progress. Several states have changed their laws and several states have now removed barriers to access.

Now, the suicide reports that we did, I think - I'll just say one thing about those reports, and we released the national Strategy for Suicide Prevention last year - in fact, this year in the spring. What we found was that, of course, suicides are very common. There are three people who take their own lives in this country every year for every two people who die by homicide. And 80 to 90 percent of the time, perhaps as high as 95 percent in some people's estimation, people who commit suicide are suffering from some mental disorder, usually depression, but certainly people who are schizophrenic are at an increased risk for suicide, and certainly bipolar disease, even certain personality disorders. So again, we believe that many suicides are preventable in the sense that if mental health problems are diagnosed early and we intervene, we believe that we can reduce suicide.

Now, I'm not even able to get into the issue of suicides when they are combined with homicides. Like we've seen, the Columbine shooting, for example, where the two students not only took the lives of 12 others, but took their own. And I can't begin to get into the mentality that would lead people to do the kind of things that the 19 people who were flying those planes the other day, but - so we have some interesting dynamics going on here that are - as it relates to mental health, but even so issues beyond mental health. That's mental health and it was a major part of Healthy People 2010.

And it's interesting, we were talking last night about the Surgeon General's prescription. Now, this is the Surgeon General's prescription. Now, that's not the actual size, it's, you know, the size of a doctor's prescription. But when they told me that I was the nation's doctor, I said, "Well, you know, I've been writing prescriptions all my life as a physician, so maybe as Surgeon General I ought to write a prescription for the American people."

So two years ago we released the Surgeon General's prescription and we've distributed them all over the country and the world really. I want to share with you what's on this prescription, and you think about your own life and habits.

The first thing on the Surgeon General's prescription is physical activity, moderate physical activity, things like walking, jogging, biking, swimming, gardening, things that anybody can do we recommend at least 30 minutes a day, five days a week. There are not many Americans who meet that requirement yet, by the way.

The second thing on this prescription is good nutrition. And the focus here is on the five-a-day program that we've been pushing, and that is we recommend that Americans consume at least five servings of fruits and vegetables per day. And again, only about 10 percent or less of Americans meet that requirement.

The third thing on this prescription is to avoid toxins, especially tobacco, that's responsible for over 430,000 deaths in this country every year. Tobacco is still the leading cause of death among males, and when I released the Surgeon General's report on women and smoking earlier this year, a lot of people were shocked to learn that more women die from lung cancer every year in this country than breast cancer. In fact, last year 27,000 more women in America died from lung cancer than breast cancer.

And so - and it's not because - there's been a decrease in smoking in this country since 1964 when the first Surgeon General's report was released, but women started to smoke after 1950 and that increased for several years, and now we're seeing the products of that in increased deaths from lung cancer and other cancers as well.

But we also advise the avoidance of toxins like illicit drugs, heroin, cocaine, but also alcohol. The abuse of alcohol is one of our major health problems. In fact, 100,000 people in this country die every year from alcohol. And it has been an increasing problem among teenagers and on our college campuses, binge drinking. Binge drinking interferes with obviously the academics on college campus, but also increases violence and motor vehicle deaths. So we believe that we should have a frontal attack on alcohol abuse. A child that begins to drink before the age of 15 is four times as likely to become an alcoholic as someone who begins to drink after 21 years of age. So parents have a very important responsibility here.

The last item on the Surgeon General's prescription is sexual health, responsible sexual behavior. We still have a lot of trouble in this country talking about sex. Some people say that we talk about it in all the wrong places and all the wrong ways, but not in the right places. And so on the responsible sexual behavior we talk about - sort of by saying abstinence where appropriate, and we have been trying to especially make it clear to young people that relationships should not begin with sex, they should begin with communication and understanding, respect and appreciation, and sex ought to be preserved for those very special committed relationships, mutually monogamous relationships, like marriage, and getting that message over to young people is so critical, because there are so many other messages out there.

Now, obviously where I get in trouble as Surgeon General with some people is that I don't stop there, I say that for whatever reason there are a lot of people out there who are sexually active, including 65 to 70 percent of our young people, and so our position is that anybody who is sexually active, regardless of age, ought to know what their responsibility is to themselves and others, to prevent unintended pregnancies and to prevent a spread of sexually transmitted diseases, including HIV AIDS. So we talk about protective sex and we talk about the limitations of that, but also the fact that most cases of HIV AIDS could be prevented from spread by the appropriate use of contraceptives. But we also try to make it very clear that sex is a very special thing, it is not to be played with.

Well, this is the Surgeon General's prescription. I've had some interesting experiences with it. I was in the airport in New Jersey, I had been to Princeton to speak to the Robert Johnson Foundations Board of Trustees one night, and I was anxious to get home. So I was in Trenton train station waiting for the train, and a young man walked up to me and he said, "Man, you look just like the Surgeon General." I said, "Well, you know, there's a reason for that." Then he started screaming, "The Surgeon General is here," and people came running from all over the place. And the first guy who got there looked at him and said, "Man, you mean you're smoking in front of the Surgeon General?" So he threw his cigarette down and he stomped it, and I wrote him a prescription to stop smoking. Well, his buddy got a kick out of that, he was laughing. He said, "Well, what are you laughing about; I mean, you've gained 20 pounds in the last year." So I wrote him a prescription. Another guy, they said, "Well, you know, the way you play around you're going to get AIDS," so I wrote - by the time the train came that night I had written about 20 prescriptions. So I don't hesitate to write prescriptions.

But seriously, the awesome responsibility which we have to take care of ourselves and our family is a major important part of being good citizens. I'm very concerned that overweight and obesity have increased in this country so dramatically in the last 20 years, including a doubling of overweight and obesity among adolescents just in the last 20 years. So if you look at adults in this country, over 50 percent of adults are now overweight, and over 20 percent obese. And we have a cutoff for obese, if you're 30 percent above the recommended - it's really - I won't explain, but it has to do with body mass index, and a body mass index of 25 is the upper limit of normal, so anything above that is overweight, between 25 and 30, and then after you get over 30 body mass index that becomes obesity. There are a lot of overweight and obese people in the country.

So we do need to pay a lot of attention to our physical fitness and nutrition and avoiding toxins. Because part of being a great nation, of course, is to be fit, and to be ready to play our part, whatever that part happens to be, but also make sure that for our children that we do out best to get them started on healthy habits. Too many schools have discontinued the requirement of physical education in K through 12. Those same schools sell pop in the vending machines and sweets, and so children are watching a lot of TV, eating snacks, less physically active than they've ever been, so the outcome, of course, is more obesity.

Well, there's a story about a man who was flying across the country in a hot air balloon. At a certain point he realized that he was lost, so he decided to lower the balloon to see if he could spot any recognizable landmarks. He got down to a certain level and he didn't see anything he recognized, but kept going down. At about 30 feet he spotted a man working in the field below. He yelled out, "Where am I?" And the man looked up at him and said, "Well, you're in a hot air balloon about 30 feet above ground."

The guy in the hot air balloon said, "You sound like a scientist," and the man on the ground said, "I am a scientist. How in the world did you know?" He said, "Because what you've told me is technically correct, but it is of absolutely no use to me right now." Well the man on the ground said, "You sound like a policymaker." And the man in the hot air balloon said, "I am a policymaker. How in the world did you know?" And he said, "Because, you know, you're in the same position you were when we met, you don't know where you are, you don't know where you are going, and now you're blaming me."

I think one of the major challenges that we face in this country is to try to bring to bear the best science on our policies and practices. And it's serious business, and I know this university has contributed so much to food safety and security, and we have major challenges ahead in terms of terrorism, biological and chemical, and I know you're going to play a great role in that. We have to continue to do the science. We have to also make sure that the science impacts upon how we do business in terms of our polices and practices. And we must continue to set high goals.

These words of Benjamin Elija Mays, who was president of Morehouse College when I was a student there, have stayed me, and I leave them with you. It must be borne in mind that the great tragedy of life is not in failing to reach all y our goals, it is in having no goals for which you're reaching. It's not a calamity to die with dreams unfulfilled, but it is a calamity not to dream. It's not a disaster if you have no high ideas for which you are striving. It's not a disgrace to fail to reach the stars, but it is a disgrace to have no stars to reach. Not failure, but low aim is sin.

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