MCHB ALL GRANTEES MEETING

Meeting the MCH Challenges and Opportunities of the Future

October 4-7, 2004

C. EVERETT KOOP: Thank you. Thank you. Well, you didn't disappoint me. And you'll know what I mean by that in just a minute, because it is a really, really wonderful pleasure to be with you this morning. Now, I didn't say to be back in Washington ; notice that. Even though it's been 15 years since I served as your Surgeon General, a trip back to Washington is really not like coming home unless I'm coming back to a meeting of you folks at Maternal and Child Health, because you know how to give a warm homecoming and I remember all too well that first hostile year that I was in Washington. And if it were not for you folks, I would have no place to go and have a welcome at all. So thank you for that. And much of what I was later to accomplish as your Surgeon General came about because of the early and generous support I received from the people at the Maternal and Child Health Bureau, Vince Hutchins, Merle McPherson, and I am still very grateful to them and to at least 20 other people I've seen here this morning. We tried to make, you'll recall, violence a public health problem instead of having it owned by jurist prudence, and we focused on children and women particularly.

Because of the interest we created in screening of newborns for hearing impairment, such practice is now law in 37 of our states. And naturally we, you and I, concentrated on special needs children, and we aim for comprehensive, coordinated, family centered, community based care for all special needs children. In fact, some of you even wrote a song about that, and it was to--for you old people who don't remember it, it was to the tune of "The Battle Hymn of the Republic." You can practice at home; don't do it here. And the words were: Comprehensive, coordinated, family centered, community based care; the Surgeon General leads the way. So we not only accomplished these things, but we had a lot of fun in doing it. Baby Doe, and Katie Beckett, and Katie Beckett's mother became members of our extended family. And we even amended the Title V of the Social Security Act. Of course, in many ways, being concerned, as Surgeon General, about the health needs of children was a continuation of my pre-Washington experience as a pediatric surgeon. I can still recall the day as though it were yesterday,

1945, when my career plans were suddenly turned right around. I was in the hospital, not as a resident, but as a patient. I was a resident, but I was a patient at the same time, and I had a strep throat, and I couldn't swallow and I was on intravenous fluids. And I had just finished my surgical residency, and I had great plans for the future when all of a sudden at 5:30 in the morning, my hospital door burst open, and there was the indomitable I. S. Ravden, my mentor, and he said, "Chick, what are you going to do with your life?" And so I began to outline how I had arranged for myself to be the surgical liaison between Cornell University Medical College and what was to become the Sloan Kettering Institute as far as surgery was concerned. And he said, "How would you like to be Surgeon and Chief of the Children's Hospital of Philadelphia instead?" Well, the first thing that came to mind was I had been trained during the war, and in order to make things work; they just cut pediatrics out of my residency.

So here I was totally untrained beyond what I read about infant feeding as a medical student. And I thought about a minute, and I said, "It's my second choice. I'll do it." I agreed to that with some alacrity because one of the things I had noticed when I didn't take pediatrics was that kids did not get a fair shake in surgery, and I wanted to do something to change that. It was my great honor to be among that handful of surgeons who pioneered in the field of pediatric surgery in America, and I count it my own greatest surgical pleasure to have been able to devote many years to what we called congenital anomalies incompatible with life, but nevertheless, amenable to surgical correction. Now, those were the really tough things to do, and in the four decades in which I was involved with pediatric surgery, we saw the mortality for many conditions of, say 95 percent, be transformed into a survival rate of 95 percent. And that's a lot of lives saved. So you could figure out that it was rather natural when I left my surgical career in Philadelphia to come to Washington that I would seek out those who shared my interest in the health of children. And I found those folks at the Bureau of Maternal and Child Health, and it's for that very reason that I am here with you this morning.

The unconscionable plight of children in America has been part of most of what I've done for the public in my public career. Both as Surgeon General as a figure on the national lecture circuit, but also more recently as the Senior Scholar of the C. Everett Koop Institute at Dartmouth Medical School. Probably most people associate my tenure as Surgeon General with the fight against tobacco and AIDS, but I want you to remember that kids were central to both of those fights. Almost every smoker in America decided at about the age of ten that he was going to smoke. He or she would smoke when they could and many took their first addicting puff as children of ten, although most of them waited about two to three years before they were really called smokers. And that's why we have targeted kids in so many anti-smoking measures, and why we have found the greatest success in anti-smoking measures aimed at children. If America could muster the political will and the money to protect its children from the machinations of the tobacco companies, we could make one of the greatest contributions ever to public health.

The tobacco industry knows, and I think most of the world knows now, that every year in the United States the industry loses about 400,000 of its very good customers. And it does this simply because those 400,000 die just because they used the product that those companies sell. And so they need to recruit more lifelong customers, and they do this from American children even if lifelong ends up in being much shorter for those kids, actually about two decades. People frequently ask me these days, "What's going on with Phillip Morris and their apparent interest in children and their health and their well-being, at least as advertised as evidenced by their advertising?" Well, let me tell you. The thing that the tobacco companies want more than anything else in the world is something they have never had, and that's credibility. They also would like a place of respect in the marketplace, and they never could have achieved that if they continued to stonewall all of us about the consequences of smoking especially in children, but now they have a new tactic, and here is how it works. They have acknowledged by full-page ads in news magazines--this is The Week, that they are more than the sum of its parts. And this is the attempt at respectability. And the nice thing about it to me is the play on words. They now call themselves a group, and they are The Altria Group. And I would bet that when everyone of you hears the word "Altria" started to be pronounced, you think of, "How could you,"--altruism. That's something that tobacco companies have never understood in spite of their new word.

Now, let me use my third oldest grandson who is over 21, a student at the University of New Hampshire where he is, perhaps, their finest skier and his national ratings are right up there at the top. He received something in the mail the other day, and if he did, you just can be certain that thousands like him, young, non-smoking, American, athletic boys and girls are now the target. It comes in this envelope. Now, don't tell me that there is anybody out there that would see this envelope addressed to them that wouldn't open it. It really is an exciting color. And what you take out of it from the inside is a beautiful picture. And it's a picture of our West, and it has, guess what, a cowboy sitting on a horse. The horse is standing at the edge of the water of the lake. And the caption says nothing about the Marlboro man, but it says, "Come to where the flavor is: Marlboro Country." This, as I recall, is an abrogation of what they said that they would do, and in this same issue of The Week Magazine, I'll read a little excerpt from a news article that has to do with this very problem.

I think it's interesting that when the United States is suing the tobacco companies for a cool $280,000,000,000.00, not because they deceive people, but because they are racketeers. This is under the RICO Law. And their chief attorney whined a little bit when he said, "It doesn't seem fair." And then he went on to say, "After all, Joe Camel was retired and the Marlboro Man has become almost invisible." Well, that almost is what sets Phillip Morris apart from other people who try to tell the truth. And then there's one more thing that comes, and this is really clever. It says, "One dollar off. One dollar off. One dollar. One dollar off. One dollar off. One dollar off." That's six dollars. So sending in each of these individual coupons one at a time or all together gets you six dollars off six packs of cigarettes. Now, anybody who knows anything about smoking knows that if you are young and you get six packs of cigarettes, you can be addicted very easily in six packs.

But their height of mendacity shows up in their adherence to the law. The law says that you must have the Surgeon General's warning. Now, what warning would you put on an advertisement to be read by the type of young, athletic boy, usually, that I'm talking about? Well, here it is. Surgeon General's warning: Smoking by pregnant women may result in fetal injury, pregnant premature birth and low birth weight. So as I've said before, they're smarter than we are, they're more foresighted than we are, they're richer than we are and you have to watch them like a hawk or they'll get ahead of you. So ladies and gentlemen, if you think that Phillip Morris has changed its spots, it's more likely that it is to happen with the proverbial leopard than it is with Phillip Morris or, as I should call them, the Altria Group. But on the other hand, they have been deceiving us for so long they really don't know how to act another way. And if they did, we wouldn't recognize them at all. Now, similarly in reference to children, the struggle against AIDS, much of our effort needs to be focused on the tiniest victims of AIDS, because babies born with HIV contracted from their mothers, those orphaned by AIDS, present a problem of staggering enormity both in the continents Africa and Asia . In our efforts, begun 20 years ago to have America consider family violence not only as a criminal issue, but also as a public health issue, our primary concern was about children caught in the web of family violence.

As I recall many of the ventures you and I took on, I realize we were able to use concerns about the health of children to leverage public health action that would benefit the larger American society. And what I've been talking about the last few minutes about smoking provides no better example. But after leaving Washington , I've attempted to keep the focus on kids and to expand it to the adult population. One of the most successful projects, small but rewarding, was involving medical students in providing health education by teaching in tandem with school teachers reaching kids in small rural schools in New England . And that was certainly an eye opener for the medical students and the beginning of healthful habits for underserved kids. You folks emphasize partnerships and that is really the way to go since so many agencies and non-profit groups in some ways can facilitate a health environment for our children. I've been involved in one way or another with the Safe Kids Program over the years, and we've been able to cut the mortality from unintentional injury by more than 40 percent for youngsters under the age of 14, and that figure is also reflected in the 200,000 children who used to be permanently disabled from unintentional injury each year.

After five years as Honorary Chair and 15 years as Chairman, I resigned just as Safe Kids went international and a whole new life is beginning for these wonderful people. And in my efforts to address the systemic problems in the American health care system, especially the problem of over 40 million Americans who lack health insurance, once again, I've tried to address first the needs of uninsured children. Fortunately, some states and even Medicaid have moved to do something about this shameful situation, although we do have a long way to go. But if there's one topic I'd like to address at greater length this morning, it's the one I've left out so far. As vital as it is to get kids to say no to smoking, there is now an even greater threat out there to their health. And this threat gets hold of them as very young children, keeps a grip on them through their adult years and shortens their lives.

Tobacco is now about to be replaced as the leading cause of illness and death in America by problems related to obesity. Some of you may have heard me say from a platform here or there that if I had a third term as Surgeon General I would have concentrated on obesity, which in 1989 was already casting a shadow formed by its upcoming potential. Once I was in the private sector by 1994, I realized that the government was not going to do anything about picking up the ball of obesity and running with it. David Satcher had not yet evidenced his welcomed interest in obesity and I founded an organization called Shape Up America as a private, non-profit agency. We did good things, and we're still in business occupying a niche not filled by other agencies, public or private. Most important, I got my feet quite wet in the public health implications, the medical problems and the policies of obesity. Shape Up America was intended to raise the awareness of obesity in America , and we did. The IFIC measured the number of media stories at three-month intervals and they rose from about 25 in March 2000 to over 1200 by June 2003.

The health consequences of obesity, for adults and children alike, is now front and center in the health thinking of our country and it certainly is now in the minds of the majority of Americans. We believe this could not have been accomplished without the investment of millions of dollars made by Shape Up America since 1994. At the time of Shape Up America's 1996 Annual Report, I recognized that we knew an awful lot about obesity and we could start to work against it right away without spending years in research. I said at the time obesity is not an issue requiring additional fact finding before action is taken. We know that many of the health risks associated with unhealthy weight can be reduced if education and changes in lifestyle, thus motivating Americans to take action will be a very significant step toward preventing one of the most common causes of death and disability in the United States today. Don't forget that you won't see obesity on many death certificates, but you will see the things that go with it like, heart disease, hypertension, stroke, breast cancer, colon rectal cancer and so on.

One thing was certain, and America seems to have lost track of this simple fact, that fat babies make fat children and fat children make fat adolescents and fat adolescents make fat adults and unfortunately, fat adults eventually turn into fat old people. So this is a problem across the board for Americans. Shape Up America has played a really central role in shifting from an understanding of height and weight tables to the use of body mass index, or BMI, to assess one's obesity. We have undertaken a major obesity education initiative on the assessment and treatment of obesity directed at health care professionals and consumers to educators, policy makers and to the media. And now it's time for us to look at prevention. Child Health Day could not have come at a better time this year. Just last week on September 30 th at 9:30 eastern standard time, The Institute of Medicine of the American Academy 's release for the public its very comprehensive report on preventing child obesity entitled "Health in the Balance." This is a 461-page report and reduced to its very simplest terms in the following summary of its findings and conclusions in just three simple statements. First, childhood obesity is a serious nationwide health problem requiring urgent attention and a population-based prevention approach so that all children may grow up physically and emotionally healthy. There doesn't seem to be much argument about that. Two, preventing obesity involves healthy eating behaviors and regular physical activity with the goal of achieving and maintaining energy balance at a healthy weight. And finally, individual efforts in societal changes are needed.

Multiple sectors and stakeholders must be involved. Now, we all have come to our ideas of how obesity snuck up on us the way it did, but some things are clear, and I'd like you to have them in your mind as background of what I hope you'll do for obesity over the next ten years. And I say ten years, because that's how long it's going to take to see things turned around. The IOM report has published a lot of data gathered from the CFII, which stands for the Continuing Survey of Food Intakes by Individuals. I'm sure you've made your own obesity observations of larger portions on larger plates, larger volumes in glasses of larger capacity. Some of the increasing sedentary nature of childhood behavior occasioned by both television and computers, having neither of these to interrupt my childhood development, I can tell you that when I was a child, we got out of school as fast as we could in order to get home so we could go out and play. One of the most wonderful things about growing up then, and kids don't even seem to understand what it means. Don't feel sorry for kids like me who grew up in Brooklyn . We had time and we had imagination, and there was no such thing as virtual reality; it was real reality.

We built our castles in the sky, and we found an empty lot once in a while, and it was just as though Lewis and Clark had discovered Yellowstone Park . The IOM Report quotes a lot from the collected data of CSII, and I'll repeat just a few items. In reference to youth and children as I've already said, portion sizes alone for children have increased from most foods consumed at home and away from home. So that's one of the things we all have to tackle. Total energy increased from 20 percent to 32 percent for children between years 1977 and 1994. Total calories consumed by adolescents increased between the ages of 12 and 19 by 243 calories for boys and 123 for girls. The USDA data showed that for adolescents 12 to 19, girls consumed 25 percent and boys 26 percent of their new calories from added fat. I don't want to bore you with a lot of numbers, but some of them are very interesting. One of these, for example, children six to eleven in 1994, '96 and '98 consumed 21 to 23 teaspoons of added sugar in a calorie designed to be 1800 to 2000, which exceeded the Food Guide Pyramid recommendations by six to twelve teaspoonfuls for a 1600 to 2200 calorie diet. Milk, which used to be the most consumed beverage, became the least consumed beverage. And in 1977 and '78, children six to eleven consumed four times as much milk as any other beverage, and adolescents 12 to 19 drank milk 1.5 times as fast as other beverages, but then that all changed. And they drank as much soft drinks as they used to drink milk, and then they multiplied that by a factor of about four.

In general, you can say that children are not eating up to the recommendations of the USDA pyramid or anything else. I'm not going to tell you anymore about those figures, because I hope you will procure a copy of the IOM report and learn some things from it and make your own plans. The strange expansion, though, of everything to do with eating--plates grew, as you know, from ten to twelve inches, and then from 14 to 16 inches. Wine glasses got bigger and bigger. Steaks overlapped even the edges of the bigger plates. And all of this spilled over to children. I saw an ad for prepared meals for men the other day, and the pictorial depiction of the amount of food was absolutely gross. But the wording of the ad said it all: it's good to feel full. Now, one of the most serious aspects comes after the IOM report just last week, and they found that significant arteriosclerosis leading to hypertension, heart disease, stroke, was found in seven-year-olds the way it used to be found in 70-year-olds.

I would like to highlight some of the recent achievements that we have tried to do with Shape Up America. In the year 2002, Dr. Barbara Moore, who is the President and CEO of Shape Up America now, traveled to 25 different medical schools around the United States to deliver invited lectures on the assessment and treatment of obesity, a topic that very much like nutrition is still not covered well in the curriculum of most medical schools. The United States is witnessing as enormous increase in the prevalence of Type II diabetes as one-third of the adult population and one-sixth of the pediatric population is now categorized as excessively fat. In the year 2000, Shape Up America organized and hosted a national conference on diabesity, which examined the cause and linkages between obesity and Type II Diabetes.

A second national conference on that topic was held on the campus of Rutgers last November, and that report is about to be published next month. And a west conference is currently under development on the same subject. Believing that studies of the regulation of food intake during pregnancy and infancy have received insufficient research attention and resources. Shape Up America organized and hosted an international conference on the prevention of childhood obesity held right here in Washington in December of last year. That conference focused on the critical development period for the regulation of appetite that begins prior to conception and continues through pregnancy, infancy and the preschool years. Today, less than one year later, we celebrate the publication of a special supplement to the Journal ofPediatrics, which describes the proceedings of that conference. Please locate one of those and at least get the drift of what we were saying. We hope it will stimulate more research into parental dynamics and development factors that promote appropriate self-regulation of food intake and energy balance in very young children.

There is good evidence that prevention begins prior to conception, but there is much, much more to be learned. During 2003 and most of 2004, Dr. Barbara Moore served on The Institute of Medicine's committee that generated a landmark evidence-based comprehensive report that I just mentioned on the prevention of childhood obesity and that I want you to make yourselves familiar with. Dr. Jeff Copland of the Centers for Disease Control was the Chair of that IOM committee that researched and prepared the report, and I really am delighted to commend him for his leadership in preparing this timely and important national blueprint for action. I'd like to turn now from that IOM report to the mention of childhood obesity entitled "Health in the Balance." I truly believe that this report is the equivalent of the Surgeon General's 1964 landmark report on the health effects of smoking.

Since 1994 when we founded Shape Up America, all I've been talking about the second leading cause of preventable death in America , obesity, that is directly attributable to the poor diet and the physical inactivity that now characterizes the American lifestyle especially for young people. We expect that within the next few years, obesity will overtake tobacco as the number one cause of preventable deaths, if it has not done so already. So "Health in the Balance" can and should influence parents and all caregivers of children and will change the values and behaviors of all segments of society if we will heed that report. The report is really an action plan that was mandated two years ago by Congress, and that mandate called for the funding of this plan by HHS, but fortunately, the Robert Wood Johnson Foundation also contributed to its preparation. The report should be reviewed as a blueprint for action. It is comprehensive, it is evidence-based, and includes recommendations for specific actions to be taken. There is advice for parents. These are the folks who serve first and foremost as role models, but they are also policymakers in the home.

Schools come next, and they educate as much by what they feed children and how they feed children as to what they teach them about nutrition. Then we have communities, which support children's activities with programs and organizations that, in turn, support physical activity and healthy eating. And therefore, we have to call on our communities to provide sidewalks and parks and a police force to protect children and keep them safe so they can play outside. And finally, healthcare professionals who guide, monitor, and evaluate the growth of children will find much in healthy balance that goes into all aspects of society. The IOM report is the first of its kind, and I hope that it will induce a broad scale of revisions in the missions and the initiatives of non-profit corporations. The appearance of "Health in the Balance" is timely. It will serve to guide and influence prevention programs, and I would encourage every appropriate organization and institution to shift at least some of its focus to the urgent need to stem the epidemic of obesity, especially in children.

There are several recommendations in the way of prevention strategies that have been linked to improvements in the BMI of children. First, decrease television and all recreational screen time to less than two hours a day. For proper implementation of this rule, parents may need to limit their own TV viewing and may need to move the TV out of all bedrooms. Second, increase vigorous physical activity of children to a minimum of 60 minutes a day. And if you folks are counting on schools in your community to do this, they are not doing it. They haven't got the money to do it. So you can fight for two things. Get that back in the schools, but in the meantime, see that your children exercise. Third, critically evaluate all foods that you find in vending machines, snack bars, as well as the school cafeteria, anything offered in schools, and call upon the USDA to set nutritional standards for those foods.

Fourth, HHS should take the lead convening a task force to examine current marketing and advertising practices to children, especially children under eight who, studies show, are unable at eight to differentiate advertising messages and persuasion from fact and consider whether and how these practices should be regulated if at all. "Health in the Balance" also points to needed changes throughout society. A better understanding by parents and healthcare professionals of the CDC growth charts and how they are derived and used to monitor the growth of every child growing up in America . To my surprise, I found that many parents believe these charts do not apply to children of Caucasian ethnicity. Many parents do not perceive their child as fat even if at the age of four he is wearing the clothes of a seven-year-old child. I believe "Health in the Balance" will influence parents and all caregivers of children, and can change the values and behaviors of all segments of our society. Eating should not be a mindless activity, but it should be respected for what it is: a vital, important and highly complex behavior that can be a shared ritual that builds loving relationships between people in what we used to call the family.

Shape Up America will be taking the lead in planning activities that ensure the rapid and thorough dissemination and implementation of "Health in the Balance." We see it as the cornerstone of our mission for the next ten years. We will continue to work with members of the corporate community who respect our work and support our message. We invite them to partner with us and be a rightful part of the solution to this huge problem. We also call upon all federal agencies who fund research and programs to allocate, soon, the necessary resources and staff to address the many gaps in the knowledge identified by "Health in the Balance." It truly represents for all of you here today a clarion call, and I hope that you listen to it and benefit by it. Thank you very much.

PETER VAN DYCK: Thank you, Dr. Koop. You know in 1988 in his role as Surgeon General, Dr. C. Everett Koop introduced a national agenda for children with special healthcare needs. It was his call to action to awaken this country to the needs for coordinated systems of care for children with special healthcare needs. This agenda, which was endorsed by over 70 professional and voluntary organizations, calls for services that are family-centered, community-based, coordinated and culturally competent. In 1989, this agenda was translated in the legislation through Title V of the Social Security Act, which requires state children with special healthcare needs programs to, as we all know the mantra, provide and promote family-centered, community-based, coordinated care for children with special healthcare needs, and to facilitate the development of community-based systems of services for such children and their families. And that was in the OBRA '89 Legislation which many of you in the room today heard me talk about yesterday. As a result of Dr. Koop leadership and support of children with special healthcare needs and their families and his promotion of a national agenda for these children, the way was paved for a myriad of other initiatives that have built upon his agenda and have had a substantial impact on families and systems of services for these kids.

Since the passage of OBRA '89, families, providers, agency leaders and policymakers have partnered with State Title V programs in the bureau to support and implement systems development initiatives that he first, Surgeon General Koop, first articulated. The result has been several fold. One, a long-term national goal around systems development articulated in Healthy People 2000 and 2010. The Division of Services for Children with Special Healthcare Needs six core outcomes for systems development and the national survey for children with special healthcare needs that provides data around these core outcomes, and three, strong partnerships between families, communities and other partners that continue to support and implement this national agenda.

Dr. Koop brought national attention, awareness and particularly leadership on behalf of children and families that continues in a manner that still encourages us today to continue efforts first mentioned in his call to action on behalf of systems of services for these kids and their families. In honor of Dr. Koop we have an award today, which we would like to present to him. Dr. Koop, would you come up please? And it says, "To Dr. C. Everett Koop, U.S. Surgeon General 1981 to '89, for your dedication to improving the health of the nation's mothers and children." It is with great honor that you're here to help the bureau celebrate Dr. Koop's attention to this area.

C. EVERETT KOOP: Well, thank you all very much. This is a clock, and I want you to know I was here an hour and ten minutes early this morning. But I do appreciate it. For the reasons I said in my initial remarks, I feel like coming home to family here. I will now make my way through the alien districts to the airport, and soon get back to New Hampshire where people behave sort of like you do here. Thank you very much.