Remarks as prepared; not a transcript

Vice Admiral Richard H. Carmona, M.D., M.P.H, FACS
Acting Assistant Secretary for Health
United States Surgeon General
U.S. Department of Health and Human Services

Keynote Speech for National Managed Health Care Congress Summit

Washington, D.C.
Tuesday, March 11, 2003

"Reducing Racial and Cultural Disparities in Health Care: What Actions Now?"

Thank you, Dr. Hughes, for that kind introduction. [Dr. Edward Hughes, Professor, Kellogg School of Management, Northwestern University]

I also want to congratulate the organizations that were recognized this morning with the coveted NMHCC "Partnership" award for their leadership in advancing health care quality, access, and efficiency.

The collaboration and cooperation that the "Partnership" award recognizes is essential to health care. In fact, we all need to get out of our silos and our sectors and work together.

It’s a message that we get repeatedly from President Bush and Secretary Thompson. It’s what Secretary Tommy Thompson is talking about when he says that we must work together across the Department of Health and Human Services and throughout state and local agencies and the private sector to keep Americans safe and healthy.

It is wonderful to be here with so many fine professionals who care so deeply about the health and safety of the American people.

I’m especially happy to be here today with my boss, Secretary Thompson. It’s an honor to serve with him, and you should all know that you have a friend and a very compassionate person in Secretary Thompson.

The threat of bioterrorism dominates the headlines. Preparing our country to face and respond to a possible attack is part of the job that Secretary Thompson and I do every day. We take it very seriously.

And the work of this summit — reducing racial and cultural disparities in health care — although it doesn’t always make headlines, is critically important to the lives and health of all Americans.

"Closing the gap" in health care disparities for minorities is one of President Bush and Secretary Thompson’s priorities, and of course one of my priorities as Surgeon General.

The President and the Secretary asked me to concentrate on three priorities:

  • Prevention,
  • Public health preparedness, and
  • Closing the gap in health care disparities for minority groups.
  • These three issues have been the big blinking lights on my radar screen for years. So it’s great to work for the President and Secretary, because they are just as passionate and committed as I am to making progress in these areas.

    I never had to worry that if they selected me to be the 17th U.S. Surgeon General, that I might have to convince my President and my Secretary that prevention, preparedness, and closing the gap are the big three public health issues in America.

    The President and Secretary are not just ‘on board’ — they’re leading the charge on these issues.

    Secretary Thompson will speak with you in a few minutes, and I know that you’re eager to hear directly from him about President Bush’s proposals to improve and strengthen Medicare and Medicaid.

    My role here today is to say that we need you — your passion, your expertise, your experience, and your partnership. You’re out there in the trenches every day. I understand from having been in the trenches, like you, for many years, what it’s like to be there in the trenches running health systems and managed care organizations.

    The work you are doing here will help secure the best possible future for all of us, regardless of the color of our skin or our ethnic heritage.

    We need you to help us meet the challenges facing Americans. Many of us have faced a lifetime of challenges. I, for one, did not follow the typical career path.

    I was born and raised in a poor section of Harlem. I dropped out of high school and ran the streets. As did most of my friends. In my community in the 1960s, being a high school drop-out was common. A high-school graduate was a reportable event!

    Despite some of the bad childhood and adolescent choices I made, I was one of the lucky ones.

    I was able to make it to adulthood relatively unscathed because some very strong people cared about me and gave me direction.

    These experiences gave me a unique vantage point to now truly understand health care disparities, since I was one of those before the term was coined. I was one of those children who was not able to go to a dentist because we had no money. Or could not get to the doctor unless we went to a public hospital. So I truly understand. And I still have family members who make that struggle to link up with a health care system that is very difficult to access, and sometimes almost impossible.

    But I had a grandmother who didn’t speak English, my abuelita, who came here at a very late age. She spent a great deal of time trying to educate me ….. to get me to understand the value of this country. Why she came here in the 1930s with 27 children ….. because she saw opportunity in a country that she could never have where she came from, and she wanted a better life for her children.

    When I was 17 years old, I had dropped out of high school and was working at various odd jobs, including selling hot dogs at Yankee Stadium. It was that year that I made one of the best choices of my life — I joined the United States Army.

    The Army is not the career choice for everyone, but for me, at that time, it was just what I needed because it allowed me to get out of the ‘hood. For the first time in my life, I was challenged.

    In the Army I learned leadership lessons and discipline that have stayed with me for a lifetime. I learned

  • accountability,
  • responsibility,
  • and loyalty.
  • These lessons have stayed with me as I’ve moved through various milestones in my life.

    In the Army, I earned my GED and served in Vietnam as a Special Forces medic. I saw more in one year there than most physicians see in a lifetime.

    One thing I figured out was that even though I was a poor kid, when I saw what life was like in a developing country, I knew that I was very fortunate to be an American.

    It was a really tough year. I saw my buddies die in combat, and I received my first combat wounds.

    In that single year, I matured more than a decade. At age 19, I delivered my first babies, a set of twins.

    When I got home, I decided I wanted to be a doctor. My family wanted me to join the electrical union.

    My family called me crazy — ‘loco’ — and a few other choice phrases you hear in Spanish Harlem. They said, "Rich, our people don’t become doctors. Our people don’t do those type of things."

    Of course, once my family realized that I was serious, that I was not suffering from delusions or some mental imbalance, they were behind me 100%. They still are.

    I went on to medical school, became a trauma surgeon, a professor, and ran a health system. Along the way I also served as a police officer, paramedic, and nurse. I got to see the best and worst of society every day.

    I constantly saw men and women serve their communities in heroic ways and make a positive difference.

    But day in and day out, I saw that our society endures the pain brought on by poor choices, whether they be impulse choices — like street crime, drunk driving, and the saddest of all, domestic violence.

    Or long-term choices — like not exercising, eating a bad diet, and smoking — that eventually lead to obesity, type 2 diabetes, cardiovascular disease, certain types of cancer, and early death.

    I’m the first to say that I’m a "recovering surgeon." Toward the end of my clinical career as a trauma surgeon, I became a bit cynical. When I was training residents in the ER, I used to tell them, "I’m not a surgeon, I’m a repairer of society’s indiscretions."

    Two out of every three cases I saw in that trauma department were preventable. They were the results of poor choices. Whether it was violence, whether it was injury, whether it was a series of bad lifestyle choices for decades.

    And today I’m here to say that we need you to help us move toward a society that is focused on preventing disease and injury, not just repairing the problems after they’ve happened.

    We need you to help us to incentivize the system to develop and implement best practices in prevention. We need your help to bridge the cultural divide ….. from a treatment society to a prevention society. We need you to help us meet the new challenges facing America.


    Today we are in fact meeting many of those challenges.

  • Childhood immunization rates are at an all-time high.
  • Infant mortality is at an all-time low.
  • Cancer is striking less often and taking fewer lives — reversing a 20-year trend.
  • Every day, we’re finding better ways to fight disease and untimely death. This is good news for America. And we must ensure that every American has access to these great medical advances. We must ensure that every American can get medical care and treatment. In too many areas, our nation is still two nations, divided when it comes to health.

    Simply put: America suffers from racial and ethnic disparities in health. To put a new twist on something that a great man — Dr. Martin Luther King, Jr. — once said:

    the inseparable twin of racial injustice is health injustice.

    We all know that is true. It is why one of President Bush and Secretary Thompson’s top priorities is to eliminate health disparities.

    Not just to reduce health disparities — to eliminate them.

    From the very beginning of life, children of color are at a disadvantage.

  • Our infant mortality rates are higher.
  • We are more likely to have low-birthweight babies, which can cause a lot of health problems. A baby born to an African-American mother has more than twice the risk of dying in the first year of life than a baby born to a white mother.
  • I mentioned that childhood immunizations rates are at an all-time high in America. That is true, and it is to be celebrated. But that good news doesn’t include all children.

    If today is like most other days in America, nearly one in four minority kids will miss at least one of the vaccines they should receive. Those kids will not be on track to be immunized against deadly childhood diseases like polio, diptheria, pertussis, and tetanus.

    Things don’t get better when the kids grow up.

    A Hispanic American has three times the risk of developing type 2 diabetes as a white American, and also has a higher risk of complications.

    Heart disease is the #1 killer of women in this country. And African-American women are 40 percent more likely to die from cardiovascular disease than white women.

    And then there is AIDS. The CDC estimates that there are approximately 40,000 new HIV infections in the United States each year. Half a million Americans are infected with the HIV virus. And in the past few years, more than 70% of new AIDS cases were among minority groups: Hispanics, African Americans, Asian Americans, and Native Americans.

    How to ‘Close the Gap’

    We obviously have a lot of work to do. Where should we begin? To start, we must never again look at the health gap as:

  • A "Latino problem."
  • An "African American problem."
  • An "Asian American problem."
  • A "Native American problem."
  • It is an American problem that demands an American solution.

    We need to improve access to health care for all Americans. President Bush and Secretary Thompson have made strengthening the health care safety net a fundamental goal of the Department of Health and Human Services.

    The President has committed to increasing the number of community health centers by 1,200 over the next five years; eventually doubling the number of people they serve to reach at least 22 million low-income Americans ….. from inner cities to rural communities.

    On the domestic HIV/AIDS front, President Bush has requested $16 billion in next year’s budget for domestic HIV prevention, care, and treatment — a 7% increase over last year.

    That includes a $93 million increase for AIDS research and $100 million more to support the AIDS Drug Assistance Program (ADAP), which provides funding to purchase medicines for people who do not have health coverage.

    Recognizing the importance of HIV testing as a way to stop the spread of the epidemic, the President has also moved quickly to increase the number of people who are tested for HIV. The President supported the recent decision by the FDA to approve a new rapid HIV test, which can provide accurate results in less than 30 minutes.

    In addition, Secretary Thompson will provide a waiver to make it easier to get the test to doctors and public health facilities throughout the country.

    And the Secretary has expanded the SCHIP program to reach more low-income children. This will benefit many minority kids. SCHIP now covers 5.3 million children who otherwise would not have access to health care.

    President Bush and Secretary Thompson are also calling for an expansion of the Vaccines for Children program to help underinsured children get the vaccines they need.

    The three initiatives of the expansion are:

    1. expanding the number of clinics that can provide vaccines at no cost,
    2. restoring tetanus and diptheria vaccines to the program, and
    3. increasing the existing stockpile of childhood vaccines.

    By doing these three things, we will provide free vaccinations to hundreds of thousands of American children.

    With your help, the Federal Government is working in many ways to close the gap. But government can only do so much. That’s why I think that all Americans — black, white, Asian, Hispanic — will also benefit from President Bush’s prevention agenda.

    Disease Prevention

    So many of our chronic, debilitating illnesses can be prevented through lifestyle choices. Let’s look at preventing obesity. I call it ‘the terror within,’ a threat that is every bit as real to America as weapons of mass destruction. Obesity is destroying us from the inside. That’s why I call it "the terror within."

    Do you know what the fastest-growing cause of illness and death is in America? The answer may surprise you. It is not HIV/AIDS, drug abuse, or alcoholism, as terrible as those things are.

    The fastest-growing cause of illness and death in America today is obesity. If we don’t do something about this, especially among our children, we will be a morbidly obese dysfunctional population with significant co-morbidities such as diabetes and cardiovascular disease that we cannot afford.

    Today, nearly 2 out of 3 American adults and about 15% of children are overweight or obese. And minorities are faring worse than the overall population: 23% of Hispanic Americans are obese. And 30% of African Americans are obese.

    What is stunning is the rate at which the obesity epidemic is growing. The proportion of overweight adults has increased 50% in 10 years. And adolescent obesity has tripled since 1980.

    We now have more than 9 million overweight young people, with millions more at risk. And we know that overweight children tend to become overweight adults.

    All these overweight Americans are at increased risk of suffering from many diseases, including one of the most widespread diseases in America today — type 2 diabetes.

    Unheard of in young people just 20 years ago, type 2 diabetes is trickling into our schools — and left unchecked, it leads to serious illness and possible death.

    Each year, diabetes costs America $132 billion in medical and other costs. It accounts for thousands of deaths, thousands of hospital stays, and immeasurable grief and sadness for families across our nation.

    The good news is that this health crisis is almost entirely preventable through proper diet and exercise.

    More than 25% of children in America spend four or more hours every day watching television or playing video games. More than a third of American high-schoolers don’t engage in any vigorous physical activity. Ever! We are seeing a generation of kids who grew up off the playground and on the PlayStation.

    We’ve got to teach our kids the benefits of physical activity: not just sports but things like taking the stairs, walking from the back of the parking lot, even playing!

    And as we are getting our kids to exercise, we need to do it ourselves. James Baldwin captured the essence of this when he said that we spend a lifetime trying to get our kids to listen to us, but they never fail to imitate us!

    I’ll be the first to say it won’t be easy. I have four kids. I know that families live such busy lives now that it’s tough to prepare healthy meals and have enough time to get in some physical activity.

    But it is so important, because the choices kids make now, the behaviors they learn now, will last for a lifetime. As adults we must lead by example. Personally, I work out every day. I do my best to make healthy choices.

    President Bush — probably the busiest man in the world — finds time to exercise.

    Secretary Thompson put HHS on a diet and has led by example by losing 15 pounds. The Secretary has his entire staff wearing pedometers, and he’s always asking them how many steps they have taken.

    And whenever he or the President sees me, they’ll ask, "Rich, have you worked out today?" And my answer is always, "Yes, Sir!"

    President Bush’s fiscal year 2004 budget proposal includes $125 million to prevent diabetes, obesity, and asthma through community-based healthier lifestyles.

    This is part of the Secretary’s prevention initiative — "Steps to a HealthierUS." Our goals for next year include reducing diabetes, obesity, and asthma-related hospitalizations.

    We also provide information on things like nutrition, fitness, and health care. In order to make progress we need to remember that language and culturally-appropriate, culturally-competent messages are very important. We know that one size does not fit all.

    For example, the HHS campaign "Si Tiene Diabetes – Cuide Su Corazon," (If You Have Diabetes, Take Care of Your Heart) aimed at Hispanic Americans, contains culturally competent messages to help people who have diabetes control their diabetes and prevent heart disease.

    All of us — government, academia, health care professionals, health insurance providers — need to work together to ensure access to essential health care services.

    But those of us in these institutions can only do so much. Each person must be a partner in his or her own individual and family health. Each person has choices to make on a daily basis that will determine whether he or she is healthy or unhealthy.

    You don’t have to run miles and miles to benefit from exercise. Start with walking a few blocks, or playing with the kids. Small steps can bring big rewards.

    With the enthusiasm and determination I see in the audience today, I know that the health and well-being of Americans will improve because of your dedication and determination and the track record you’ve established individually and through your association with NMHCC.

    Dr. King once said, "Life’s most persistent and urgent question is: What are you doing for others?" I think that he would find his answer right here.

    I wish you good luck in all your discussions and deliberations at this important summit. Your work and our partnership will pay off. For all Americans. Thank you.


    Last revised: January 9, 2007