Abstract
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Let's start off with the concept of success in public health. I always keep saying that in public health, first and foremost, what is our role? We deal with health issues. And I go back to the basics of the World Health Organization's definition of health. It says that health is the complete physical, mental, and social well-being, and not merely the absence of disease or infirmity. And realize that a lot of our society in the last century-plus has really focused not necessarily on the concept of health. We have focused so well as a nation, put so many of our resources into the concept of what? Of illness, of sickness. Do we have a great healthcare system in this country? Before recently, we haven't. What we've had is a wonderful—expensive, but wonderful—sick care system.
And in essence, when we look at that concept of public health, saying, “Okay, we have health as a definition by the World Health Organization,” and then we delve into the health of that society, the health of populations, we now look at the concept of partnerships in public health.
We're now bold enough to say that the Federal government, we can't do it all. Maybe there was an era where we can say, “Oh, you know, give it to us. We'll do it.”
The reality is that when you look at the definition of public health, which is the health of populations, intertwined in that is what? The concept of this now is everybody's game. This includes leadership at all levels. It includes partnerships at all levels. It includes all facets of our society to be able to attain that public health vision.
From 1990 to 1999, we had incredible public health progress. The Centers for Disease Control and Prevention (CDC) chronicled the Ten Greatest Public Health Achievements in the 20th century. And in some circumstances, it was an evolution of technology, problem description, and resolution. For example, motor vehicle safety is listed on there. And you realize in the year 1900, there were barely any cars around. So we're talking about not only the inception of a technology, but the ability to mass-produce that technology—Henry Ford. The ability to use that technology throughout the nation—Eisenhower and the interstate highway system. And then, ultimately, a problem developing, “Oh no, people are dying. People are getting injured, and oh no, we, the Big Public Health, have to do something about it.”
Through partnerships with engineering, partnerships with others, partnerships with the industry, we come up ultimately by 1999, with not something that is so completely safe that no one dies or is maimed, but, in essence, is a pathway of resolution.
And yet, notice in that 100 years, if we talk about breastfeeding, breastfeeding's not on that list of accomplishments in 100 years. And in fact, in those 100 years, we regressed as opposed to progressed. There are multiple reasons for that: the changing of society, the changing of social norms, the changing expectations of women. The power of an industry that's out there selling a product. We've seen all this before.
First and foremost, we have the ability to progress. And we're on that pathway. I need to remind you that in public health there is no place—no place—for pessimists. If you're a pessimist, you are going to be so distressed, you'll have to choose a different career path.
So first and foremost, I present to you an optimism that although breastfeeding is not listed on that 10 best accomplishments of a whole century, I propose to you that we, working together, shoot for the idea that perhaps at the 50-year mark of the 21st century, CDC comes out with a list and says, “What has been the major progress in public health?,” and breastfeeding stands as number one on that list. The concept that we have a goal, we have the ability to change and turn things around.
Let's talk about anniversary years. In 1984, a Surgeon General's Workshop on this issue was held by C. Everett Koop. I'm Acting Surgeon General. I'll tell you the truth. What's fantastic about this position is we have a legacy of incredible leadership. I'm honored and humbled to be here as the Acting Surgeon General of the United States. I'm a simple guy from Chicago. I've been riding a career wave.
And yet I stand, as we always do, on the shoulders of incredible leaders of the past. I represent a uniformed service of the United States. This is not a uniform just given to the Surgeon General: “Oh, parade around. It makes you look fancy. It fits the name Surgeon General.” But in fact, it's the uniform of the U.S. Public Health Service Commissioned Corps, 125 years this year as a uniformed service, led for all those years by Surgeons General. 1984, Surgeon General C. Everett Koop, “the lion of Surgeons General.” If you poll the audience who are old enough, that's the last Surgeon General anyone remembers in a general population survey. In 1984, among all the other issues—and mind you, this is just a year into his term as Surgeon General of the United States—he takes on this issue, has this workshop.
We're now in the 30-year mark. So we look back at leadership like that, who back at 30 years ago said, Okay, in this position—and the secret I'm going to tell you is, guess what? There are two components to being Surgeon General of the United States. I'm a very simple guy. I put things into boxes.
Box number one is leading the Commissioned Corps of the U.S. Public Health Service.
I have 6,900 stellar officers stationed in 800 locations worldwide serving 26 different departments and agencies of the U.S. government. I am proud of them and the work they do for the good of our country, with a mission of being here to protect, promote, and advance the health and safety of our nation. If one believes in conspiracy theories, what is this unknown service that's infiltrated 26 different departments and agencies of the U.S. government under the leadership of a single person? This is conspiracy theory. This is, we have infiltrated the highest levels of the U.S. government. But it's all for good, right? That's the good thing about it. It's all for making sure we move ahead in public health.
My tie-in with C. Everett Koop is he's the one who commissioned me. And so when I look back at anniversaries, this being a 30th of that workshop, I was a young lieutenant a few years after that first workshop coming in. I still have my commissioning papers signed by C. Everett Koop, signed and dated July 4th, 1988. Years later, I would turn to him and say, “Dr. Koop, you signed my commissioning papers. You must have been the only federal worker at work that day, because it was July 4th. Everybody's watching fireworks. He's sitting at his desk, stamping my commissioning.” He'd always turn to me and say, “Boris, frankly, I never remember signing those things.”
Then we move ahead. I love the fact that you have the agendas of the five previous Summits, because sometimes we forget to look back, and we always think to ourselves, “Okay, so who was there? What's been happening? What do we discuss?”
Well, at the First Breastfeeding Summit, there was actually an Acting Surgeon General here. It was Steven Galson, who I met my first day on the job back in Cincinnati. We were stationed at CDC NIOSH [National Institute for Occupational Health and Safety]. He ultimately became Acting Surgeon General, and he was the guy speaking here at the first such conference.
There's more recent connectivity, too. Dr. Regina Benjamin hired me to be her deputy. And, in fact, one of the first events I was at as a much younger, a much less stressed person was in fact coming to the release of the Call to Action to Support Breastfeeding and feeling overwhelmed at that event, first of all, by your participation, by the enthusiasm in the room, but also being reminded at that point of really what the job of the Surgeon General is.
I keep hinting at the secret, is that, you know, I have that Commissioned Corps component, and I also have the other component, which one can surmise as being what? “The Nation's Doctor” is the way we like to put it. It's the ability to have a person, a public figure come out and say, “Here's an issue we need to deal with from a public health perspective. Here's where we think we should be going.” The secret I've been sort of holding back on you is, guess what? I don't have very much money. And guess what? I don't have a huge research staff. And guess what? There ain't too much behind that Office of the Surgeon General in terms of money, personnel, or research opportunities. But what I have, and that you can't take away—unless, of course, they decided to fire me soon—is the ability to speak out, the ability to, yes, in a captivating uniform, but with some sense of authority, to say, “Nation, here's a problem.”
This year we have an anniversary, a 50th anniversary of Surgeon General Luther Terry's first report on smoking. We grasp that, and we say, “We have a problem.” We did that 50 years ago. A Surgeon General's report comes out with a simple statement. It's a big report. It basically, for the first time, came out and said, “You know, we in this panel are saying this is bad for you.” The conclusion of the report was, “Cigarette smoking is a significant hazard in the United States to warrant appropriate remedial action.” And in that subtlety, in those subtle words, 50 years of activism started. And in fact, I was captivated by the “First Food” video that was shown before I took the mic here, which showed us a nadir in breastfeeding, and the actions taking place, and as things turned around, it's incredible, the analogies we have with cigarette smoking, because what I have is, I have a 50-year mark that I can see progress where, in fact, it's the opposite, because we want things to head in the opposite direction with cigarette smoking. We want smoking to go down to zero, while with breastfeeding, we're shooting for 100%. But it's the ability for, once again, the Surgeon General to play a role. And again, I'm not naive or bold enough to say, “Oh, it all depends on us.” We are but partners to you. We are but one part of the team.
So, I'm the Acting Surgeon General. My staff knows that I believe in the premise that acting, the first three letters are A-C-T, “act,” which means “do.” We take that legacy of previous Surgeons General. I take that legacy of my previous boss, Dr. Benjamin, and I recommit to you that the Surgeon General supports breastfeeding, that we need to continue to pursue it in a path forward to achieve what is best—that's First Food, and the reality that this is the essential role. That can't be denied. So we rededicated ourselves in this anniversary year.
Last year, CAPT Larry Grummer-Strawn spoke about some of the numbers. I'm not here to talk about numbers. What I'm here to talk about is at least some aspect of success from a federal perspective. He had the numbers, but we realized there are still many barriers in the way.
The CDC, in the Journal of Human Lactation, showed us yet another study of barriers. 1 Work gets in the way. We really have to look at our whole world of policies regarding return to work issues, and making sure those workplaces are friendly, friendlier, encouraging for women to continue breastfeeding.
Because when we look at this, it's initiation, it's exclusivity and duration. So how do you start? How do you keep it up as the only source for those key components of a baby's growth? And how do you keep it on for a long time? If women return before 12 weeks, that doesn't set them up for success in meeting their own intentions to breastfeed. If it's longer, well, we have a chance. We have barriers that we have to acknowledge in workplaces.
The disparity issue. We have to reconcile the fact that, when we look at certain communities out there, we're behind. The analogy, once again, goes to smoking. I have an opposite problem in the smoking world. I have people ahead, and I don't want them to be. What we do have is a recognition now that disparities exist.
The concept here is how do we deal with this problem? One program is the National Prevention Strategy. It's set up in the Affordable Care Act to really change the focus of a nation from one on sickness and illness to one on health and wellness, on prevention. In that realm, we look at pillars, and we recognize one of the pillars, one of the things we have to break through, is the disparities issue. But the second one's almost just as important, and it really falls in great with breastfeeding decisions, and that's the concept of empowered people.
The reality of the situation is how do we break through disparities? How do we break through decision making in general? And we are a nation that loves its freedom, you know, and we've tried this in the past, right? “Don't smoke.” “Well, I'm an American. I'll decide whether I smoke or not.” “Do breastfeed.” “I'm a liberated person. I'll make my decisions.” And the concept of empowerment is not to basically say, “You will do this.” The concept of empowerment is utilizing those incredible facets of us as freedom-loving people to be able to have that health literacy component fully blossoming, to be able to get information from people like you in your work, people like me in my work, and to be able to say, “Here's all the information. Now make the choice.” Empowerment means that we strive for a person to make the right choice, and the right choice for breastfeeding, as well. And that's embedded within our National Prevention Strategy, and is an important tenet to this.
Certainly, we look at the Affordable Care Act because there are preventive services that include lactation counseling, including breast pumps embedded in that. That's a step forward, where we have an important reform movement when it comes to health care in this country, and prevention in this country, and the rededication to say this is important. That's so key.
So we had this Call to Action back in 2011. What transpires from that? Do we just walk away? We issue a report saying, “Oh, Dr. Benjamin, your job is done?” No. The baton is handed to an Acting Surgeon General. At some point, the 19th Surgeon General will be nominated and ultimately confirmed by the Senate. When that's going to be I don't know, but when that moment happens, the legacy then gets passed on to that person. We don't drop an issue as important as breastfeeding. We continue on in support of this.
But in essence, what do we do? Again, I didn't put a ton of staff behind this. I didn't put a ton of money. The Call to Action is exactly that, the Surgeon General and the Office of the Surgeon General working in conjunction with our partners. Guess what? We don't really write the reports either. We certainly know that the partnerships are out there. But that's the beauty of our partnerships. And at the end of the day, it's there to inspire others to say, “Oh, that's important enough that these people think it's important. So therefore, let's do something about it.” So we have Call to Action “droppings” that occur, but droppings in the good sort of way, right? I mean, in the physical world. And I don't mean to be sort of rude in that strange analogy. But in essence, a “dropping” is leftovers that have been processed. So give me a little bit of space here to be able to develop this concept. And in many cases in the animal world, those droppings contain seeds. So it's information, it's important things, it's nutrition that has been processed. And yet ultimately those droppings can lead to seedlings sprouting up all over. The seedlings include aspects of so many different programs, many of them you've been involved with. The CDC's Guide to Strategies to Support Breastfeeding Mothers and Babies (www.cdc.gov/breastfeeding/pdf/BF-Guide-508.PDF) looks at the important role of policy in all this. The CDC, as a result, also continues to fund important work, and funding is always an issue. But certainly, we try to continue to fund at high enough levels to enable state health departments to support breastfeeding and maternity care quality improvement.
Various federal and nonfederal agencies have worked with the Office on Women's Health on the campaign “It's Only Natural: Mother's Milk, Mother's Love.” The National Institute for Children's Health Quality has a cooperative agreement with the CDC, a close partnership with the Baby-Friendly Hospital Initiative, for the Best-Fed Beginnings program. This is important. These are all those seedlings that come from the partnerships that perhaps are inspired by a Call to Action.
Within the National Prevention Strategy, our partners are there. The concept, the importance of breastfeeding, is included in the National Prevention Strategy. That's important, because once again, if I'm taking that focus from sickness and illness to one of health and wellness, this is a key feature of that.
We look at what the Department of Defense is doing, implementing initiatives in medical facilities that encourage military beneficiaries to breastfeed infants through 6 months. These are steps forward. Our own Commissioned Corps last year began developing further policies for our own officers in uniform. How do we encourage that? If the Surgeon General is out there saying, “Do it,” how dare my service not be actually leading in some of those policies and initiatives?
The Department of Labor, again, in our partnerships within the National Prevention Council, administers Section 6 of the Fair Labor Standards, ensuring that female employees of covered employers have that reasonable break time, to have the facilities to express their milk at work. The Indian Health Service and its Baby-Friendly Hospital Initiative are key partners, as well.
So you can see how this Call to Action catalyzes, how it's an important step. And what we need to do is re-inspire ourselves to do even more. Whether it's under the flag of the Call to Action, whether it's under the flag of the National Prevention Strategy, whether it's under the flag of just the concept of breastfeeding, I don't care. I don't have an ego to say this is all about us in the Surgeon General's Office. It's all about us in this room. It's all about us as individuals. It's all about us as families. It's all about us as communities. And then ultimately, that has its repercussions on the health and wellness of the nation.
I go back to the smoking analogy. You know, if people say, “You've already issued 32 reports on smoking in 50 years, and we're down to 18% of our population smoking, stop. You're doing okay. Why are you wasting more of our time?” If I accepted that, I allow 480,000 people to die every year from smoking-related diseases. That's good enough? If I just allow it, that's $289 billion of direct and indirect costs related to tobacco use. Is that good enough? If I just sort of let things lie, saying, “Hey, we've done enough,” that's 5.6 million kids, one out of every 13 children now living, under the age of 18 years who will die prematurely. Is that good enough?
We have to take that same passion, that same sense of dedication to breastfeeding. You know, are the numbers now good enough? They aren't. Are they trending? Yes, in some circumstances they are. But we know we can do better.
Footnotes
Disclosure Statement
No competing financial interests exist.