DEPARTMENT OF HEALTH 8a HUMAN SERVICES

Public Health Service


Office of the Assistant Secretary
for Health
Washington DC 20201

MEMORANDUM FOR THE RECORD

From :  C. Everett Koop, M.D.
.        Surgeon General-Designate

Subject:  Trip to Paris, Marseille, and Madrid,
       October 26-30, 1981

Paris

Meeting at Ministry of Health in Paris with Dr. Jeanne
Broyelle and Professor Aujaleu, 2:30 p.m., October 26, 1981.
I was accompanied by my Embassy control officer,
Mrs. Adrienne Stephan.  Although both French physicians
spoke English, the conversation was carried on by them in
French and was translated by the Information Officer,
Monsieur Visin.

Infant Formula Code

The French expressed their understanding of the problem
the United States faced at WHA, and were particularly
sympathetic that Dr. Bryant had to vote "no" under the
circumstances.  They understood that it was not a matter of
health but a matter of a decision made at a different level.
I assured the French that we were pushing breastfeeding to
the best of our ,ability and had a target of 75% maternal
hospital discharges by 1990.   I told them that we would
report to the WHA, but that I did not yet know the content
of that communication.  There was no question that they
understood full well why the United States vote went the way
it did in 1981.

Pharmaceutical Activities

The Infant Formula Code discussion led readily into a
concern that we might be in a position of facing a similar
situation with pharmaceuticals.  Professor Aujaleu was very
firm in saying that his country did not support a pharma-
.ceutical code in any way and he agreed with me that it would
be a poor use of the prestige of WHO.   He also indicated
that had the milk formula code been legislation, rather than
a guideline, that France would not have signed.   It was not
possible to get any word from Dr. Broyelle about the status
of things in reference to pharmaceutical discussions at
E.U.R.O. of WHO.  Her comment was that discussions had just
begun, nothing definite was decided, but that she would not
anticipate any definite recommendations.   I made it clear
that this information from the French would be welcomed by
us and that we would look to France if possible at E.U.R.O.


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to soft peddle any pharmaceutical control.  We both agreed
that pushing the essential drug program for LDC's would do
much to blunt the desire for any pharmaceutical code.

Health for All/2000

I indicated that we were trying to implement our
recommendations of 1980, and that we had a half-way mark of
1990 when we would be able to reassess the plans we had
made.

Disabled and Handicapped

The French acknowledged that they did not separate as
readily as we did true handicaps from other types of
maladies and therefore their statistics were not as good
as ours.  We talked a little bit about the definition of
handicaps, the fact that our numbers of disabled were
increasing while other signs of improving public health
were improving.  We talked a good bit about the
International Year of Disabled Persons and the manner in
which this was used as a spring board to alert the public to
the plight of the handicapped and to help change attitudes
and opinions concerning those who are disabled.  I explained
my concern about the aging handicapped and how the cost of
caring for the disabled would increase over the course of
the next decade.

They said they faced the same things.  We talked about the
role of the family in dealing with the handicapped.
Although I thought the family was the stronger unit in
France, the French were not so sure that they had not
deteriorated in this regard as rapidly as we had over the
past decade.  They still make an effort for home care and
increase their allotment to elderly people who live
independently in order to keep them out of nursing homes.

Drug Abuse

We discussed this on a philosophical basis and indicated
that we both were faced with a varied picture in different
parts of the country and that it changed rapidly.
Philosophically the French acknowledged that whereas drug
addiction was something found only in the intellectuals,  the
artist colony, and physicians 15 years ago (when Dr. Aujaleu
was the administrator of Public Health of France), now it
was a universal problem.  They also acknowledged that
alcoholism in adults was on the decline in France but
inasmuch as the alcoholism rate was so high they did not
think that they had anything to brag about in the slight
decline.  They also acknowledged that, as in the United
States, younger and younger people are becoming dependent
upon alcohol.


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The Elderly

This subject took the greatest portion of our time and
ranged from the philosophy of teaching medical students, the
advisability of separating geriatrics from general medicine,
the advisability of having gerontology courses in medical
schools, to discussions of senile dementia and the necessity
for research programs to focus on these particular disabling
elements of the aged.  Their problems are much the same as
ours, their perceptions of them agree with my own, and they
look forward to the economic problems being far greater than
the health problems in the future.  My discussion was closed
with my bringing up the White House Conference and how that
would prepare us for initiatives that might be taken to the
UN Conference on Aging in Vienna in the summer of 1982.

The meeting was extremely cordial, and I think the impression
was a mutually agreeable one.  Professor Aujaleu was
embarrassed in not knowing of my surgical background and my
acquaintance with a number of Parisian surgeons.   Had he
known, he said, he would have had a luncheon for me and he
made me promise that the next time through there would be a
longer lead-time in information so that proper social
affairs might be arranged with people I had known in the
academic community and in surgery in Paris.

Marseille

This is an overview of my time with the Public Health people
in the city of Marseille, October 27, 1981.

It should be remembered as background material that the city
of Marseille is the site of prominent medical activity that
is situated between two ancient universities: that of
Montpellier, the oldest medical school in France, and Aix,
with which university Marseille has made an affiliation in
recent years.  Secondly,  it should be remembered that the
Mayor of Marseille has been responsible for building the
most modern children's hospital in France and that the
Deputy Mayor in charge of Public Health is also the
Professor of Pediatric Surgery at the University of Aix
Marseille as well as the Chief of the Surgical Staff at the
Children's Hospital.  Their conversations and concerns
expressed to me had more to do with the future of medicine
in France than it did with specific health problems in
Marseille and its environments.

With the election of Mitterand as President, there came into
being a socialist government in France.  During the campaign
the French communists had been opposed to Mitterand but as
soon as he was elected he appointed four high-level
ministers from the communist party.  One of these was in
health.


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The trends which seem to be clear are the establishment of
Public Health Clinics which will be patterned after some
European totalitarian clinics where the freedom of choice of
physician and of hospital will be removed from the patient.
These clinics will serve specified groups of the population
by geography and alphabet and will be staffed by government
paid physicians.  The second trend would seem to be breaking
down the old system of European medical hierarchies where
there was a dominant and powerful chief of staff for the
various major disciplines within hospitals.   Instead there
will be very much smaller units without any overall manage-
ment at the discipline level.  It is seen as the beginning
of the end of strong services of ophthalmology, pediatric
surgery,  cardiac surgery, etc.
It should also be remembered that these changes take place
in a country which has, as far as the individual is
concerned, an ideal medical system.  In France the patient
has a complete freedom of choice of hospital or clinic as
well as surgeon and there is no cost to the individual.

Private practice by full time hospital physicians will cease
on January 1, 1982.

Madrid

Meeting of IAMER October 29 and 30 Madrid.   I was welcomed
at the meeting by the Secretary General, Dr. Jose R. Chelala
Lopez,  and met Professor Dr. Jaime Villablanca who was the
moderator and is a member of the faculty of the University
of California in Los Angeles.  Before the meeting I had
secured the support of Monique Begin of Canada, Francisco
Beltran-Brown of Mexico and Carl G. Samuda of Jamaica, the
three English speaking representatives, concerning the
wording of the document.

As it turned out no advance preparation was necessary; all
of the things we were concerned about either were changed in
the final draft presented to us at the meeting or we were
able to change without much controversy at the time of the
debate.

I made a number of interventions during the day, including
30 deletions of a phrase "to elaborate legal provisions".
The controversial breastfeeding clauses were altered to
produce bland statements with no specifics of the words
"all" or "majority" and no percentages were used.
In general it was obvious that the English translation of
the Spanish deliberations was rather poorly done and there
were a number of absurdities in the English translation.
Some of these could be corrected, but to have corrected them


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all would have meant a revision of the English manuscript
with a subsequent revision of the Spanish manuscript and
there was not time to accomplish this in the days in Spain.

The English translation of the final draft of the document
to be signed at the closing ceremonies was due in the lobby
of the hotel Costelbanc at 11:OO a.m.  The Spanish trans-
lation arrived at noon but there was no English translation.
I was advised to go to lunch and was even called at lunch to
be told that the English translation was ready.   It was not
ready when I returned to the hotel and I had a call at 3:ll
which said it would not be ready until 5 or 10 minutes
before the signing ceremony.  The reason for the delay was
that at a purely Spanish speaking lunch additions were made
to the document.  I told Dr. Villablanca that even if the
ceremony was delayed there was no way that I could sign
until I had read the entire document and particularly had
time to think about the amendments that had been made today.

Whereas the meeting on the previous day had been a very
leisurely one with people nit picking re phraseology, the
mood of the signing ceremony was one of speed.   Dr. Maureen
Law of Canada and I, accompanied by Robert Goeckerman, the
Science Attache to the United States Embassy, went into an
anti-room to read the English document while the remainder
of the Ministers and delegates read the Spanish document.
We had barely finished three pages when it was announced
that they were ready to sign.  They were obviously annoyed
that we were not ready to sign and I was distinctly
surprised a few minutes later to be told that Jamaica and
Canada had already signed the document without seeing it in
English. Dr. Law and I continued to correct the English
translation until we found one substantive change that had
to be made, namely the legal obligation to provide time off
from work for pregnant women.

It was suggested to me by Dr. Villablanca that I sign the
English document but not the Spanish document but make no
statement.  I said this is against my principles and asked
to make a statement.  This I did, explaining that the
translation of the day was even less accurate than the
translation of the previous day, that had required
considerable correction,  that I had made one substantive
change and that I would be able to sign the English document
but not the Spanish document.  It was obvious from the
demeanor of the Spaniards on the dias that they were very
displeased with my attitude and I was told later that they
could not understand why I was so particular about small
things.

We completed the translation corrections and I secured the
signatures on that corrected draft document from the
Minister of Canada and the delegate from Jamaica.   We have


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the assurance from the Executive Secretary and the
Director-General that the corrected English version would be
placed before the signatures in the final and official
copies.

While we were completing the translation the Minister from
Peru moved that we make the Spanish version conform to the
English version and this was apparently passed unanimously.
After this I signed two Spanish documents and two English
documents.

The substance of the foregoing was committed to paper at the
Embassy for transmission to the State Department.

cc:  Dr. Edward Brandt
   Dr. John Bryant
    Mr. Fred Krause
     Mr. Harold Thompson