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REMARKS BY: DONNA E. SHALALA, SECRETARY OF HEALTH AND HUMAN SERVICES PLACE: NATIONAL CONGRESS OF THE MEDICINE/PUBLIC HEALTH INITIATIVE, CHICAGO, ILLINOIS DATE: March 3, 1996
With barely disguised irony, Robert Frost once wrote, "Good fences make good neighbors." Well they don't -- not where we live, and not where we tend to the health needs of our country.
Good communication is what makes good health. So I want to thank and congratulate all of you for lowering the fence and reaching across it. Because, when all is said and done, the spirit that you bring to this task and the recommendations that you have so carefully developed have the potential to usher in a new revolution in health.
Revolutions frequently find their voice at large meetings called for noble purposes. Over two hundred years ago, the Congress met in Philadelphia to create a "more perfect union." A second Philadelphia conference, this time in 1833, led to the founding of the American Anti-Slavery Society. And, the Seneca Falls Convention in 1848 -- became the birthplace of the women's right movement.
When these meetings convened, nobody knew that the seeds of revolution were being planted. Nobody knew that history was being written. But it was. And it will be again if we seize this golden opportunity to form a "more perfect union" of medicine and public health -- so that we can reach our common goal of good health for all Americans.
Because, as you well know, too often public health and medicine have operated as two trains on parallel tracks -- with windows facing opposite directions, looking out on different terrain.
The public health train sees the forest: a large population of trees, similar in size -- growing together and weathering the same storms. The medical train sees the individual trees: the subtle differences in size, color, age and health.
But, because of your work here, we can now out of two trains forge one -- and empowered by the fuel of our partnership, send it back into every corner of America: Into the crowded south side of Chicago and the open plains of the Midwest. Into the coal mines of the Allegheny Mountains and the bayous of the Mississippi Delta.
Wherever Americans live, they must be touched by what you are building here: an integrated, gap free, flexible, research supported, health network for the twenty-first century. And that's never been more important than right now.
Because if we don't build this network -- if we don't craft a seamless partnership among medicine, public health and the research that supports both -- then it will be our health system, not the patient, that is, in T.S. Eliot's words, "Etherized upon a table."
We must not let that happen. Today, we are here to spark a new health care revolution -- a revolution that exchanges the traditional medical model with a collaborative health model focused on prevention. And, only a coordinated, interdisciplinary approach will do.
This is an Administration -- and a Department of Health and Human Services -- that understands the importance of partnerships in achieving change.
That's why, I'm very pleased that so many of our top officials have worked with you to make this meeting such a success -- from Phil Lee to David Satcher to Cliff Gaus.
That's why we've eliminated bureaucratic responsibilities for the Assistant Secretary for Health -- thereby strengthening that extraordinary public health leadership role. Today, all of our health agencies -- CDC, FDA, NIH, ACHPR, HRSA, SAMHSA, and IHS -- report directly to me.
That's why, as part of the Vice President's plan to reorganize government, we are searching for ways to better integrate the work of government -- and have formed a new Data Council to do just that.
The council will develop a Department-wide data collection strategy that will include: better data standards; coordination of surveys; and policies to protect privacy. Our goal is to make sure that the data we collect is accessible and useful -- not just for HHS employees, but for the research community, states, and the private sector.
That's why we've created a similar Governing Council on Children and Youth -- to make sure that children, youth and their families receive comprehensive, and easy to obtain, medical, public health and social services.
And, through our performance partnerships, we're working with states and communities to define goals -- in areas ranging from HIV/AIDS to teen pregnancy rates, and from infant immunization to substance abuse prevention -- and then giving states the flexibility they need to achieve real results.
Let me be clear: I'm not talking about an in-house approach. This is the strategy we are using in every one of our major health initiatives.
Take the issue of domestic violence. No longer can it be a stealth public menace -- or a family problem to be solved behind closed doors.
We are placing domestic violence on everyone's radar screen -- where it belongs. With tougher penalties for abusers. Better training for police, prosecutors, judges and doctors. More community policing and prevention. And now, to tie all the pieces together, a new toll free national hotline that women all over America can call 24 hours a day -- every day of the year.
But, we must do much more. We need to work more with doctors -- as the AMA has so successfully done -- to recognize the signs, ask the right questions, and refer their patients to sources of help.
We need a seamless system that protects women at risk and follows their progress. A system that trains police, judges, teachers, employers, doctors and social workers to identify, understand, and respond to domestic violence.
We need a seamless system that reaches out to women where they work, live, and go to school -- and puts them in touch with all the services they need. A system that understands that it is not only cuts and broken bones that have to heal -- but wounded spirits as well. A seamless system that leaves no gaps.
That's the right approach -- the coordinated approach that you are working to create. And it's the same approach we've taken with our historic tobacco initiative, childhood immunizations, AIDS, drug prevention, and breast cancer.
But, these efforts are only the tip of the iceberg. We have some big challenges ahead of us. These are not your challenges. They are not somebody's else's challenges. They are our challenges.
So, in the spirit of David Letterman, I offer you Donna Shalala's top ten list of things we must do together -- to create the 21st century health system that our citizens need and deserve.
10. We Must Hop Onto the Information Superhighway.
To knock down the barriers between public health and medicine, everyone must know what the health problems plaguing our country's communities are; have a common base of knowledge to solve those problems; and then be able to assess -- and report -- the progress that's been made.
To accomplish that, we must have a unified data collection and distribution system.
Community by community, we need to be able to ask the right questions and get the right answers: Who makes up the fastest growing population of AIDS victims in our county -- and how are they getting it? Why are breast cancer rates high in one part of a State -- and low in another? Are the promising results of one clinical trial applicable and available to another?
With regional and national data bases, individual health care plans and clinical research institutions wouldn't have to reinvent the wheel.
To make sure everyone has access to the best information, we envision a health care information network linking federal, state and private sector data bases; a network that is not owned and operated by the Federal government, but that follows federal guidelines; and, a network that has national standards, is easily accessible, and has strong privacy and security protections.
And, as we work to make every dollar count, we must create a network that helps us set clear goals, ensure accountability, and focus on the only thing that really matters: results. But, to get those results, great science will never be enough -- which brings me to number nine:
9. It's Time to Focus Like a Laser Beam on Prevention.
We are moving into the 21st century in an America with more seniors, higher health care costs, and fewer hospital beds.
When 50 percent of preventable morbidity has its roots in personal behavior, we know that to save money and save lives, all of us must focus on prevention.
And where are the gaps? Let me give you an example:
There's a simple shot for Pneumococcal. It's even covered by Medicare. But only 28% of Americans over 65 are receiving it. Those kinds of disparities must end.
From flu vaccines to smoking, we must foster a dialogue between public health and medicine -- so that we can identify the problems and create a united front to prevent them -- before they start.
8. Let's Ensure that Research not only Survives -- but Thrives.
When it comes to developing unique research strategies for our communities, everyone -- from doctors to public health experts to scientists to teachers -- must bring their expertise to the table.
In one community the problem might be diabetes. In another proper nutrition. And, in another breast cancer.
We must continue to unlock the incremental mysteries in basic science that culminate in blockbuster discoveries over time. But, we must cast our net wider than that. It must encompass behavioral research, occupational research, health services and outcomes research, and environmental research -- all of which hold the potential to prevent disease -- and help Americans live healthier lives.
But research cannot survive in a world of uncertain budgets. To create real security for research -- and the young doctors, biologists, and public health officials who are helping to conduct it -- we have to find more stable ways of financing research.
Because it is only through real security that we can nourish the seeds of research. And it is only with real security that we can create an atmosphere in which the best young minds enter medicine and public health, stay there, and go on to train the next generation of health professionals. Which brings me to number seven:
7. We Must Train Tomorrow's Workforce Today.
It is not enough to have the best trained health care professionals -- if they're only trained to respond to today.
What do we know right now? We know that we may be facing an excess of physicians in medical practice. And, we know that, at the same time, there's a shortage of physicians and other health professionals in the field of public health.
To train a workforce that can solve the health problems of the future, we need to ask ourselves some very basic questions:
As we rein in costs and shift toward managed care, who -- from primary care providers to public health officials to beginning investigators -- do we need to work for us tomorrow? And, how can we find them and train them today?
How do we create a health workforce that really looks like America? We need professionals who come from a broad spectrum of the community, and understand the social, culture and economic realities of the people they serve.
And when it comes to training, what does the health care workforce of the next century need to know? And, how can we ensure that we're teaching it today? That means nutrition. Bioethics. Occupational safety. Behavioral sciences. Social sciences. Toxicology. Epidemiology. Biostatistics.
And, it means ensuring that professionals entering the worlds of public health and medicine are trained to understand one another -- and work together. But, that kind of research and training will not simply survive on its own.
6. We Need to Protect the Treasure of Academic Health Centers.
I don't have to tell you about the impact that cost-cutting is having on these cherished institutions. It is not easy or inexpensive to run an Academic Health Center.
I know, I ran one.
But, our Academic Health Centers are the envy of the world.
They are the places where we will educate and train the next generation of researchers, doctors and other health professionals. They are often the places that take care of our neediest citizens. And they are the places where we make some of the most important scientific breakthroughs.
Their mandate is unique -- and their goals will not simply survive in the marketplace. As a country, we must address the complex -- and potentially devastating -- pressures squeezing Academic Health Centers. At HHS, we're forming a working group -- led by Phil Lee -- to do just that.
We want to find innovative ways to safeguard the irreplaceable -- absolutely irreplaceable -- contributions that these great institutions make. At the same time, we must ensure that we do not punish progress.
It is time to protect and strengthen the treasure of clinical research. That's why Harold Varmus has convened a panel to put a magnifying glass up to patient-oriented research. Under the leadership of David Nathan, a group of experts is looking at how we can protect the critical role -- the "translational role" -- of clinical research.
We need to reinforce the link between the laboratories of science and the living rooms of our citizens -- so that the best science in the world reaches people all over the world. And, what's that going to take?
5. All of Us Looking Beyond our Professional Backyards
What do poverty, lack of education, age, minority status, and rural background all have in common? As you know too well, these are often determinants of health -- and all of us must address them.
Because, too often, members of vulnerable populations face an array of evils -- like substance abuse, domestic violence, elder abuse, environmental hazards, poor nutrition, and substandard housing.
Together, we must address the needs of all vulnerable populations -- from the women living in poverty in the South Bronx to the young people with AIDS and other special health problems in Los Angeles.
Together, we must maintain Medicaid and Medicare's historic promises of health care for seniors, the poor, and the disabled.
And, together, we must team up with other parts of government, educational institutions, and community based organizations; look beyond our individual training; and, apply our skills in new directions. That's what Dr. John May did.
As a resident at Cook County Hospital, time after time, he watched young people coming into the emergency room riddled with bullets. Many he could not save with even the best trauma care.
He looked around and saw public health messages about heart disease, diet, and cancer -- but nothing about violence. So he decided to do something about it. He started a public health campaign to stop violence. He's teaching other doctors how to prevent violence. And he's developing anti-violence messages that are reaching his community and communities all over America.
One doctor, looking beyond the borders of his training -- who saw a public health gap and is working to close it. And, that's what we must do as well.
4. Our Bioethics Must be Just as Sophisticated as our Science.
As advances -- from data collection to the Human Genome -- continue to emerge, they will raise serious ethical questions.
And, those questions must be answered quickly and fairly.
Because, we must not create a world where our genetic map is used to deny us jobs or health insurance. We must not create a world where scientific breakthroughs widen the chasm between the haves and have nots -- and send us backwards.
We must not create a world where data systems force Americans to give up their right to privacy and confidentiality. And, we must not create a world where the worthy goal of scientific progress eclipses our fundamental sense of humanity, fairness and values.
3. We need to take the long view.
The promise of gene therapy -- while awe inspiring -- is still miles from being realized. That's the tough wake up call we recently heard from a panel of experts. And from it, we were reminded of some important lessons.
We were reminded that we have to invest more in the incremental gifts of basic science. We were reminded of the importance of honesty and self criticism, the importance of being able to change directions -- even in midsentence -- if it will help us wage a coordinated attack on America's public health problems. And we were reminded that we have to do a better job of educating the profession and the public about what's really possible right now -- and what's not.
Taking the long view also means investing in our public health infrastructure. Only about one-cent of every dollar in the health sector goes to support critical public health functions that guarantee our food, water, disease control and the environment. Which brings me to number 2.
2. Literacy Must Mean Scientific Literacy.
It's not enough to just train the best scientists; every citizen in America must be scientifically literate.
That's why we've supported the new science education standards from day one -- so that every American is introduced -- and excited by -- science from the time they start crawling. For that to happen, we must write the poetry of science in the prose that the American people can understand.
We need a sophisticated electorate that has the context and intellectual discipline to absorb great breakthroughs; an electorate that understands the historical, social, and economic urgency of investing in health; an electorate that cares deeply about how the changes in health care touch and benefit their lives; and an electorate that understands the critical link between good medicine and good public health. Which leads me to my final challenge.
1. We Must Bring Everyone to the Table.
I began this discussion by saying that the time had come for a "more perfect union" between medicine and public health. That time is now. And that union must flourish at every level -- from our national leadership to our local communities.
Community by community, all of us must know what the unique health problems are -- and have a coordinated strategy for addressing them.
As clinicians and public health experts, as hospital specialists and primary care providers in HMOs, we have a responsibility to bring everyone in our communities to the table -- from environmental engineers to teachers to clergy to local governments to private foundations to parents. Not just because it's the right thing to do -- but because it's the only thing that works.
From Baltimore to Chicago to San Diego, I've heard about the success stories written when medicine and public health join hands; when non-traditional players are brought into the fold; and when a coordinated attack on infant mortality or smoking or domestic violence dramatically improves the health of the community. We need to write those success stories all over America.
You have made an extraordinary start over the last few days. But, as you well know, a meeting can spark a revolution, but by itself, it does not make one.
Because ultimately, creating a 21st century American health care system is not about what we do here today. It's about what all of us do back home tomorrow. All of us have a unique leadership responsibility -- to our communities and our country -- to help create good health.
And so, we must ask ourselves: When we are long gone and the history books of this period have all been written, what will they say about the pathways we cleared and the footprints we left?
Did we train and sustain a new generation of health care professionals today -- with the skills they'll need tomorrow? Did we maintain our strong commitment -- our international commitment -- to cutting edge research? Did we give our citizens the tools they needed to make smart choices with the only lives they will ever have?
Did we find ways to share information across lines of geography and discipline? Did we become our brother's and our sister's keepers -- all of us addressing the needs of those citizens too often left out in the cold? Did we embrace our common vision and move forward on our common ground?
Quite simply, did we do the right thing? Because, just like the dying woman who plants a tree for her grandchildren to enjoy, every seed that we plant today, every inch of soil that we cultivate tomorrow, has the potential to open the doors and enrich the lives of this generation -- and every generation to come.
Thank you.