Conference Keynote Address by

David Satcher, M.D., Ph.D.
Assistant Secretary for Health and Surgeon General
Office of Public Health and Science

at the

Opening General Session

of

The American College Health Association
2000 Annual Meeting
Toronto, Ontario, Canada

Wednesday, May 31, 2000

[This text is the basis for the Assistant Secretary for Health and Surgeon General’s oral remarks. It should be used with the understanding that some material may be added or omitted during presentation.]

Thank you very much for that very kind introduction, Jackie, and to all of the other officers of the American College Health Association, members of the Board and Foundation, and to all of you distinguished people, especially the students that have done such a great job in the last hour and a half.

When I was sworn in as Surgeon General on February 13, 1998, I said, among other things, that I wanted to be remembered as the Surgeon General who listened to the American people and who responded with effective programs. So, I hope you know how special this morning has been for me. Let's give the students another hand.

I also want to commend all of you for your ongoing efforts to protect and advance the health of our nation's college and university students. For students who have moved away from home and who, in many ways, are gaining their independence, you are often the first health professionals that they will meet, and that means that you have a critical role to play in their overall development. Your role is certainly to emphasize health—not just health care, but health. That includes health care, of course, but it includes much more than health care. It includes helping to keep people healthy and promoting health. It also means that through your day-to-day contact with students, you have the opportunity to really impact their lives in a lasting way so that they, in fact, adopt sound health practices and improve their overall health. In that sense, you should be very proud of the difference that you are making.

Let me mention how special the partnership we share with the American College Health Association is to me. Immediately before becoming Surgeon General, as some of you know, I was Director of the Centers for Disease Control and Prevention (CDC) for five years. In that position, had an opportunity to really come to appreciate the role of the American College Health Association. I know that CDC has cooperative agreements with you related to HIV/AIDS education and in some other areas. I also know that you recently entered into a new partnership with our Department and, that through HRSA's (Health Resources and Services Administration) tissue donation initiative, we are working together to improve organ donation.

I want to say a word about how important that is to us and to the nation. At the end of 1999, there were over 72,000 people registered on the National Organ Transplant Waiting List—over 72,000. Six thousand people died last year waiting for organs or tissue donation. By contrast, last year, only 5,800 people who died last year donated organs. In short, the problem we have is that the number of candidates for organ donations far exceeds the number of people who are actually donating their organs. That means one of two things: either they did not fill out their cards, or they filled out the cards but forgot to talk about their decision with their family. We encourage people to fill out organ donor cards in conjunction with their driver's license, and then to follow up with a discussion with their family. Should something tragically happen that puts you in a position to donate organs but your family members object because you haven't taken the time to explain what you want to do and why, then your decision is no good. So, I think this innovative idea that you have of using the college campus to discuss the issue of organ and tissue donations and, from a theoretical prospective, to examine all of the kinds of issues that are involved in whether or not one decides to be an organ or tissue donor is a tremendous opportunity to save lives. Partnering with you gives us a new opportunity and perspective from which we can examine this issue, and I want to again express our appreciation for that. All of the partnerships that we have with you now and those certainly to come in the future are very special to us.

I want to talk briefly this morning about Healthy People 2010. I am the second person in history to be both Assistant Secretary for Health and Surgeon General. The first person was Dr. Julius Richmond, an outstanding pediatrician, who was also the first director of the Head Start Program. I'm sure some of you may know Dr. Richmond. Among other things, he issued a Surgeon General's report in 1979 on health promotion and disease prevention that led this nation to embark upon a healthy people planning process, whereby every ten years we look at the health of the American people to see how far we've come and where we need to go. Then we set goals and objectives for the next ten years. So, in 1980, under Dr. Richmond's leadership, the nation agreed on 3 goals and about 236 objectives for 1990; and they were called Healthy People 1990: Goals and Objectives. In 1990, we released Healthy People 2000, again with 3 goals and over 300 objectives. Several months ago, we released Healthy People 2010 with 2 major goals, over 400 objectives, and the newly added 10 leading indicators, which I want to talk about.

When I became Surgeon General and Assistant Secretary for Health, we were nearing the end of Healthy People 2000. So one of the first things I did was to ask myself how we were doing. I found that for about 60 percent of the objectives we were either achieving them or moving in the right direction to achieve them. For about 20 percent, we were moving in wrong the direction, and for about 20 percent, we realized that we didn't have adequate data to answer that question. But let me just share with you a few of the areas where we were moving in the right direction.

We continued to see a decline in deaths from cardiovascular diseases in this country in the 1990s, albeit not as great as in the previous decade. The declines started showing up in the 1960s and continued through the 1970s and 1980s. We also found in the 1990s that we continued to see a decline in deaths from motor vehicle crashes—that news is especially important for our young people because motor vehicle crashes, which are often related to drinking, is one of the leading causes of death for college-age students. That decline is due in large part, I think, to the efforts of public health and groups like Mothers Against Drunk Driving and Students Against Drunk Driving, and others. Also, in the 1990s, for the first time really, we saw a decline in deaths from cancer in this country, which was very gratifying. Even for cancer of the breast, we saw a significant decline in deaths in the 1990s, and we look forward to even more dramatic declines in the future.

We also found a decline in violence. When I went to the CDC in 1993, I made a statement that turned out to be very controversial in the minds of some people. I said that we were going to treat violence as a public health problem, that we felt that violence was preventable, that it was subject to the same type of surveillance and prevention as infectious diseases, and that if we really targeted areas for prevention we could reduce violence. I think it was because of that, the Brady Bill, and several other things that we saw and continued to see a decline in homicide and in violence overall in the 1990s. While that was the good news for the nation as a whole, the good news was not shared equally. There were disparities on the basis of race and ethnicity in all of these areas.

The bad news is that for about 20 percent of the objectives, we found we were either not making progress or we were moving in the wrong direction. One of those areas was physical activity. In the 1990s, the American people became less physically active; in fact, we say that this is probably the most physically inactive generation of Americans in our history. We also saw a dramatic increase in overweight and obesity in the 1990s. In fact, since 1980, overweight and obesity have doubled in children in this country. Remember, I said earlier that we saw a decrease in deaths from chronic diseases such as cardiovascular disease and cancer, but that's not true for diabetes. In the 1990s, right along with the increase in overweight and obesity, we saw an increase in Type II diabetes, which represents 95 percent of the diabetes we see. It's not the kind of diabetes that is single-gene inherited; rather, it is related to obesity and probably has familial components. Type II diabetes leads to end-stage renal disease, blindness, the need for lower-limb amputation, and other problems.

In addition, we saw something that we have not yet been able to explain, which is a dramatic increase in asthma in children since 1980. In fact, there has been a tripling of asthma in the nation in children under 5 since 1980. We were in Harlem last week discussing this problem. There's something about our environment, or host environment interaction, that we can't explain. It's not just in this country. I just returned from leading the U.S. Delegation to the World Health Assembly in Geneva, Switzerland, where it was clear that the problem of asthma increase is a worldwide problem and one that we are struggling to understand. Well, that's a synopsis of how we shaped up in the 1990s.

We developed Healthy People 2010 with 2 goals, 467 objectives, and something new called the "Leading Health Indicators." The first goal relates to the fact that American people are aging. In the last century, we gained 30 years of life expectancy. In 1900, the life expectancy was about 47 years of age; in 2000, it is 77 and rising. Not only that, but 35 million people in this country are over 65 years of age, and the fastest growing group of people are actually people over 80 years of age. So, we know that one of the issues we must be concerned about is quality of life. It's not just enough to increase years of life, but we must also focus on quality, including such areas as Alzheimer's, arthritis, osteoporosis, the management of chronic pain, the aggressive diagnosis and treatment of depression in the elderly. This whole issue of quality of life raises some very interesting challenges for all of us, but especially for people like you who are primarily concerned about health promotion and disease prevention in the early years. We cannot afford to wait until a person is elderly to begin focusing on quality of life; we must be concerned about quality of life for all ages and all along the life cycle. That's because what we have found is that the quality of life of people in old age is often determined by lifestyles that begin at birth, or healthy pregnancies. We know that what happens in adolescence, in the teenage years, and in the young adult years often determine a person's quality of life later on.

The second goal of Healthy People 2010 relates to the fact that we as a nation are becoming increasingly more diverse. About three years ago, President Clinton at a commencement address at University of California at San Diego, announced the Race Initiative. He basically said that we are probably the most diverse nation in the world. Diversity is potentially one of our major strengths. It should be and can be, but in order for it to be, we have to embrace it and we have to deal with it. We have to care about people across racial and ethnic lines. We have to reach across those lines and try to understand people and their histories, their culture, their language. He appointed a national advisory council headed by John Hope Franklin, and they worked for almost two years preparing a report called, "One America in the 21st Century." What a lot of people missed, however, and I hope you didn't miss it, was that President Clinton also asked each cabinet head to develop some strategy for supporting the Race Initiative. And, in our Department of Health and Human Services where Donna Shalala is Secretary, we debated this issue extensively and made the decision to make a commitment to eliminate disparities in health on the basis of race and ethnicity. A few weeks after I was sworn in as Surgeon General, President Clinton announced in one of his Saturday morning White House radio addresses that I would be leading that effort. We later folded into Healthy People 2010 the initiative to eliminate disparities in health on the basis of race and ethnicity.

When we took on this goal to eliminate disparities, we prepared ourselves for one of the nation's biggest challenges. Now, let me just tell you, I represent the Public Health Service—that's what this uniform is all about. We don't shoot guns. We fight diseases. For more than two centuries, we have been fighting for the health of people, and supporting our soldiers in times of war by making sure that their health is protected. It doesn't matter where a problem breaks out— if it's Ebola in Africa, the plague in India, or the floods in North Carolina that threatened the lives and health of the residents—generally somebody from the 6,000– member Public Health Service Commissioned Corps would be sent there to promote and protect health and to report back to the Surgeon General.

The Public Health Service has a rich history that dates back more than 200 years. It was in 1798, when John Adams signed the Act of Congress giving rise to the Marine Hospital Service. (This took place in Philadelphia, Pennsylvania, when that was the nation's capital.) The Marine Hospital Service was targeted to a very vulnerable group of people, merchant seamen, who often returned from sea with illnesses that threatened their health and the health of their families and communities. The Marine Hospital Service, which would later become the Public Health Service, was founded on the basic principle that, to the extent that we respond to the health needs of the most vulnerable among us, we do most to promote the health of the nation. That's what we believed from the very beginning, which is why today we believe that the commitment to eliminate disparities is not just a minority problem, it's a health systems problem. We believe that the best way to improve our public health system and ultimately to improve and protect the health of all Americans is to ask ourselves why some people are lagging behind in certain areas and what can we do to correct that.

For example, in the area of infant mortality, an African-American baby born in this country today is more than twice as likely to die in the first year of life—the first year of life!—than a majority baby. An American Indian baby is at least 1-1/2 times more likely to die in the first year of life. In the area of maternal mortality, an African-American woman during pregnancy and delivery is four times as likely to die as a white woman. These rates are very low, and as a nation, we have made dramatic progress. We don't have a lot of deaths associated with pregnancy and delivery. But, we still must acknowledge and address the disparities that do exist.

In the area of cancer, there are some dramatic examples of disparities. Beginning with breast cancer, white women in this country have the highest risk of breast cancer; but African-American women have the highest death rate from cancer. We don't have all the answers, which is why research is so important, but we think this disparity relates to difference in access. It may also relate to the fact that there is a difference in the nature of the cancer that we see in young African-American women, which tends to be so aggressive. Vietnamese-American women are five times as likely to experience cervical cancer. Asian Americans are three to five times as likely to die from liver cancer often associated with hepatitis, which is so comparatively common in Asia, especially Southeast Asia. African-American men are twice as likely to die from prostate cancer.

Even in the area of heart disease, again where we have made dramatic progress, African-Americans are 40 percent more likely to die from heart disease.

Diabetes is, I think, one of the most interesting areas of disparity. In this country, American Indians have the highest risk for diabetes—three times the risk of the majority population. Hispanics have twice the risk of the majority population. Some of our American Indian tribes, especially the Pima tribes, have the highest risk of diabetes of any group that we have found in the whole world, and we have looked wide and far. African-Americans have the highest death rate from diabetes, and we think that this is probably related to the fact that often diabetes and hypertension come together. So, you see, we are struggling with these issues. They are not all chronic diseases, however.

The AIDS epidemic, which is an epidemic where we have made some progress, started in the early 1980s as primarily an epidemic of white gay men. All of our biases came out. We even burned the homes of people with AIDS. It was a bad time in the history of America. But we have made a lot of progress since then. The community, the gay community especially, has contributed significantly to that progress by doing a great job of organizing and communicating. I am not sure that is equally true of the young gay population or the gay men of color that we are trying to target better now. In this country, this epidemic has become increasingly an epidemic of women, people of color and the young. I remember, in 1986, when the number of AIDS cases were reported to the CDC, as is done every year at the end of the year, 60 percent of the new cases were in white men, 25 percent were in African-Americans, 14 percent in Hispanics. Last year, at the end of 1999, when the new AIDS cases were reported to the CDC, 45 percent were in African-Americans, 22 percent in Hispanics, and whereas in 1986, only 8 percent were in women, less than 1 in 10 in 1999, almost 25 percent, were in women. And if you look at the younger age group between 13 and 24, almost half of the new infections were in young women. What does that mean? It means that this epidemic has become increasingly a heterosexual epidemic, often spread heterosexually, often related to injection drug use. A young woman who has sex with a man who has been injecting drugs may not know it— it could have been 3 years ago, it could have been 3 months ago, or even 3 weeks ago that he injected drugs—but she is at increased risk for HIV. And increasingly, we are seeing that happening.

This is especially important because a student can come to college already infected with HIV, graduate, and never have any symptoms. With regard to infectious diseases, we haven't seen anything like AIDS since the plague of the 14th century (I'm sure you read about that), which wiped out a third of the population of Europe, or maybe the influenza pandemic of 1918, which killed 40 million people in the world. What's the difference today? Influenza hits hard and fast. People get infected, and they die or they survive. Not AIDS. People get infected. The virus sets up a partnership with the host. The host doesn't even know that he or she is carrying the virus, and yet, for 10 years, can spread it to other people. And that's why this is such a successful, if you will, pandemic throughout the world, especially impacting people who are poor, lower educated, increasingly people of color in Africa and Southeast Asia, and the Caribbean islands. But the thing about it is, regardless of your color, you're at risk for AIDS. It's an equal opportunity virus.

We made a lot of progress, because of our drugs, in treating this AIDS epidemic but what's important to remember is that students need to be aware of the nature of this epidemic and the fact that people don't have to be sick to be infected with HIV. They don't have to be sick to spread it to other people. It's an awesome burden and responsibility.

Immunizations is another area we are both concerned about, especially as we experience epidemics of measles and meningitis on our college campuses. We must use the best resources available, in terms of vaccines, to make sure that students are immunized. We do a great job of immunizing children in the first two to three years of life, but in some instances, that's not enough and people need boosters later on. It is critical that students get their immunizations before starting college; without them, we face an increased risk of a small epidemic spreading rapidly across the college campus, as I am sure some of you have probably experienced. So, in my opinion, vaccines continue to be the safest and most effective medical intervention known to man. They are not perfect, but compared to all of the interventions we have, including surgery and other medications, vaccines are the safest and most effective. They are very potent. We used them to wipe out smallpox, which killed hundreds of millions of people, and they have brought us very close to wiping out polio. That was another one of the major topics of our discussion in Geneva a few weeks ago.

You may be wondering how we are going to do what we said we are going to do in the next 10 years, and how we can work together. You must know that this is difficult, whether it's in terms of improving quality of life or eliminating disparities in health. I like to repeat a very meaningful quote by John Gardner, whom many of you know because he has written extensively about leadership in education, and who was Secretary of Health, Education and Welfare (today, it's Health and Human Services). He said, "Life is full of golden opportunities carefully disguised as irresolvable problems." And I believe that. I have seen it in my own life, and I am sure many of you have seen it in yours.

Let me turn to a discussion of the Leading Health Indicators. When we announced Healthy People 2010 on January 25, we knew we would be challenged to find a way to communicate the message directly to the American people. So we used the new 10 Leading Health Indicators as a way for people to grasp the message. We shared them on the Oprah Winfrey Show and we highlighted them on Cosby Show. We knew that it was not enough for us only to talk with each other, whether we are in public health or medicine or whether we are on college campuses or participants at a meeting like this. We had to find a way to get this message to the American people, and we believe that the 10 Leading Health Indicators is the answer. We also realized back in the 1990s that we could never communicate 300 objectives to the American people, and we certainly can't communicate 467 today. But we can measure them. We can have different people in their individual groups doing visual and hearing and cardiovascular.

We developed the 10 Leading Health Indicators after a conceptual study with the Institute of Medicine, with regressive analysis of objectives. I want to leave them with you because I think this is where we can work together. I hope that you will post them on every college campus. We are going to monitor these 10 Leading Health Indicators the way we monitor leading economic indicators in this country. And they will inform us as we ask ourselves some serious questions, such as: How are we doing as a nation? How are you doing as an individual? How is your family doing? How is your college campus doing?

Five of these Leading Health Indicators are what we call health systems indicators, and five are lifestyle. The five health systems leading health indicators are improving access to care, enhancing our approach to mental health, immunizations, injury and violence prevention, and environmental quality.

Access, as you know, is very critical. The United States probably has the most sophisticated health system in the world. We probably have the best trained people. I know I'm in Canada and, in some ways, Canada may have the best health system, but we have the most sophisticated. We spend over $1.3 trillion a year and, despite that fact, we have almost 45 million people who are uninsured. If you get sick while you're here at this meeting, you don't have to worry because you're in Canada and you have universal access. We don't. I don't mean to say that Canada has the answer, or England or Switzerland, because I don't believe that we have seen the answer yet. But I believe we can, together, find the answer, especially because we are spending $1.3 trillion a year.

It reminds me of a story I heard from Governor Hodges, while I was in South Carolina at a family conference. In his welcoming statement, he told this story about a Texan who visited South Carolina. Now, this was the Governor of South Carolina telling the story, but he said that Texans like to boast. He said they think that they have the biggest of everything. So he said there was this Texas farmer who was visiting South Carolina and, as he traveled around, he stopped to visit with a South Carolina farmer. This Texas farmer had a 5,000-acre farm back in Texas. So, he stopped to visit with a South Carolina farmer, and he said, "Sir, about how many acres do you have here?" The South Carolina farmer thought about that a minute, and he said, "Oh, I have about 40 or 50 acres." So, the Texas farmer thought to himself, "My goodness. This guy wouldn't even understand if I told him how big my farm was. He wouldn't even know what I was talking about." So he said, "I'll give him an example." He said, "Sir, do you know something? Sometimes I get up in the morning and I get in my truck just as the sun is coming up. I get in my truck and I drive across my farm. And, do you know that, when the sun is going down, I have not reached the end of my farm yet?" The South Carolina farmer thought about that and he said, "Well, you know, I used to have a truck like that once."

Well, when it comes to our health system, there is something wrong with the truck. We are investing a lot. We have all kinds of technology. I assure you that, despite all of the debate you are hearing, very soon we will map the human genome. We will know where every gene is. In time, we will be replacing genes. We will be curing genetic diseases. To a certain extent, we can do some of that now. We're that close. Our technology is amazing, and yet, we can't get basic health care to people in rural and inner city communities. There's something wrong with the truck.

The college campus is an interesting model because you probably do a better job than the rest of our health system in terms of providing access, and I think that maybe you have part of the answer. But I didn't come here just to praise you; I came also to challenge you, because there are some things we can do together to improve health across the nation. We have too many people that are uninsured, underinsured, underrepresented, who live in underserved communities, who are uninformed, and who are untrusting of the system. I could go on and on with these "un's", but the point is that our system is characterized by too many "un's," and we must change that. That's what we have to do together.

I believe the answer (and I know you are waiting for the answer), is in a balanced community health system, a system which balances health promotion, disease prevention, early detection and universal access to care. That's what I believe. What does that mean? If you are not aware of it, we spend well over 90 percent of our budget on treating diseases, many of them in their late stages. The majority of it is spent on treating diseases in their late stages. We have to. When people get sick, you've got to treat them. But the problem is, we are not investing on the front-end to keep people healthy; we have not really invested in prevention. In fact, we invest less than 2 percent of our budget on population-based prevention—less than 2 percent. There's something wrong with this truck.

Five of these Leading Health Indicators are what we call health systems indicators, and five are lifestyle. The five health systems leading health indicators are improving access to care, enhancing our approach to mental health, immunizations, injury and violence prevention, and environmental quality.

We believe that the answer is in a balanced community health system, because in a balanced community health system, the community has to be involved. Whether it's' the college campus, which is a great community, or some other portion of the community, the community has to be informed and energized and talking about issues the way these students did this morning. I'm talking now specifically about health issues because that's my area. The community has to begin making decisions about how are we going to prioritize resources. They have to begin asking: What are the risk factors on this campus? How can we better protect the health of each other? I heard the students having some great discussion about stopping somebody from driving when drunk—that's fantastic—and about dealing with prejudice against sexual orientation. The community has to be involved if we are going to have a balanced community health system that really focuses on health promotion, disease prevention, early detection and universal access to care.

Well, let me talk about another one of the health systems indicators, mental health. When I released the Surgeon General's Report on Mental Health on December 13, 1999, it shed light on what had only been a silent, dark issue.

Surgeon General's Reports through the years have brought much-needed attention to many areas. The first-ever Surgeon General's Report was released in 1964 by Dr. Luther Terry. It was a great report on smoking and health. It is so great that, since then, we have had 28 Surgeon General's Reports on smoking and health, and they have proven not to be in vain. In fact, 40 percent of the American people were smokers in 1964; today, it's about 23 percent. So, we have made some progress. Yet, almost 50 million people in this country still smoke. And every day, 3,000 teenagers become smokers. Many of them will be addicted before they are old enough, 18, to legally purchase cigarettes. A third of them will die from some smoking-related illness. So, Surgeon General's Reports have had a tremendous impact on America's health, and we expect nothing less from this Report on mental health. I was so happy to see all of the students' hands that went up when you asked: "How many of you have stopped smoking?" And then almost no hands went up when you asked: "How many of you smoke?" Well, I wish these students were representative of the nation at-large, but I'm afraid they are not. They can be leaders, though.

We have never had a Surgeon General's report on mental health, even though mental health has an impact on all of the indicators. I told you that I said I wanted to be remembered as a Surgeon General who listened, and some people said to me, "Why did you do a Surgeon General's Call to Action on Suicide Prevention? Was that planned when you took office?" No it wasn't—by no means. I listened. I heard people talk about suicide. Those of you know my history know that when I was CDC, I was concerned with homicide, and you know how hard I worked. But, you never heard me give a speech on suicide at CDC, because it was not an issue that was registering with me. But, when I became Surgeon General, the American Association of Suicidology invited me to attend a meeting and to talk about the public health aspects of suicide. I met people like Dr. Kay Redfield Jamison, the outstanding psychologist at Johns Hopkins, who herself has bipolar disease and has attempted suicide many times during her struggle, who talked about suicide. So, I called together a group of people, got some money from Congress, and in October, 1998, had a workshop in Nevada, which has the highest suicide rate of any state in the country. From that workshop, we put together a Surgeon General's Call to Action for Suicide Prevention, which was released in June 1999. We said in that Call to Action that suicide has tripled among adolescents in this country since 1952 and that since 1980 it has doubled among 10-14 year olds. Some people say suicide is a white problem and homicide is a black problem. But since 1980, suicide has doubled among young black males. This is all of our problem. This was an opportunity to prevent this tragedy, and in case you haven't picked it up yet, I'm prevention oriented. So the Call to Action was a call to understand that 80-90 percent of people who committed suicide were suffering from a mental illness. They weren't just having a bad day. They didn't just fail a course or fail to make the football team, even though that could have prompted something. They were suffering from a mental illness. Most of the time it was depression, a treatable mental illness.

I was listening to teenagers in Portland, Oregon, a few weeks ago. We were announcing a new suicide prevention strategy with the American Foundation for Suicide Prevention, and these teenagers were talking about their experience with suicide. They talked about the fact that sometimes they don't know what to do when a friend says, "I'm thinking about taking my life." They asked, "Do you tell on them? I mean, do you rat on them? Do you tell your parents or do you tell their parents? If you are their friend, they trust you to keep it in confidence." And then, one young lady said, "I decided that it was better to lose a friendship than to lose a friend." That's suicide prevention. Suicide results from a mental illness 80-90 percent of the time. If somebody needs help, if they were having chest pain, I believe we would rush them to the emergency room. Wouldn't we? If they had a broken limb, we would rush them somewhere to get it set. Well, depression is an illness. It's not a character disorder. It's not a bad day, it's an illness. It needs to be diagnosed and treated. And so that's the message.

Obviously, we didn't wait for the release of the Mental Health Report to address this issue of suicide; we came out with the Call in June and then followed in December with the release of the Mental Health Report, which a panel of experts had been working on for two years. What did we say in the Report? Let me summarize it for you. We said that mental health is fundamental to overall health; it cannot be separated. We said that, because of all of the research in the last 25-30 years, we know that not only are mental illnesses inseparable from physical illnesses, mental illnesses are physical illnesses. They result from changes in chemical secretions in the neurons of the brain. Therefore—and this is the good news— most mental disorders are treatable.

We also said in that report that 1 in 5, or 20 percent, of Americans suffer some mental disorder every year—every year 1 in 5! But the bad news is that fewer than half of them seek care. Why? Because of the stigma—the blame, the shame surrounding mental illness. But just as things go wrong with the heart and lung and the kidneys and the liver, things go wrong with the brain. There should be no doubt about that and no shame in that. So, we said that we had to work to de-stigmatize mental illness. People have to understand that, if you are suffering from a mental illness, you have as much right to be diagnosed and treated as somebody suffering from cardiovascular disease or kidney disease. You are not to be fired from a job because you had to be treated for mental illness. You are not to be turned down from anything because you had to be treated for depression or schizophrenia or bipolar disease. That is ridiculous. That is outdated. It's time for this country to move on. And that's what the Mental Health Report is intended to do.

The college campus is ripe for mental illness. That's not a negative statement. I think I read somewhere that your average age is 25. It just happens to be an age, actually the entire 18-25 age group, that so many of the mental illnesses that we see have their onset, including schizophrenia and bipolar disease. Depression is very common at all ages. And so, if your college campus doesn't welcome students who need help in this area just as readily as you welcome students who need a vaccine or a test for heart disease or diabetes, then it's time to change. It's time to de-stigmatize mental illness.

I hope you will help us do that. We are committed. We are developing a major de-stigmatization program that started with the report. I visited Australia in November before releasing the report, because they have had a very successful de-stigmatization campaign and I wanted to copy its positive aspects. Also, they have done a better job than we have at organizing community mental health services. So, we need to change our system. We also, as you probably know, discriminate. Our insurance companies discriminate in covering mental illnesses. We don't have parity of access to care. Even the federal government has problems. President Clinton announced last year that, henceforth, at least beginning in 2001, every health plan that insures federal health employees would have to provide parity of access, not just for federal employees but for anybody else that they cover. And so we hope that this will become the norm. Thirty states have now passed parity laws saying that if you are an insurance company that operates in this state, you have to provide parity of access.

So, we are making progress, but we have a long, long way to go. We've got to start earlier, and the college campus ought to be a major focus of our efforts to de-stigmatize mental illness. Certainly, at that point, we ought to make sure that everybody is educated about the nature and importance of mental illness and the good news about our ability to treat it. That's the real message. That is what's going to de-stigmatize it—the very fact that 80-90 percent of the time, we can return people to productive lives and positive relationships.

Well, let me close. I'm not going to talk about the remaining three health systems indicators, injury and violence, environmental quality, and immunization, because I want to close with the other five Leading Health Indicators. (We designed this bookmark, which has all 10; if you want a supply, just order them from our office.) The last five relate to lifestyle; if you are taking notes at all, be sure to take these. They are tobacco use, physical activity, overweight and obesity, substance abuse, responsible sexual behavior. And, some of you know that, about a year-and-a-half ago, I started passing out "The Surgeon General's Prescription." I think I gave all of the college students one, even though they didn't ask for them. I don't know if the Surgeon General has ever had prescriptions before; I'm a doctor and so I wrote a prescription for the American people, my patients. I want to read to you what it says. (You probably can't see that, so I brought a big one.) The students can read along with me.

The first one is moderate physical activity, at least 5 days a week, 30 minutes a day. I wish I had time to tell you all the benefits of physical activity. Unfortunately, only about 30 percent of Americans engage in regular physical activity and less than 50 percent of college students. Only one state in the Union requires physical education in K-12, that's Illinois. We are cheating ourselves, especially when you consider that physical activity can reduce deaths from cardiovascular disease by 50 percent and reduce the onset of type II diabetes by 30 percent. Physical activity can reduce stress, and I agree with the young lady that it is a good stress management strategy. It obviously improves muscle tone and fitness. Physical activity can reduce the risk for several types of cancer including colon cancer, breast cancer, and prostate cancer, especially when you combine physical activity with nutrition.

The second thing on here is nutrition. We recommend that you eat at least five servings of fruits and vegetables per day. The American diet is too loaded with fats and sweets and too deficient in fruits, vegetables and grains. So, when the new Dietary Guidelines for Americans came out yesterday (I hope you didn't miss that), we were all over the television all over the country highlight their new areas of focus, including an emphasis on physical activity. Although this is the fifth set of Guidelines, which by the way are re-issued every five years, we have never emphasized physical activity the way we did this time. We also separated the grains from the fruits and vegetables category because they are both so important. We talked about reducing saturated fats and cholesterol, and moderating your total fat intake.

Physical activity and good nutrition combined can save a lot of lives in this country—over half of the premature deaths that occur in this country every year are the result of physical inactivity and poor nutrition, combined with a few other things.

This next area is especially critical; that's avoiding toxins, starting with tobacco. We consider tobacco use to be a pediatric disease, because it most often starts in children. We don't have the authority to regulate it, but I hope we're going to get that soon. In addition to tobacco, we are concerned about substance abuse. I'm not just talking about illicit drugs like heroin and cocaine and marijuana. Those have stabilized and, in some ways, decreased, although they are still very serious and kill about 12,000 people a year in this country. But, alcohol is a drug that we are very concerned about. At least 100,000 people a year die from alcohol abuse. According to our last survey, 43 percent of college students binge drink—whether it's 21 drinks on your 21st birthday as the students just pointed out, or it's the more formal definition of 5 drinks or more, once a week or twice a month in one sitting—that's binge drinking, and it's a major concern. Alcoholism is an addiction, although binge drinking is not necessarily an addiction. Students who do it are playing around in a sense; they are not necessarily addicted. But it's very dangerous. It increases the risk of automobile crashes, increases violence, increases the risk for indiscreet sexual behavior, and it obviously interferes with academic performance. So, we are concerned about that. We are willing to work you. I am very pleased with the screening program for alcoholism that we have developed together, as well as the screening program for mental illness in general.

The last thing on here is responsible sexual behavior. Americans have traditionally had a lot of trouble talking about sex, except in dark corners or vacant buildings, and that ought to change. We have said that sex education ought to be taught not only in schools but also in homes and in churches and everywhere else that people congregate to talk. They ought to talk about sex, the beauty of sex, the wonder of sex—also, the responsibility of sex. Sex is about meaningful relationships. One of the messages that we have tried to get out to young people, and I have spent a lot of time talking to middle school and high school students and listening to them, is that relationships should not begin with sex. They ought to begin with communication, understanding, appreciation, respect. And sex ought to occur in the context of a meaningful committed relationship. That's the message. Now, there are some people who disagree with me. They don't think I've gone far enough. But the message is that sex is special. It's beautiful. It ought to take place in the context of a meaningful committed relationship; otherwise, it's cheapened. That's the message. There are a lot of adults who never learn that message, but it would be great if our young people did.

Well, let me just say to you how much it has meant to me to be with you. I consider this a very important partnership. You know, the playoffs are going on. Portland beat the Lakers last night. But wait. With that in mind, I want to close with this story about a college student who was just a great basketball player. I mean, everybody knew his name. So, when he graduated, he was drafted very early and he went to play with the Chicago Bulls along with Michael Jordan. And this rookie worked very hard. He was determined to make the team. And, sure enough, one day the coach came and said, "Tonight, you're gonna' start right along with Michael Jordan." He was excited. He got in the game. He played hard. He really played hard. Michael Jordan was at his best that night. He scored 60 points, and the rookie scored 1 point—a free throw. When the game was over, the press was anxious (you know the press). They were anxious to interview Michael Jordan and the rookie. So, they interviewed Michael Jordan; he was great. They interviewed the rookie, and they all asked one question of him, "How will you remember this night?" He thought about that, and he said, "I will remember this as the night when Michael Jordan and I combined for 61 points."

Well, I am convinced that there is almost no limit to what you can achieve when you combine with the right people. So, I am here to combine with the American College Health Association to achieve the goals, objectives and the Leading Health Indicators of Healthy People 2010. Together, I know we can do it. I know we can do it. Because of that, I leave you with my favorite poem called "God's Minute", and it goes something like this. I heard it from the President of Morehouse College when I was a student there. I never learned who wrote it, nobody knows. But Dr. Benjamin Elijah Mayes used to say this poem:

"I have only just a minute,
Only 60 seconds in it,
Forced upon me, can't refuse it,
Didn't seek it, didn't choose it,
And yet, it's up to me to use it.
I must suffer if I lose it,
Give account if I abuse it.
Just a tiny little minute,
And yet eternity is in it."