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U.S.-Mexico Border Health Promotion Policy Institute
April 4-6, 2003
U.S. Surgeon General Dr. Richard Carmona's Speech
(Abridged version)
... Arizona ... is my primary home. I feel deeply connected to the border and the people along the border because I've had the privilege to serve them and work with them for a couple of decades. ...
We all have common needs and common problems. While my primary focus is on improving health care for Americans, what we do here, I will never forget, has a global impact. Here in the border region, we have significant public health challenges, but I am committed to meeting those head on. As Surgeon General, I have been tasked by the President with three priorities: public health preparedness, prevention--which I'll say more about in just a few minutes--and closing the gap in health care disparities, especially for minority groups, which are particularly severe along the border.
First of all, I would like to commend PAHO, the Pan American Health Organization, the U.S.-Mexico Border Health Commission and others who have helped improve the understanding of this disease-burden along the border with the solid baseline data that you've all provided and continue to provide. Through the partnership of the groups here and the Department of Health and Human Services, we have developed Healthy Border 2010, a model adapted from Healthy People 2010, to prevent disease and promote health in the border region. I know the Commission is using Healthy Border 2010 objectives to focus their strategic planning to improve health on the border. I would like to speak to some specific issues we're addressing.
Closing the gap. America's health care system is the envy of the world, but for too long we've seen chronic illnesses affect minorities at a higher rate than whites. You know that I'm of Puerto Rican descent. I was raised in the poor section. ... I dropped out of high school, ran the streets, and however fortuitous this is, I never realized how important those experiences would be to me in this job. Yes, I've gotten some degrees now and I've had education, and I've been a public health officer and a surgeon and so on. But probably the most important thing I know about health disparities I learned as a poor kid who couldn't get health care--... having toothaches because you can't go to the dentist, (not getting) to the doctor because you don't have money. You don't have support. You don't have access. So to me, those are not theoretical constructs. ... They're things that I really lived and I understand ... (I understand) how difficult it is to cross that chasm. ...
Just a few statistics: 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-birth-weight babies, which can cause a lot of other health problems. Our immunization rates are lower. Hispanics and African Americans account for roughly 75 percent of all adult AIDS cases, though they comprise only 25 percent of the United States' population. Hispanic Americans are almost twice as likely to have diabetes than whites of a similar age. Cardiovascular disease accounts for one third of all deaths in the Hispanic population. Mexican-American women are more likely than non-Hispanic white women to have high blood pressure. Among all who have high blood pressure, Mexican Americans are the most likely to be unaware of the condition or have it treated. These problems are even worse along the border.
We, obviously, have a lot of work to do. This is an education issue and an access issue. For instance, we need to improve access to health care to all Americans, period, (but) especially those who live in areas that have been traditionally underserved: rural areas, inner cities and the border. ...
... (T)his is the first time in my career that we've had a President and a secretary (of Health and Human Services) who get it, who understand what the issues are. ... I don't have to go to the White House ... or my boss, Tommy Thompson, and say, "Disparities are an issue. Prevention needs to be in the forefront. We've got to forget being a treatment-oriented society." ... The only debate we have now is how much money can it take to do that. And we're all struggling for that dollar. But the good news is, I've got bosses that have embraced this and understand it's the right thing to do. Now we've got to convince Congress it's the right thing to do and get the dollars moving in the right direction. ...
So many of our chronic debilitating illnesses can be prevented through lifestyle choices. ...I was at a press conference not too long ago, and reporters were talking about preparedness. I think we were talking smallpox during that one. One of the reporters mistakenly said to me, "Well, Dr. Carmona, what is the biggest single health problem we face in the United States today?" (He was) thinking I was going to go off on a discourse on preparedness and terrorism. I said, "Obesity." ... He said, "What do you mean"?
I said, "Pretty simple. We've got a bunch of kids and adults who are overweight today. We know that the curve is going to continue. We know that if we don't put appropriate prevention into place, what we will have is an overweight, if not obese, dysfunctional, middle-aged group of people in 20 or 30 years that have type II diabetes at an unprecedented level, as well as accelerated cardiovascular disease and other co-morbidities. So, we're at about 15 percent, almost, of our gross national product on health care expenditures today, and we can't deal with the disease burden we have today. I'm telling you, in a couple of decades, it will be two or three or more times that--both economically and in disease. So, is that not the terror within?"
... We need to do something about it. And I know I'm preaching to the choir here, but I've got to ask you to help me. My voice gets pretty dry sometimes and I need a lot of help. But I think you all are the leadership of health care in this country and especially along the border, where many of these things I'm mentioning are disproportionately represented.
Two out of three Americans are overweight or obese. That's a 50-percent increase from just a decade ago. Nearly 15 percent of our children and teenagers are overweight. And overweight children usually grow up to be overweight adults. Hispanics in the United States are faring worse than the overall population. Twenty-three percent of Hispanics are obese, up from 16 percent in '95. And although we don't have the specific obesity rates along the border, I can tell you that from 15 to 19 percent of the population in Arizona, New Mexico and California are obese, and about 20 percent in Texas.
Being overweight and obese invites a host of health problems, as I said, including diabetes, cancer, stroke, heart attack, etc. The cost of the illnesses is high. Personal costs really are unquantifiable--lost opportunities, disability, death and grieving for those who suffer with these problems. The economic costs are huge, as I've already pointed out, and we are in a very bad situation now in this so-called health care crisis. We can predict that it will get significantly worse unless we put prevention first in everything we do.
One particular health problem that has hit the border very hard is diabetes. There are about 5,000 deaths (from diabetes) along the border every year, about half on the Mexican side, about half on the U.S. side. Why do we have such a large and growing problem with diabetes? There are several reasons for this in the border region. The first is the nutritional issue, and then activities and all of the things that you're all aware about that I won't belabor. But the good thing is, we have the knowledge. We know from science the basis of the problems. How do we put those messages together in a culturally competent fashion to effect behavioral change so we start to see an improvement in the health status of these very diverse populations along the border?
The U.S.-Mexico Border Health Commission has identified diabetes control and prevention as one of its objectives in Healthy Border 2010. As obesity continues to rise, more and more residents here will be at risk for developing this serious chronic disease. I certainly don't want to see that happen. Government has a role in prevention, but government is not the whole story. It can provide information on things like nutrition, fitness and health care. And we need to do a better job of getting the word out through the media and through health providers. In order to make progress, we need to remember that language and culturally appropriate, culturally competent messages are very important. ...
It's tough in this area. Life in the border region is a daily struggle to achieve what most Americans take for granted--immunizations, clean water, ample food and clothing and access to health care. Many people are surprised when I tell them one of the biggest disciplines within the U.S. Public Health Service is engineering. They (ask), "Why would you need engineers? What do engineers do?" Go out on the Native American reservations and see that a significant amount of those little villages along the border have no running water, have no sanitation. And they are suffering from diseases that we, in our population that is urbanized, haven't seen in a century because they don't have sanitation. ... So what we take for granted is luxury for somebody else in the rest of the world. ...
I got Secretary Thompson to run the border with me and Deputy Secretary (Claude) Allen in the last few months. ... We took him up in a plane and we flew ... for about 80 miles along the border of Mexico and the southern (edge) of the reservation. ... We landed and looked at some of the little villages (where) the people still live without water and without food. I had my engineers brief him, and they said, "Sir, we have a three-year backlog to bring water to all of these villages, to bring sanitation to these villages. We don't have enough engineers; we don't have enough water."
We have roads that are inadequate. The death rate and injury rate from automobile accidents on the reservation is the highest in the country. Simple things. Road design. The shoulders are too narrow. Trucks roll all the time as they go to the edge. But infinite needs, finite resources. We've identified problems that we can't deal with yet. ...
I'll be the first to say it won't be easy. I have four kids. I know families live very busy lives now, and it's tough to prepare healthy meals and have enough time to get in some physical activity. In some areas of the border, people face real challenges in their daily lives that impair their ability to prepare healthy meals and get some physical activity. ... Sometimes survival is more important ... making sure you've got a place to sleep and making sure you have anything to eat--and you're happy to get that. ... But we've got to get that message out and we shouldn't give up.
I would like to close with a quote on leadership from management expert James Hayes. He writes: "A leader does more than his or her job. Leadership starts where job ends--beyond his duties and responsibilities. He exercises power with people, not over them. He learns from defeat. A leader is his brother's keeper who cares about people and worries about them. He never gives up."
This is really a room full of leaders. This is a room full of people tasked with that responsibility of leadership and health on America's border and in Mexico. I charge all of you to join me to be a partner so that we can bring more people with us. This is the kind of leadership that we need, by example.
It's going to be hard, it's an uphill battle, but we need to not give up. ... I will dedicate myself to creating a legacy of positive change for the border region, for America and for the global community, which I now serve, and I will do that with your help and leadership. Thank you very much.
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