REMARKS BY C. EVERETT KOOP, M,D,, Sc,D, SURGEON GENERAL OF THE U,S, PUBLIC HEALTH SERVICE UISl DEPARTMENT OF HEALTH AND HUMAN SERVICES PRESENTED TO THE AMERICAN COLLEGE OF LEGAL MEDICINE WASHINGTON, DL JULY 22, 1988 1 (GREETINGS TO HOSTS, GUESTS, FRIENDS, ETC,> THANK YOU VERY MUCH FOR YOUR KINDS WORDS AND HONORARY FELLOWSHIP IN YOUR COLLEGE, AND I'M AFRAID I WILL HAVE TO REMAIN AN HONORARY FELLOW, SINCE I DOUBT THAT 4 YEARS OF LAW SCHOOL ARE TO BE FOUND ANYWHERE IN MY FUTURE, BUT I SAY THAT WITH JUST A TOUCH OF REGRET, THIS PAST SPRING I DELIVERED A SERIES OF 6 COMMENCEMENT ADDRESSES ON THE GENERAL THEME OF "ETHICS AND MEDICINE/' I BELIEVE THEY CAME OFF WELL ENOUGH, 2 BUT I HAVE A SUSPICION THAT, HAD I KNOWN A LITTLE MORE ABOUT THE LAW, I MIGHT HAVE MADE AN EVEN STRONGER CASE FOR CERTAIN ETHICAL POSITIONS, BUT IT REMAINS ONLY A SUSPICION, BECAUSE IN SOME AREAS -- THE POSSIBLE ARRIVAL OF A "GRANNY DOE" CASE, FOR EXAMPLE -- WE STILL HAVE VERY LITTLE LEGAL PRECEDENT FOR GUIDANCE, ALTHOUGH WE KNOW THAT BOTH THE LAW AND MEDICINE WILL BE FULLY ENGAGED IN JUST SUCH A CASE, 3 THERE ARE SOME AREAS, ALSO, IN WHICH WE OUGHT TO DO SOME NEW AND FRESH THINKING, RELATIVE TO THE CONTRIBUTION OF LAW AND MEDICINE TO THE GENERAL WELFARE, WHAT I'D LIKE TO DO, THEREFORE, IN THE NEXT FEW MINUTES, IS SUGGEST THREE SUCH AREAS TO YOU, THEY'LL BE FAMILIAR TO YOU, I'M SURE, YET EACH HAS A CERTAIN QUALITY OF NEWNESS AND STRANGENESS NEVERTHELESS THE FIRST AREA HAS TO DO WITH THE RELATIONSHIP BETWEEN TECHNOLOGY AND HEALTH CARE, THE INFLUENCE OF TECHNOLOGY HAS BEEN QUITE PERVASIVE SO FAR IN THIS CENTURY, BUT WILL IT ALWAYS BE SO? IS THE PRE-EMINENT ROLE OF TECHNOLOGY NOW FIXED IN THE MEDICAL PANTHEON? 4 TEN YEARS AGO WE WOULD HAVE SAID "YES" TEN YEARS HENCE WE MIGHT WELL BE SAYING "NO/' FOR A VERY LONG TIME, THE PUBLIC HAS ASSUMED THAT THE CONTINUED IMPROVEMENT OF ITS HEALTH STATUS WAS CLOSELY LINKED TO THE CONTINUED EXPANSION OF THE PERIMETER OF BIOMEDICAL TECHNOLOGY, THAT LINKAGE WAS A KEY ELEMENT IN THE LOCAL DEBATES OVER ACQUISITION OF "CAT" SCANNERS A FEW YEARS BACK, "WE NEED THEM," PEOPLE SAID, "IF WE WANT TO AVOID DISEASE AND MAINTAIN OUR HEALTH." 5 HOWEVER, IN RECENT YEARS, THERE'S BEEN A DISTINCT COUNTER- TREND, IN WHICH THE PUBLIC -- AND EVEN SOME MEMBERS OF THE MEDICAL PROFESSION ITSELF -- QUESTION THE HIGH COST AND LIMITED RESULTS OF NEW MEDICAL TECHNOLOGIES mm, INCLUDING THE SECOND AND SUBSEQUENT GENERATIONS OF IMAGING TECHNOLOGY, AND I'M SURE MANY OF YOU ARE AWARE OF THE LIVELY PUBLIC DEBATE OVER THE USE OF SO-CALLED "EXTRAORDINARY" MEASURES TO SAVE OR PROLONG THE LIVES OF PERSONS PROFOUNDLY TRAUMATIZED OR TERMINALLY ILL, THERE IS GROWING PUBLIC SENTIMENT AGAINST THE USE OF SUCH MEASURES 6 I WOULDN'T SAY THAT MOST PEOPLE FEEL THIS WAY, BUT CERTAINLY A SUBSTANTIAL MINORITY DOES NOT WANT MEDICINE TO PROLONG THEIR LIVES, IF THE RESULT IS GOING TO BE QUALITATIVELY INFERIOR TO WHAT THEY'VE HAD SO FAR, IN OTHER WORDS, MANY AMERICANS DON'T WANT LONGEVITY AT ANY COST, AND THEY SEE TECHNOLOGY, IN A SENSE, 'PERPETRATING' LONGEVITY UPON A DUBIOUS AND EVEN UNWILLING PUBLIC ADMITTEDLY, THIS IS WHAT YOU HEAR PEOPLE SAYING, AS THEY DISCUSS THE MATTER WHILE THEY ARE THEMSELVES IN GOOD HEALTH, BUT I WOULD GUESS THAT MANY OF THESE SAME PEOPLE -- WERE THEY TO BE ENGULFED IN A PROFOUNDLY SERIOUS ILLNESS AND FACING DEATH, ON THE ONE HAND, OR THE CHANCE FOR A QUALITITATIVELY DIMINISHED LIFE, ON THE OTHER mnn BUT LIFE NEVERTHELESS -- THOSE PEOPLE MIGHT WELL BE INCLINED TO CHOOSE LIFE, STILL, THE DISCOMFORT WITH TECHNOLOGICAL HEROICS DOES EXIST, IN ADDITION, THERE DOES APPEAR TO BE A GROWING SKEPTICISM AS TO THE ADEQUACY OF TECHNOLOGY FOR SOLVING THE MAJOR CONTEMPORARY HEALTH PROBLEMS OF OUR PEOPLE, 7 TO SOME EXTENT, WE IN PUBLIC HEALTH HAVE BEEN RESPONSIBLE FOR THIS SKEPTICISM, BECAUSE WE'VE BEEN STRESSING THE FACT THAT EACH PERSON, DAY-BY-DAY, MAKES THE REALLY IMPORTANT DECISIONS REGARDING HIS OR HER OWN HEALTH , ,a DECISIONS, FOR EXAMPLE 8 0, 9 TO EAT SENSIBLY AND EXERCISE REGULARLY 1. m 9 TO STOP SMOKING AND STOP USING DANGEROUS DRUGS ,,a * TO ENSURE THAT ONE'S WORKPLACE IS SAFE AND HEALTHFUL . , , u AND TO CONDUCT ONE'S SELF AT HOME OR AT PLAY IN A MANNER THAT WILL ENHANCE AND NOT IMPERIL ONE'S HEALTH STATUS, 8 IN FACT, AS MORE AND MORE PEOPLE MAKE -- AND BENEFIT FROM -- THESE KINDS OF PERSONAL DECISIONS, WE MAY FIND THAT FEWER AND FEWER PEOPLE WILL RETAIN THE KIND OF COMPLETE AND UNCRITICAL FAITH IN HIGH-TECH MEDICINE THAT WAS THE CASE, SAY, IN THE 1950s AND 6Osm SO THERE'S THE ASSOCIATION OF TECHNOLOGY WITH MEDICAL "HEROICS" a,, THERE'S THE RECOGNITION THAT PERSONAL WILL-POWER, AND NOT NEW MACHINERY, IS THE KEY TO GOOD HEALTH , m m AND FINALLY THERE'S THE FACT THAT MOST OF TODAY'S NEW TECHNOLOGIES RESPOND TO CONDITIONS THAT ARE RARE IN THE PATIENT POPULATION OR THEY REQUIRE THE KIND OF DIFFICULT ETHICAL AND MORAL CHOICES THAT MOST PEOPLE WOULD RATHER NOT MAKE, 9 FOR EXAMPLE, I WOULD NOT MINIMIZE THE SIGNIFICANCE OF THE NEW TECHNOLOGIES THAT REVERSE INFERTILITY, HOWEVER, THE POPULAR PREFERENCES FOR DEALING WITH THIS MEDICAL PROBLEM STILL SEEM TO BE ADOPTION, ROUTINE DRUG THERAPIES 11, AND RESIGNATION, IN FACT, ACCORDING TO THE CONGRESSIONAL OFFICE OF TECHNOLOGY ASSESSMENT, BETWEEN 85 AND 90 PERCENT OF INFERTILE COUPLES HANDLE THEIR INFERTILITY IN THESE RATHER UNDRAMATIC AND "LOW-TECH" TERMS, 10 IN A TOTALLY DIFFERENT AREA, I'VE BEEN CLOSELY INVOLVED WITH A SPECIAL RESEARCH PROJECT IN WHICH OLDER, INCONTINENT PERSONS ARE TRAINED TO DEAL WITH THEIR INCONTINENCE IN A WAY THAT PERMITS THEM TO CONTINUE TO LIVE IN THE COMMUNITY, RATHER THAN BE INSTITUTIONALIZED, AND, AS YOU MAY KNOW, INCONTINENCE IS THE ONE OF THE MORE COMMON AND MORE SOCIALLY UNDERSTANDABNLE REASONS FOR SENDING OLDER PEOPLE TO NURSING HOMES BUT WITH SOME TRAINING FOR BEHAVIOR MODIFICATION, SOME MEDICATION, AND THE HELP OF A DEVICE OR TWO, WE NOW KNOW IT'S POSSIBLE FOR ELDERLY INCONTINENT PATIENTS TO ESCAPE INSTITUTIONALIZATION AND ALL THE HIGH COST AND LOW SELF-ESTEEM IT BRINGS IN ITS WAKE, 11 JUST TO PURSUE THIS LINE OF THOUGHT A BIT FURTHER, I BELIEVE WE'RE GOING SEE AN INCREASINGLY IMPORTANT ROLE FOR MANY, MANY MORE SUCH "LOW-TECH" APPLICATIONS TO HEALTH CARE AND HEALTH ADMINISTRATION, IN ONE OF HIS PLAYS, GEORGE BERNARD SHAW ASKED WHY WE PAY DOCTORS TO TAKE A LEG OH BUT WE DON'T PAY THEM TO KEEP A LEG ON, NOW, ALMOST 80 YEARS HAVE PASSED AND WE STILL HAVEN'T COME UP WITH A GOOD ANSWER, OUR TECHNOLOGY-DRIVEN REIMBURSEMENT SYSTEM -- WHETHER BY GOVERNMENT OR OUT-OF-POCKET -- IS STILL PREDICATED ON TAKING THE LEG O&u 12 THAT'S THE SYSTEM TODAY, BUT I SUBMIT THAT THAT WON'T BE THE SYSTEM TOMORROW, OUR ROMANCE WITH GADGETS MAY BE COMING TO AN END, I THINK WE SHOULD TRY TO UNDERSTAND HOW AND WHY THAT MAY BE HAPPENING AND WHAT IT COULD MEAN FOR THE FUTURE OF MEDICINE AND HEALTH CARE IN GENERAL, A SECOND ISSUE IS THE CHANGING RELATIONSHIP BETWEEN THE PUBLIC AND THE HEALTH CARE SYSTEM ITSELF, MANY FACTORS ARE BRINGING ABOUT THIS CHANGE, ONE IS THE INCREASED MOBILITY OF THE AMERICAN PEOPLE, WHICH MAKES IT LESS LIKELY THAT THE AVERAGE PATIENT WILL BE KNOWN AND SERVED BY THE SAME PHYSICIAN AND SAME HOSPITAL STAFF FOR A LIFETIME 11, SOMETHING THAT HAS BEEN OUR NORM FOR ALMOST THREE CENTURIES, 13 ANOTHER FACTOR IS THE RISE IN PRE-PAID PRACTICES OF ONE KIND OR ANOTHER, THESE, WHILE MORE COST-EFFICIENT, ALSO TEND TO ATOMIZE PATIENT CARE, I'M NOT SAYING THE CHANGE IS GOOD OR BAD, I'M SAYING IT'S DIFFERENT AND THE DIFFERENCE IS SIGNIFICANT FOR THE LONG-TERM RELATIONSHIP BETWEEN HEALTH CARE AND THE PUBLIC, A THIRD FACTOR CHANGING THE RELATIONSHIP BETWEEN THE PUBLIC AND THEIR SYSTEM OF HEALTH CARE IS THE WELL-ADVERTISED AND WELL- DISCUSSED SHIFT IN THE DEMOGRAPHY OF OUR COUNTRY, THE SO-CALLED "GRAYING OF AMERICA," 14 ALREADY THE SPECIALTY OF GERIATRICS IS RESPONDING TO NEWLY RECOGNIZED HEALTH NEEDS OF THE AGED, THIS SPECIALTY JOINS TWO OTHERS -- PEDIATRICS AND FAMILY MEDICINE -- TO DIVIDE UP PRIMARY CARE AND, AGAIN, CHANGE ALL OUR TRADITIONAL IDEAS ABOUT CONTINUITY OF CARE, I'M AFRAID THAT MANY OF THE ASSUMPTIONS UPON WHICH WE BASE MUCH OF OUR HEALTH PLANNING -- AND FINANCING, I MIGHT ADD -- MAY STILL REFLECT A PATIENT-TO-SYSTEM RELATIONSHIP THAT, FOR MANY INDIVIDUALS AND MANY INSTITUTIONS, NO LONGER EXISTS 15 LET ME ILLUSTRATE THIS WITH A LITTLE ANECDOTE, LAST WINTER I CONVENED A "SURGEON GENERAL'S WORKSHOP ON SELF-HELP," MY PURPOSE WAS TO GAIN A BETTER SENSE OF WHAT WAS GOING ON IN THIS NEW AREA AND WHAT THE GOVERNMENT'S ROLE MIGHT BE -- IF ANY, I DISCOVERED THAT AN ESTIMATED 15 MILLION AMERICANS ARE INVOLVED IN THE SELF-HELP MOVEMENT ,,a THAT THEY REPRESENT ALL SOCIAL, RACIAL, ETHNIC, GEOGRAPHIC, AND ECONOMIC GROUPS ,,a AND THAT THEY ARE FIERCELY INDEPENDENT, 16 I ALSO DISCOVERED THAT THEY ARE PROVIDING LEADERSHIP IN THREE HEALTH AREAS IN WHICH TRADITIONAL MEDICINE AND PUBLIC HEALTH ARE STILL SEARCHING FOR MEANINGFUL ROLES: HEALTH PROMOTION, DISEASE PREVENTION, AND THE COUNSELING FUNCTION, CALLED "COGNITIVE MEDICINE" BY SOME PHYSICIANS THE SELF-HELP MOVEMENT EMBRACES ALCOHOLICS ANONYMOUS AND A NUMBER OF ALLIED ORGANIZATIONS 11, SMOKING CESSATION GROUPS AND PROGRAMS mm u AND COUNSELING AND TREATMENT GROUPS FOR DRUG ADDICTS 17 THERE'S ALSO AN EVER-EXPANDING ASSORTMENT OF "SUPPORT GROUPS" FOR PERSONS WITH PROBLEMS ENGENDERED BY PERSONALITY, SEXUALITY, FAMILY RELATIONSHIPS, OR INFECTIOUS DISEASE, THERE ARE SUPPORT GROUPS FOR PERSONS WHO'VE JUST "KICKED A HABIT" OF SOME KIND, AND THERE ARE GROUPS FOR PERSONS RETURNING HOME AFTER A MAJOR HEALTH ORDEAL, SUCH AS A HEART ATTACK, CANCER DIAGNOSIS OR TREATMENT, A STROKE, AND SO ON, YOU'LL NOTICE THAT THE DISEASES AND DISORDERS I JUST MENTIONED ALSO HAPPEN TO BE AMONG THE MOST SERIOUS PUBLIC HEALTH PROBLEMS WE FACE TODAY: SUBSTANCE ABUSE, INCLUDING CIGARETTES ,, . THE EPIDEMICS OF SYPHILIS, HERPES, GONORRHEA, AND AIDS ,,a AND THE THREE PERSISTENT MAJOR KILLERS OF OUR PEOPLE: HEART DISEASE, CANCER, AND STROKE, 18 TRADITIONAL FEE-FOR-SERVICE MEDICINE OR TAX-SUPPORTED PUBLIC HEALTH PROGRAMS HAVE NOT YET MADE A COMPELLING ENOUGH RESPONSE TO THE INTENSELY PERSONAL ASPECT OF THESE HEALTH PROBLEMS ALSO, SINCE THE INDIVIDUAL DECIDES WHEN SUCH ASSISTANCE IS NO LONGER NEEDED, THERE IS NO GENERALLY ACCEPTED END-POINT; THEREFORE, THERE IS NO SPECIFIC POINT AT WHICH EXPENDITURES MUST END OR REIMBURSEMENTS MUST BEGIN, 19 I'M AMAZED AT THE EXTRAORDINARY DEGREE TO WHICH AVERAGE AMERICANS ARE ENGAGED IN THESE "DO-IT-YOURSELF" HEALTH PROGRAMS AND ALSO THE DEGREE TO WHICH THEY ARE TRULY HELPED BY THEM, THESE ARE NOT "BUBBLE-GUM" PALLIATIVES THESE PROGRAMS DO WORK, MY ONLY CONCERN -- AND IT'S A MAJOR CONCERN -- IS THAT SOME PEOPLE WHO NEED THE HELP OF MEDICALLY TRAINED EXPERTS AREN'T GETTING IT OR ARE AVOIDING IT a.. AND THEIR HEALTH AND POSSIBLY THEIR LIVES MAY BE IN PERIL AS A CONSEQUENCE, 20 FRANKLY, I'D LIKE TO SEE MORE PHYSICIANS, NURSES, AND ALLIED HEALTH PROFESSIONALS BECOME INVOLVED IN WHAT IS NOW CALLED "SELF- HELP" OR "DO-IT-YOURSELF" HEALTH CARE, MY INSTINCTS TELL ME IT WOULD BE VERY USEFUL IF THEY DID, BUT WHETHER TRADITIONAL MEDICINE AND PUBLIC HEALTH DO OR DO NOT GET INVOLVED, I BELIEVE THIS MOVEMENT WILL CONTINUE TO GROW AND BECOME NOT MERELY AN "ALTERNATIVE" SYSTEM OF HEALTH CARE BUT, IN FACT, OUR OTHER NATIONAL SYSTEM OF HEALTH MAINTENANCE, HEALTH PROMOTION, AND DISEASE AND DISABILITY PREVENTION. 21 AND THAT LEADS ME TO THE THIRD AND FINAL ISSUE I WANT TO TOUCH ON THIS MORNING, IT'S THE RELATED ISSUE OF HFALTH, COMMUNITY VALUES, AND PUBLIC SUPPORT, I MENTION IT BECAUSE, IN THE COURSE OF MY INVOLVEMENT WITH THE AIDS EPIDEMIC, I'VE SEEN THE OUTLINES OF THIS ISSUE ALREADY FORMING, ALSO, IT'S A KIND OF COROLLARY OF THE ISSUES I'VE DISCUSSED SO FAR, LET ME BEGIN BY SAYING THAT THE AMERICAN PEOPLE ARE GENEROUS TO A FAULT, THROUGH TAXES AND THROUGH PERSONAL, OUT-OF-POCKET DONATIONS THEY WANT TO HELP EVERYONE IN OUR SOCIETY ACHIEVE GOOD HEALTH AND THE GOOD LIFE THAT COMES WITH GOOD HEALTH, 22 BUT THE AMERICAN PEOPLE CAN ALSO BE IMPATIENT, FOR EXAMPLE, MOST AMERICANS DISAPPROVE OF SMOKING AND WOULD LIKE TO SEE ALL SMOKERS STOP, AND, THROUGH THE SELF-HELP MOVEMENT, MANY SMOKERS ARE INDEED QUITTING THE HABIT, BUT IT'S HAPPENING VERY SLOWLY, HENCE, THE NON-SMOKING PUBLIC IS ASKING FOR NEW AND STRONGER STATE AND LOCAL LAWS TO CURB CIGARETTE SMOKING IN THE WORKPLACE AND IN ALL PUBLIC GOVERNMENTAL AND COMMERCIAL BUILDINGS, MOST HEALTH AND LIFE INSURANCE COMPANIES NOW HAVE A SEPARATE -- AND HIGHER -- PREMIUM FOR SMOKERS, ALSO, ON THE THEORY THAT A PERSON WHO SMOKES OUGHT TO PAY A LARGER SHARE FOR THE CONSE- QUENCES OF THAT UNHEALTHY BEHAVIOR, 23 NEW LAWS, HIGHER PREMIUMS, AND SEGREGATION AT THE WORKSITE ARE EXAMPLES OF PUBLIC RETRIBUTION DIRECTED AGAINST SMOKERS, BUT IT IS BEING EXERCISED AGAINST OTHERS AS WELL: DRUNK DRIVERS, DRUG ADDICTS, PROMISCUOUS AND PREGNANT TEEN-AGERS, AND OTHERS WHO ARE PERCEIVED AS DEVIATING FROM THE COMMUNITY'S STANDARD OF NORMATIVE BEHAVIOR, BUT THE AMERICAN PEOPLE ARE STILL VERY GENEROUS AND VERY FORGIVING, THEY & HONESTLY BELIEVE IN -- AND WILL CONTINUE TO SUPPORT -- PUBLIC HEALTH PROGRAMS THAT PROM I SE REDEMPTION, 24 BUT THEY AREN'T PUSH-OVER% AND IT'S POSSIBLE THAT THE AMERICAN PEOPLE -- ALREADY TRAVELING THE ROAD OF RETRIBUTION -- MAY BEGIN TO EXERCISE THEIR RETRIBUTIVE POWERS MORE AND MORE, THE OBJECT WILL CONTINUE TO BE THE INDIVIDUAL WHO WILFULLY BEHAVES IN A HIGH-RISK MANNER: DRUNKS, DRUG ADDICTS, CIGARETTE SMOKERS, SEXUALLY PROMISCUOUS PEOPLE OF ALL AGES, DANGEROUS DRIVERS, CHILD BEATERS, AND OTHERS, AND AT THE TOP OF THAT LIST RIGHT NOW IS THE PERSON WITH AIDS a,, SOMEONE WHO MOST LIKELY CONTRACTED THAT LINGERING BUT FATAL DISEASE THROUGH WHAT THE COMMUNITY REGARDS AS AN UNSAVORY ACT: SODOMY, WHICH IS STILL ILLEGAL IN 25 STATES, OR INTRAVENOUS DRUG ABUSE, 25 IT'S POSSIBLE THAT A PUBLIC REACTION OF RETRIBUTION TOWARD PEOPLE WITH AIDS MAY COME ABOUT IN THE 199Os, WHEN THE ANNUAL COSTS OF AIDS-RELATED RESEARCH AND PATIENT CARE ARE EXPECTED TO REACH OR EXCEED $5 BILLION, THE 1990s IS ALSO WHEN NEW CASES OF AIDS WILL BE REPORTED AMONG PEOPLE WHO MOST LIKELY BECAME INFECTED SOMETIME AFTER -- AND MAYBE LONG AFTER -- THE HUMAN IMMUNODEFICIENCY VIRUS, OR H&V,, WAS IDENTIFIED AND THE NATIONWIDE AIDS EDUCATION PROGRAM WAS WELL UNDER WAY, 26 SUCH A PUBLIC RESPONSE WOULD BE A TRAGIC DEVELOPMENT -- BUT NO LONGER UNEXPECTED, IT WOULD BE CONSISTENT WITH THE OTHER TRENDS IN RETRIBUTION I MENTIONED EARLIER, OUR CHALLENGE, THEN, WOULD BE TO RECOGNIZE THIS REACTION BY THE GENERAL PUBLIC AGAINST HIGH-RISK INDIVIDUALS AND TRY TO CHANNEL IT INTO MORE POSITIVE, MORE TOLERANT RESPONSES, AT STAKE IS THE VERY BASIS OF THE AMERICAN APPROACH TO PUBLIC HEALTH: 27 THAT IS, THE MAJORITY OF THE AMERICAN PEOPLE WHO LIVE THEIR LIVES IN A GENERALLY HEALTHFUL, M-RISK MANNER ARE WILLING TO SUPPORT THOSE SERVICES THAT TAKE CARE OF THE MINORITY OF PEOPLE WHO LIVE IN A GENERALLY UNHEALTHFUL, HIGH-RISK MANNER, IN MANY RESPECTS, THIS MAY BE THE MOST IMPORTANT ISSUE I'VE RAISED THIS MORNING, LET ME CLOSE, THEN, BY SAYING THAT I ANTICIPATE CERTAIN MAJOR CHANGES IN AMERICAN HEALTH CARE OVER THE NEXT SEVERAL DECADES, SOME WILL BE EASIER TO EXPERIENCE THAN OTHERS, 28 BUT, ON BALANCE, I BELIEVE THEY WILL CONTRIBUTE TO A STRONGER, MORE RESPONSIVE, MORE CONTEMPORARY SYSTEM OF HEALTH CARE FOR THE NEXT AND SUCCEEDING GENERATIONS OF AMERICANS, THANK YOU, ########