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

June 11, 1999

[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.]

Introductory Remarks

Acknowledgments

Thank you, Ms. Tonya Williams, for that kind introduction. To University officials, members of the administration, faculty, staff and especially to the graduating students and their families, friends and guests, good afternoon. It’s my pleasure to be with you. I bring you greetings from Washington, DC, and the Department of Health and Human Services’ Office of the Surgeon General. I want to offer a special salute to the Wright State University Graduating Class of 1999.

Let me commend the School of Medicine for the many contributions you have made toward advancing and improving the Nation’s health.

To begin with, each of you graduating today is not only making a public commitment to serve and improve the Nation’s health, but your being here today has also made a personal contribution on your part to the Nation’s health. Research has shown that a person’s educational accomplishments have a direct relationship to their health; so the very fact that you are graduating today increases the likelihood that you will be in better health than had you not come this far.

In addition, your longstanding commitment to community and your attention to ensuring diversity are the ingredients that make a difference in the lives of the American people. Indeed, they are the stuff that hopes and dreams are made of, and we must continue that.

I said when I was sworn in as Surgeon General and Assistant Secretary for Health February a year ago that "the American dream does not end when it comes true for you. You must make it come true for others." And I still believe that.

Soon after President Clinton appointed me as Director of the Centers for Disease Control and Prevention in Atlanta, a reporter who doubted that any good thing could come out of Anniston, Alabama, decided to do some investigative research in preparing to write a story about me. He searched for information about my life and even talked to my boyhood neighbors, family and friends, hoping to find something to spice up his story. As it turned out, he ended up writing a magnificent piece that his editor put on the front page of the Anniston Star. Shortly after that, I arrived home one evening to receive a bundle of letters with postmarks from Anniston. As it turns out, the article appeared in the paper just about the same time that an 8^th grade teacher from Anniston had been struggling to find some way of giving her students a new outlook. Mrs. Young had them read the story and then write letters to me. At my wife’s insistence, I began reading them.

The first was from a young boy, who said that he had just gotten in a gang, but after reading the story about me, he decided that gang life was not for him and he was going to get out.

The second one was from a young girl, who said that she did not know what she wanted to be when she grew up before she read the article, but after having read it, she now knows that she wants to be the director of the CDC.

The third letter was from a boy who must have been like me when I was growing up. He must have been daydreaming or only half-listening when this assignment was being discussed, because his letter said that he did not know what the CDC was but he sure hoped I found a cure for it.

Hopes and dreams are important.

But your contributions to the Nation’s health don’t stop with your personal health. Wright State is known as a model for building successful community partnerships. Your commitment to health has not just positioned you in the community, you have made yourself a part of the community—working together with it to care for underserved populations.

You may have heard the story of the rookie basketball player who did well in college basketball, and made it to the pros. He was drafted by the Chicago Bulls and played his first game with Michael Jordan. Michael had an outstanding night, scoring 60 points, and the rookie scored 1 point. The media was there after the game. They interviewed Michael and he did great. Then they interviewed the rookie. All of the reporters had just one question for him. They asked him how he would remember this night. The rookie said: "I will remember this as the night that Michael Jordan and I combined for 61 points."

There’s really no limit to what you can do when you partner with the right people.

Yesterday the Department released our most recent data from the Healthy People 2000 initiative showing continued improvement in the health of Americans during the current decade, and it showed that, as a Nation, we were on track to reach, or that we have already reached, the targets for more than 50 percent of our objectives.

In many ways, Americans of all ages and in every race and ethnic group have better health today than a decade ago. Yet, considerable disparities remain.

Our Commitment to Eliminate Disparities in Health

I want to partner with you today in working to achieve our initiative to eliminate racial and ethnic disparities in health by the year 2010, which I have adopted as one of my priorities as Surgeon General.

This priority also grows out of the President’s Race Initiative, unveiled about 2 years ago during a speech at the University of San Diego. The President said that we in America represent the most diverse country in the world. He said diversity is one of our major strengths and we ought to deal with it that way. As other countries throughout the world become more diverse, they ought to be able to look to America as a model of positive diversity. The President challenged us to educate ourselves about each other and to get to know people across racial and ethnic lines. To spearhead the Nation’s efforts, he appointed a national advisory board led by historian John Hope Franklin.

Subsequently, we made the unprecedented commitment in our Department, under the leadership of Secretary Donna Shalala, to work toward the elimination of disparities in health, recognizing that for all the medical breakthroughs we have seen in the past century, we still see significant disparities in the medical conditions of racial groups in this country.

We have selected six areas as starting points: infant mortality, cancer screening and management, cardiovascular disease, diabetes complications, HIV/AIDS infection rates and treatment, and child and adult immunizations. These areas represent grave problems as well as great opportunities for improving the Nation’s health. Look at these examples with me:

• A baby born to an African-American mother has more than twice the risk of dying in the first year than a white baby. An American Indian baby is 1.5 times more likely to die.
• Vietnamese women living in this country experience cervical cancer at five times the rate of white women. Hispanic women over 65 have twice the risk.
• African-American men under 65 suffer from prostate cancer at nearly twice the rate of whites.
• African-American men suffer from heart disease at nearly twice the rate of whites.
• African-American women are 40 percent more likely to die from cardiovascular disease than white women.
• American Indians suffer from diabetes at nearly three times the average rate. For Hispanics, the rate is nearly double that of whites. And African Americans suffer 70 percent higher rates of mortality from diabetes than whites.
• Although the incidence of breast cancer is greater for white women, African American women are more likely to die from breast cancer.
• Asian-Americans are more likely to get liver cancer.
• Despite its makeup in the past, HIV/AIDS is increasingly becoming a disease of women, of people of color, and of the young.

As we work to eliminate disparities, we must keep in mind that this is not a zero-sum game. We are not taking anything from anyone when we focus on the health needs of those most at risk.

Removing the Barriers to Care

To eliminate disparities, we must remove the barriers to care and services. We can begin by asking ourselves some tough questions. Why is it that even when people are equally insured and even when they get equal access to care, the treatments and outcomes are still not the same?

A recent report by Kevin Schulman in the New England Journal of Medicine and studies in other journals have pointed out that disparities are not always the result of lack of insurance or even access to quality care as had once been believed. Schulman noted that physician biases, intentional or not, often result in disparities in treatment—even when all things are equal in patients. That being the case, lack of insurance coverage is sure to be a guarantee that disparities will continue. In order to succeed in eliminating disparities, we must ensure coverage for underserved populations.

We also must look at cultural and racial/ethnic issues, which can become barriers, too. That means we must be honest in recognizing that the same race and gender biases that affect the rest of the population also affect the doctor-patient relationship. That means our physician supply must include those who have shared cultures and backgrounds with their patients and who can effectively communicate with their patients. But beyond ensuring diversity in the health professions, we must make sure that medical schools are willing to talk about issues that relate to race and gender equity. Any issue that threatens trust must be dealt with.

Another barrier can be lack of trust in the health professions. The public is holding us to a high standard of practice. And we must live up to it. We need physicians who are willing to ask questions about their patients’ lifestyles and to develop prevention strategies before their patients get sick. Too many doctors still focus too much on treating the complications of disease and too few physicians are putting prevention into practice.

And we must work on creating a reimbursement system that supports physicians in their efforts to put prevention into practice.

Balanced Community Health System

You must be wondering how we plan to reach this goal of eliminating disparities in health. I concede it is a huge challenge, and we cannot do it unless we move toward a balanced community health system that balances health promotion, disease prevention, early diagnosis, and universal access to quality care. We need a balanced system that brings together public health and medicine like we’ve never before had in this country. That system must include the home, the schools, faith-based organizations, local groups—the entire community, if we are going to be successful.

It was in 1993 when the President introduced health care reform. Since that time, the ranks of the uninsured have increased from 37 million to 43 million people. As a Nation, we spend $1.5 trillion each year on health care, but only 1 percent of that amount goes to population-based prevention.

Getting a handle on such a massive problem is not easy. It reminds me of the Texas farmer who was visiting South Carolina. He drove past a fellow farmer who sitting on his porch. The Texas farmer wanted to give him an idea of the size of his farm back home and so he said: I get up in the morning when the sun rises, I climb into my truck and start driving across my farm. And by the time the sun sets that day, I still have not reached the end of my farm. The South Carolina farmer paused and said: You know, I had a truck like that once.

What must a balanced community health system achieve?

We begin with a commitment to children and making sure that every child has an optimal opportunity for a healthy start in life. When we talk about giving every child a healthy start in life, we mean responsible parenting—making sure that babies are born to parents who are ready to be parents. We mean safe pregnancies, which begin even before conception with Folic Acid intake and other forms of good nutrition, the avoidance of toxins, and early prenatal care. A healthy start also means a safe and nurturing environment in which to grow, an environment free from toxins, injury, abuse and violence.

Second, a balanced community health system promotes healthy lifestyles. It means paying greater attention to physical activity, nutrition, the avoidance of toxins, and responsible sexual behavior, which includes abstinence.

Since I am the called the "Nation’s doctor," my staff thought it appropriate that they make some prescription pads for me that I carry whenever I am on the road. They say (1) engage in moderate physical activity at least 5 days a week at least 30 minutes a day; (2) eat at least five servings of fruits and vegetables a day; (3) avoid toxins, such as tobacco; (4) and responsible sexual behavior, including abstinence as appropriate.

I was at Princeton, New Jersey, the other evening speaking to the Board of the Robert Wood Johnson Foundation. And since I am away from home so much I was determined  to get back to Washington that night. We rushed to the train station after I spoke to catch the last train from the Trenton station. Even though we rushed down into the station, the train was a little late. As we were standing there, this young man looked over and he noticed me. He said: "You know, you look just like the Surgeon General." I was dressed in full uniform, just like I am now. I said: "There’s a reason for that." Well, he discovered that I was so he started shouting, "The Surgeon General is here, the Surgeon General is here." So other people started coming around who were supposed to be working. The first guy got there and said to his friend: "You mean you are smoking in front of the Surgeon General?" So he threw his cigarette away and stomped it. And I wrote him a prescription that said "stop smoking." The other guy started laughing and he said: "Well you can’t laugh, you’re overweight." So I wrote him a prescription. Then there was another guy laughing, and one of them said to him, "You can’t laugh, the way you mess around, you’re going to get AIDS or something." So I wrote him one. By the time I left there, I had written about 10 prescriptions.

We’re serious about promoting healthy lifestyles.

We hope to get to the place one day where every physician is writing prescriptions to promote health and prevent disease and not just for drugs. If we can do that, we can make a difference.

And we want to get to the place where physicians are having an impact on their patients’ lifestyle choices. I want to encourage you to talk to your patients. Ask them questions about their lives and, then, ask them to change the habits that are harmful to them. Many smokers report that if their physicians would only ask them to quit, they would be more inclined to do so.

Also, we know that if we could get people to commit to moderate physical activity for at least 30 minutes a day, 5 days a week, we could reduce cardiovascular disease and deaths from cardiovascular disease by one-half in this country. Beyond that, we could lower the incidence of colon cancer and we could reduce the onset of Type II diabetes by one-third.

So the opportunities for improvement are there, we just need to take them. Health, Education and Welfare Secretary John Gardner had a wonderful saying that I like to repeat. He would say: "Life is filled with golden opportunities, carefully disguised as irresolvable problems."

Our challenges ought not defeat us; rather, they should drive us.

So let us begin today. I want to leave you with this quote from one of my mentors, Dr. Benjamin Elijah Mays, who was president of Morehouse College for 27 years, including the 4 years that I was there.

It must be borne in mind that the tragedy of life doesn’t lie in not reaching your goal. The tragedy lies in having no goal to reach. Don’t be afraid to dream. It isn’t calamity to die with dreams unfulfilled, but it is a calamity not to dream. It is not a disaster to be unable to capture your ideal, but it is a disaster to have no ideal to capture. Reach for the stars. It is not a disgrace to fail to reach the stars, but it is a disgrace to have no stars to reach for. Not failure, but low aim is sin.

Godspeed.