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Despite this and other formidable obstacles bound to confront them, Satcher made a strong case to psychiatrists gathered at APA's annual meeting in May for the rewards of a medical career spent working to improve the public health.
Much of the buzz surrounding Satcher prior to his lecture, however, arose from a rumor that President Clinton was on the verge of naming him to be the next U.S. Surgeon General. Satcher humorously acknowledged--and did not discourage--that speculation when he took the podium.
Satcher was at the annual meeting to accept the Solomon Carter Fuller Award, which is given annually by the APA Committee of Black Psychiatrists to an individual whose work has benefited the quality of life of African Americans. A family physician by training, Satcher was president of Meharry Medical College and chair of the Council on Graduate Medical Education, a Congressional advisory body, before assuming the stewardship of the CDC in 1993.
The CDC staff has not allowed a lack of sufficient funding to deter them from their mission, he emphasized. They understand that the success of the nation's public health endeavors "depends heavily on good partnerships" between federal health officials and state and local health departments, business leaders, and academia, he said.
Satcher noted that the CDC is trying to reverse public health problems in the nation's most troubled areas, particularly those in deteriorating African-American communities. Many of them are fighting uphill battles against HIV infection, homicide, and suicide. In doing so, he said, the CDC tries to enlist the help of "nontraditional" resources such as churches.
Satcher cited as an example the strong partnership the agency has built with the Congress of National Black Churches, whose congregations represent 20 million people. "For communities disproportionately affected by poverty, the concept of the community approach to medical practice is very important," he noted.
But he stressed that the real key to successful public health programs lies with strengthening the communities whose residents are suffering the most from health-related crises. Unfortunately, the challenge of building up these "broken communities" is especially hard because people who live in them don't communicate with or trust each other, jobs are lacking, and residents often prey upon each other.
"Unless we can deal with the problems of broken communities, we can't reverse the trends" devastating them, such as the spread of HIV and the increase in violence, he said.
One of the most formidable challenges facing the CDC, and one to which it is devoting considerable time and money, is eradicating infectious diseases. This effort has been assigned a heightened level of urgency as health experts identify signs of a growing resistance of these diseases to antimicrobial drugs that once successfully treated them, Satcher pointed out. "We have to educate people about the overuse and underuse of medications and of the dangers of taking them improperly," he said.
Another daunting public health challenge for the CDC stems from changes in behavior and demographics brought about by the aging of the U.S. population, a trend that will accelerate dramatically in the next several decades. Making sure educational and treatment resources are available to cope with a significant rise in the number of people with Alzheimer's disease and other dementias is but one example, he noted. As the population ages, socioeconomic gaps will continue to widen in this country and will, as in the past, disproportionately affect the health of people of color, he said.
An evaluation of the CDC's record of successes and disappointments teaches several critical lessons about what factors lead to constructive public health changes. High on the list is that "there is no substitute for rigorous, quality science in public health. We accomplish more when we have science to back up our advocacy," Satcher said.
In addition, "our ethics must be as sophisticated as our science." He praised the strict adherence to informed-consent procedures that now guide all public health research efforts--a major improvement over lax standards used by some researchers in the past. He noted that a week earlier President Clinton had formally apologized on behalf of the federal government to survivors of the infamous Tuskegee syphilis experiment involving a group of black men whose syphilis went untreated for decades so researchers could study the disease's effects.
Another crucial lesson sometimes overlooked by government officials is that "public health must be global in perspective," he pointed out. "Infectious diseases don't need visas or passports to cross national borders." For proof of this, one need look only to New York City where a few years ago health officials found themselves battling a tuberculosis outbreak; 35 percent of the cases eventually were traced to people who had recently arrived from overseas.
"We have come to appreciate the fact that if there is an ebola outbreak in Africa, we can't sit back in this country and say, 'Well, it's not our problem,' because infectious diseases can start in one place today and tomorrow can be all over the world."
Acknowledging that his recitation of daunting public health challenges was depressing his audience, Satcher ended his lecture by describing opportunities that could lead to a more optimistic climate for improving the nation's health, starting with a concerted push to put more emphasis on population-based prevention. Physicians could contribute enormously if they took on leadership roles in this effort, he suggested.
Another opportunity lies in the explosion of technological advances leading to "new vaccines, antivirals, and antibiotics that are saving lives," laboratory discoveries that allow more rapid diagnoses, and satellite mapping of disease outbreaks. In 1976, for example, it took six months to identify the bacterium causing Legionnaire's disease; in 1993, it took just 23 days to pinpoint the Hanta virus as the cause of a disease outbreak in the southwestern U.S.
"The ultimate challenge is how to bring all of this together and take advantage of the opportunities we have to advance the health of people," Satcher said. Critical elements that will be necessary if progress is to occur are finding ways to build trust between disadvantaged populations and their government and to restore hope among individuals who now have none.
(Psychiatric News, July 4, 1997)