US Public Health Service

VADM C. Everett Koop, USPHS*

F or the first time in almost years, the responsibilities of
the Surgeon General stand as separate entities. During
the previous years, the Surgeon General and the Assistant
Secretary for Health were joined in the same person and
office. My major effort as Surgeon General since the first
of the year has been to define the scope and responsibilities
of this office. Before sharing this important task with you,
let me touch in general on major health concerns of the
Public Health Service.

An estimated $247 billion was spent for health care in
1980, an amount equal to 9.4 per cent of the Gross Na-
tional Product. Health spending was 1.5 per cent higher
than in 1979, compared with an increase of 8.8 per cent in
the Gross National Product. On a per capita basis, 1980
health spending from all sources amounted to $1,067. Of
that amount, $450 (42 per cent) represented spending by
federal, state and local governments.

Against this background, HHS Secretary Richard S.
Schweiker convened a task force last spring to find the best
ways of injecting greater efficiency into America's health
care system. The administration believes that this ap-
proach can be the greatest single force for holding down
costs while delivering quality health care.

Using the best thinking we can find, we have been pin-
pointing what we know and do not know about health
competition. We are studying ideas that have already been
tested, as well as new ones. For example, we want to know
how we can give employers and employees incentives to
choose cost-effective health insurance coverage that more
closely fits their actual needs.

We know that people are increasingly purchasing more
and more comprehensive first-dollar coverage, which insu-
lates them from the true cost of the health decisions they
make. We are all paying for this trend in higher insurance.
We must also continue to encourage the development of
health care delivery systems that provide quality care at a
lower price. It is the investment and innovation from the
private sector that will expand the number and types of
available health plans and make choice a reality.

In the case of the Public Health Service hospitals, we be-
lieve the original need of two centuries ago has long been
fulfilled. Long underutilized, these hospitals can now go to
public and private ownership.

I have a particular interest in the area of prevention and
the promotion of health. This commitment by the Admin-
istration runs through not only our research programming,
but also the conduct of many of our remaining categorical
programs and our approach to providing assistance to
states, territories, and fpreign governments for the pro-

`Asst. Secretary for Health (Dept. HHS) and Surgeon General, USPHS,
Washington, D.C. 20201.

grams they run. While prevention is uppermost in our
thinking, it does not and will not replace other approaches
to care that are appropriate, such as improved diagnostics
or the introduction and strengthening of modalities of
treatment.

However, it does appear that the federal government
may be the most appropriate as well as the most capable
mechanism for initiating this major re-orientation of think-
ing in the field of health and medical care-this new accent
on prevention.

The costs of detection and treatment of lung cancer or
cardiovascuiar disease are many times the cost of getting
people to stop smoking. 1 would include in the costs not
just the dollars paid out for certain services, but also the
losses in income suffered by the individual and his or her
family, plus the losses in productivity suffered by that indi-
vidual's employer.

A group of 2,OCO experts from outside government, rep-
resenting a broad spectrum of public health, has developed
IS goals for the public health community in the field of
prevention-goals to be met by the year 1990. We in the
Public Health Service are completing implementation
plans to address each of the areas and will present an out-
line as to just what the PHS contribution will be in achiev-
ing the goals.

The 15 goals are summarized in a published volume
called Objectives for the Nation: Promoting Health and
Preventing Disease (available from the Centers for Disease
Control). The subjects include occupational health and
safety: accident prevention and injury control; toxic agent
control; lifestyle and personal or family behavior; the
abuse of alcohol and drugs: cigarette smoking; the prob-
lems of stress and violent behavior; the mounting complex-
ity of sexually transmitted diseases; and dental health
problems.

The Office of the Surgeon General has a particular con-
cern for the health problems of the aging in our society.
Many of our elderly today are survivors-survivors of dis-
eases that would once have killed them-stroke, heart dis-
ease, and others.

While the record has been excellent in prolonging life
and allowing our senior citizens to lead better lives, we
must do even better in the future as their numbers dramati-
cally increase. We have 25 million senior citizens now: by
2010 there will be 50 million. We must absorb the fact that
people are living full, active lives on into their 70s and 80s
and, therefore, each person over 6.5 deserves as much of
our health promotion effort as does each person under the
age of 65.

We must also face the fact that the increasing age of
Americans creates additional stress on our health care re-
sources. The elderly are the heaviest users of hospital care,

939         Military Medicine, Vol. 147, November 1982


Federal Medical Chiefs on Progress and Plans

and their rate of hospitalization has increased while the
rates for all other age groups have decreased.
The need for nursing home care also rises sharply with
age. Over 20 per cent of the population over age 8.5 are liv-
ing in nursing homes and the cost is high. Nursing home
expenditures doubled between 1975 and 1980 and are pro-
jected to double again in 1985. This, too, is an area that
needs study and careful planning.

Another area of interest where I feel the Commissioned
Corps can plan a major role is in major health car emergen-
cies. Our officers have a proud record of accomplishment
in recent emergencies (e.g., Legionnaire's Disease and toxic
shock syndrome), in moving in to help people threatened
by the Mt. St. Helen's erupting or the incidents at Love Ca-
nal and Three Mile Island, or in screening the thousands of
individuals and families who sought sanctuary here from
Southeast Asia, Cuba, Haiti, and other countries.
Let me now describe in more detail the major compo-
nents of my office in terms of objectives. I have four major
components within the Office to meet my desire to provide
effective, visible oversight of major initiatives.
The Office of International Health serves to assure effective
US participation in the programs and activities of interna-
tional health organizations. During most of my profes-
sional career, I have been involved in improving health
care throughout the world. Through this office, it is possi-
ble to formulate overall US Government policy for inter-
national health, and foster and facilitate the participation
of US Government agencies in international health activi-
ties. A major objective of this office is to ensure adequate
and appropriate policy guidance for and coordination of
the ongoing binational cooperative health programs.
Dr. Faye G. Abdellah serves as Deputy Surgeon General
and Chief Nurse Officer. In relation to the latter, she pro-
vides leadership and coordinates nursing policy in the PHS
and other DHHS components. She is the category officer
for nursing responsible for 4,600 nurses, both Civil Service
and Commissioned Corps.

Much of my surgical practice has been devoted to the
handicapped. It is logical then that I would establish an Of-
fice of Disability. This is an area of deep personal commit-
ment on my part. It is important that we build a national
policy on disability using "health" as a springboard or
model: identify what services are offered in the private and
public secton: develop a roadmap of services; a means for
communicating that roadmap and an attempt to involve
those in WK! out of government for a broad based policy
for the diltd in MINIS of services. The year 1981 was the
IntematioM! Ytpr d Disabled Persons (IYDP). On behalf
of thQ white HOW* a Surgeon General, I serve as liaison
to participating ftdnll mies which are building IYDP
follow-up activkks md to coordinate them into a national
objective.

Perhaps tht most bllmti~ and challenging office is
"$ecial initiatives." fhrr rrfh major areas of interest
and involvement d my rtdf. &TV M placed the responsi-

bilities for planning, developing, and implementing the fol-
lowing special short-term activities and monitoring other
long range or ongoing activities:

AMSUS. For 1981-1982 1 serve as your President. PHS
is responsible for planning and implementing the 89th An-
nual Meeting, October 1982 in Orlando, Florida. This of-
fice serves as staff in coordinating AMSUS activities.

USUHS. This office will continue to have the coordinat-
ing and monitoring role for the PHS participation at
USUHS which involved PHS Students and faculty. We will
continue liaison with training commands of the Army,
Navy, and Air Force for placement of PHS graduates in
residency training. This is an ongoing activity and one in
which I take a close personal interest.

Emergency Preparedness. The Office of the Surgeon Gen-
eral has taken a leadership role in the coordination of the
various PHS functions in the area of emergency preparedness
in conjunction with FEMA, DOD and other governmental
agencies. To this end, a medical officer has been detailed to
OSG to provide liaison with PHS Office of Management
and other PHS emergency planners, to rewrite The Ship's
Medicine Chest. Medical Aid At Sea, and to develop a
system for providing appropriate medical advice for ship-
to-shore radio communications with the Coast Guard and
Merchant Marine vessels.

PHEAP (PHS Employees Assistance Program). The Sur-
geon General has responsibility for coordinating and mon-
itoring this program. PHS units are Washington area:
Parklawn/Hyattsville, NIH, St. Elizabeths Hospital; At-
lanta: CDC; plus various smaller installations of HSA,
NIH and CDC. The office also assists in program evalua-
tion with input from ADAMHA, HSA/DFEOH and pro-
vides consultation to the DHHS prograr+

Long-Term Care. The Surgeon General chairs a PHS
task force charged with coordinating long-term care poli-
cies related to all programs within PHS and for the devel-
opment of a long-term care policy, planning, and strategy
document.

US Coast Guard. The Chief Medical Officer, US Coast
Guard, reports to the Surgeon General for policy coordina-
tion and professional oversight of the quality and appropri-
ateness of health care services provided by USPHS officers
detailed to the Coast Guard.

.In summary, I feel that the future of the Public Health
Service and the Commissioned Corps is bright. We have
weathered a variety of situations and have become stronger
in the process. Our mission is public health. The profes-
sionals I serve as Surgeon General are experienced, dedi-
cated, and uniquely qualified to carry out the mission to
improve the Nation's public health.

At some future time, I hope to be able to describe some
of our health relationships with tlie Federal Bureau of Pris-
ons, the National Oceanic and Atmospheric Administra-
tion (NOAA), and emergency health care services aboard
sailing vessels.

Military Modkin+, Vd. 147, WWTIW tm