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Dr. Louis Sullivan: how to keep healthy? Mind your habits.


In last month's issue we told you about Dr. Louis Sullivan, his wife, Ginger, and their morning three-mile power walks. After our conversation on the White House south lawn, we knew that our readers would enjoy a firsthand visit with this dynamic new Secretary of the very large U.S. Department of Health and Human Services. The department he heads up has an annual budget of more than $400 billion. To him report: the National Institutes of Health, the Food and Drug Administration, the Centers for Disease Control, the U.S. Public Health Service, Medicare, Medicaid, and many other agencies.

He's a down-to-earth man with whom health promotion and disease prevention will take top priorities. This became apparent when early in his tenure he made refreshing statements to the effect that those vulnerable for preventable diseases should take responsibility for their health and understand that lifestyle of smoking, drinking, obesity, lack of exercise, and promiscuity cause many of their unfortunate health problems.

How Dr. Sullivan thinks will have a profound effect on how you medical care is delivered when you need it, how much will be available, and even how good it will be.

We settled onto a comfortable couch in his spacious office, and after letting him know of our pleasure at his recent aggressive attacks on those who sell cigarettes to minors and minorities, we urged him to brief our readers. We found him charming, persuasive, innovative, and a visionary. His smile displayed the healthiest row of gleaming white teeth you can imagine. No tobacco stain there! He was relaxed and obviously relishing success in his mission. We asked him about his thoughts on tobacco advertising:

Dr. L.S.: I'm following with interest the fact that there are a number of communities around the country now where there are groups who are objecting to the high density of billboards in low-income and minority communities because, of course, the billboard ad is something you can't turn off. At least you can turn off your television, or you can put down the newspaper.

We are also following with interest what's going on in California, where they've increased the tax on cigarettes and are now using that money to run public service ads warning people about the dangers of tobacco. So I'm very pleased with that, and one of the things we're doing is collecting this information and distributing it to other states--to health officers, legislators, and governors.

I spoke with Gov. Terry Branstad, of Iowa, the chairman of the National Governors' Association, before we announced our vending machine initiative, and he was very interested and very encouraging in terms of wanting to work with the states to enforce the laws--first of all, the laws that already exist on the books in 44 states.

Another thing we're looking at is the whole issue of cigarette ads' really conveying an inappropriate message. You see these young, healthy, obviously successful people frequently suggesting they've just finished a vigorous round of tennis or something like that. The ads convey the message that smoking is compatible with vigorous physical activity.

Dr. C.S.: Do you ever wish that cigarettes were ten dollars a pack? During the Depression men didn't smoke much because they couldn't afford to. Do you have any thoughts about how we could force the cigarette companies to charge ten dollars a pack and contribute some of their profits to cover the cost of tobacco-caused diseases? Would that be good?

Dr. L.S.: Well, . . . let me say this: we do know that the young people who smoke are the most sensitive to changes in the price of cigarettes, and certainly that is something we re interested in. The whole issue of taxes is something the Treasury, of course, and the President, with his overall budget concerns, would really need to sign off on. But we have indeed simply stressed the fact that if the prices were to go up by taxes or by whatever mechanism, it would have an effect in reducing the number of young people starting to smoke. Or those who already are smoking would be given a great incentive not to smoke.

Dr. C.S.: It's illegal for adolescents to smoke until they're 18? It's a law?

Dr. L.S.: It's a law but it's not enforced.

Dr. C.S.: Do you think that we should issue cigarette retailers licenses that could be revoked?

Dr. L.S.: Oh, yes. Exactly. That's actually what we've proposed in our model legislation that we've just presented during a hearing before the Congress: that there should be a specific license for stores to sell tobacco and that we have punitive measures should they violate the law by selling to underage individuals--this would be much better. First of all, what exists now has not been enforced. In many states there is no penalty; it simply is a law on the books without any teeth. But having the licensing and then having . . . fines, including loss of license, as an enforcement would be very helpful. So we have that in our model legislation.

Dr. C.S.: Doctors and employers have been criticized for not sufficiently exerting their powers to help people quit smoking--because they have the best opportunity to influence people who are smoking and endangering their health. Do you think that we should ask doctors and employers to come down harder? One civic-minded employer of 2,500 people led off several years ago by saying, "No smoking in our buildings because I don't want to watch our employees commit suicide by inches."

In an attitude of benevolent paternalism, should all employers say, "If you're a smoker, we can't afford to hire you until you quit"? And should doctors say, "If you keep on smoking, I'll stop caring for you until you quit"?

And the government has some clout too with their welfare checks. Could they say: "If you're going to expect us to take care of you when you have health problems, you're going to do your share by not smoking and particularly not smoking around your children. Not smoking would do more for your welfare than your government check. If you continue to destroy your health by smoking, we won't give you support checks until you quit using the money to buy cigarettes"? Would that be too strong?

Dr. L.S.: That's something that I would be hesitant to suggest that we move onto because I know that it would get us into difficulty with the lawyers who are on that. But short of that, though, I think there are a number of things we can encourage physicians and employers to do in making their workplaces smoke free.

Doctors' offices clearly ought to be smoke free. And the hospitals! And by the way, I'm sending letters to every hospital in the nation urging that if they have not already made their facilities smoke free they should do so, and we're then doing the same with every grant recipient for this department, which includes colleges, universities, medical schools, community clinics, and child welfare agencies, etc. I'm urging all of them because of the adverse health effects of tobacco to make their facilities smoke free, because it's not only the smoker himself or herself who's hurt by this, but the people who are in the area, whether it's children or co-workers.

And as you know, there has now been recent evidence that passive smoking might actually cause heart disease. The previous evidence has been that people, from passive smoke inhalation, had a higher incidence of lung cancer while it turns out that the incidence of heart disease might be about ten times as great. We haven't reviewed it, but the study suggests a link between passive smoking and several causes of death. So it's really for that reason, as well as for the health of the smoker himself, that we should not have smoking within the facilities--in the workplace, in restaurants, and in other public places.

Dr. C.S.: We know that smoking causes low-birth-weight babies and that our teenage girls are smoking, but isn't poor nutrition also contributing to high infant mortality in this group? After reading about the research you have done one foliates, I'm interested in your thoughts on whether giving preconception multivitamins containing that B vitamin (folic acid), to adolescent girls with poor diets might not be a way to prevent serious birth defects. Some studies in England showed that high-risk pregnant mothers didn't have a second spina bifida baby when given multivitamins with 800 micrograms of folate prior to conception, while those taking multivitamins without folate did not decrease their risk. We'd like your ideas about how we can use our Children's Better Health Institute to help adolescents and teenagers prevent spina bifida and other birth defect babies. Would you suggest giving adolescent girls of childbearing capability (those likely to become pregnant) pre-conception supplemental vitamins with folate because their diets are traditionally poor during adolescence?

Dr. L.S.: Sure. Well, I would say certainly, very definitely. But what I would also want to do is to be sure that we have programs in place for those teenagers and others to really give them good advice on nutrition, because so often we have people who simply consume a lot of junk food and have no idea just how calorically or nutritionally poor such foods are. So I would be certain to do that as a first step and certainly for anyone during pregnancy, because we know that the folic acid requirement increases during pregnancy. I think folic acid supplements certainly are indicated.

Dr. C.S.: Do you have ideas about controlling the predicted population explosion when we will run out of flight paths for all the airplanes and essentials like food? Dr. Noel Perrin, a professor of English at Dartmouth, wrote an editorial appearing in the Post in which he has a solution to prevent death from overcrowding on the planet. He suggests that population control could be accomplished at substantial savings by paying all 13-to 53-year-old females not to have babies. A nonbearing girl the year after puberty would receive a check for $500, the second year $600, and on up to menopause at 53, when she would be getting about $4,500 per year. Those choosing to have babies would be paid again when they went another year without a baby. A woman could receive around $100,000, which Dr. Perrin calculates would be about half the cost of bringing up one abandoned child in New York City and less than a fifth of the cost of bringing up one psychologically disturbed child in the District of Columbia.

I wonder if you think his ideas might also be an innovative way of encouraging the junior-high and high-school girls not to get pregnant by rewarding them with increasing payments for each year they refrained from having babies.

Offhand, do you think this approach has any merit?

Dr. L.S.: I'd want to think about that. Certainly I agree with the objective of discouraging teenagers from becoming pregnant, because first of all, they are themselves still children, they have not yet finished their own development and their own education in most instances. I think it's a tragedy for the teenager when pregnancy occurs, and secondly they're physiologically not ready for pregnancy. That's where we have a high incidence of low-birth-weight babies, as you mentioned, and complications--cerebral palsy and high infant mortality, etc. So clearly I think we need to do everything we can to discourage them. Now whether a monetary award like that would be the way to go--I'd want to think about it. Of course the question is who is going to pay for it. Is that the federal government, the state government, private sector, or foundations?

Dr. C.S.: According to Dr. Perrin, the government would save, because he estimates it costs $200,000 to bring up one abandoned baby in New York and more than double that amount to rear a psychologically disturbed child in a group home in Washington, D.C. Out in Iowa, where I'm from, they say what you subsidize you get a lot of. When soybeans are subsidized, the result is a surplus of soybeans. So if we're subsidizing unwed youngsters who have babies then we'll probably get a lot more premature babies with birth defects.

Dr. L.S.: Well, I want to look at his paper--that's an interesting thought.

Dr. C.S.: You're in charge of the FDA and the National Cancer Institute. We were pleased when Kellogg came out with the "lessen your colon cancer risk with fiber" campaign. We've been interested in fiber since we went to Africa years ago and learned of Denis Burkitt's discoveries there. You probably know him.

Dr. L.S.: Yes. Burkitt's lymphoma.

Dr. C.S.: We were caught up with his enthusiasm for preventing disease with fiber, and we then wrote the first Bran and Fiber Cookbook. Well, we were delighted when Kellogg came out with the National Cancer Institute story about fiber on their cereal boxes because they printed millions of boxes and people could see it and the idea would catch on faster. They printed facts straight from the NCI, but then at the same time the FDA was saying that's a no-no, you can't put that on a food box. You can sell it--the NCI can spend tax dollars trying to educate the public--but you can't put it on a cereal box. How do you address that?

Dr. L.S.: Sure. I think this shows we need to have some better coordination within agencies in the public health service. But overall, I think the evidence concerning fiber is really quite convincing, at least in terms of colon cancer.

Dr. C.S.: And soluble fiber like oat bran for preventing heart attacks. The cereal people have a bigger advertising budget than the government--they reach far more people than our books and magazines can. People who can't afford to buy magazines can see the information in the supermarkets and in their kitchens if it's on their All-Bran or Quaker Oats boxes. But do you feel uneasy about putting health messages on foods when the health messages are true?

Dr. L.S.: No, no. I think that should be done, but we are right now in the midst of developing proposed rules on that, which I announced about four months ago--proposals for nutrition labeling of processed foods. We are working on coming forward with those. Again as part of that we have an ongoing evaluation of health messages on foods also. First of all, we want to be sure that our public understands what's in the box of cereal or what have you and then that they do get accurate information as to whether the consumption of this is shown to be associated with lower incidence of colon cancer or helps with high cholesterol or....

Dr. C.S.: Right, and that's where literacy comes in. You're probably here [in the President's Cabinet] because of your interest in literacy. Aren't you really?

Dr. L.S.: Yes, right.

Dr. C.S.: We feel that being illiterate is a health problem because if people are illiterate they aren't going to learn and they're the very ones who need health information the most.

Dr. L.S.: Very definitely. Very definitely. I think that indeed there is a connection because someone who is not literate can't receive these messages. It's difficult for them to get a job. Even to not read street signs in a new city . . . fill out an application for employment, etc. So yes, I think there's very definitely a connection, and even beyond that, say when it comes to something like smoking, as you know, there's good evidence that the higher the level of educational attainment, the lower the incidence of smoking.

Dr. C.S.: You would be so sorry to see the U.S. tobacco advertising in areas where people are starving. Have you been to Ethiopia?

Dr. L.S.: No. I've been in Zimbabwe and Tanzania.

Dr. C.S.: In Ethiopia they have "Winston" and "Marlboro" ads all over the sides of cars, and in their big country club in Addis Ababa, there were huge signs for cigarettes on the clocks. No warnings at all. And out in the camps teenage Ethiopian boys were smoking cigarettes while feeding the refugees. When I told them of the harm, they were surprised . . . completely unaware of any risk. I gave them Nicorette and they believed me, and the next day when I came back, they weren't smoking, they were chewing their Nicorette. No one had ever warned them before. Do you feel strongly about trying to keep the United States from sending cigarettes to Thailand and other countries and saying, "You take these cigarettes or we won't buy your products"? Do you worry about that?

Dr. L.S.: I worry about that, but it's one of those difficult issues because that really gets over into the responsibility of our U.S. trade representatives. But what I have done is this: About three weeks ago, I was at the World Health Organization's annual meeting in Geneva. In my report to the Ministers of Health there and their 166 nations around the world who are members, I stressed the dangers of tobacco and what we were doing here in the United States to discourage tobacco use generally, and certainly focusing on teenagers, and indicated our willingness . . . and indeed our desire to work with other nations that would want to mount similar efforts, similar programs, so that we could help them there.

Dr. C.S.: You personally just got sick when you tried to smoke long ago.

Dr. L.S.: Oh, yes.

Dr. C.S.: So you never really sullied up your lungs from smoking, and you power walk three miles a day with Ginger.

Dr. L.S.: Yes, right.

Dr. C.S.: Could you tell our readers how it helps you? Do you feel fantastic or do you think better?

Dr. L.S.: Absolutely. It helps tremendously. First of all, I started about 11 years ago in a weight-control effort because I was going to so many luncheons and dinners, etc. So I started to walk three miles every morning at a brisk pace just to burn off calories, but I found that my level of energy throughout the day is much better, and that my clarity of thinking is also better. I find that when I travel to different time zones, my ability to adjust to a different time zone is much easier.

Dr. C.S.: Do you carb up? Do you eat high complex carbohydrates, low fat? How does Ginger keep you looking so vitally healthy? Do you care if I ask her for some recipes?

Dr. L.S.: No, that's fine. You'll have to get those from her because I frankly don't pay that much attention. I do tend to watch my caloric intake and fat intake too. For example, I will have for breakfast, typically, a glass of grapefruit juice and then some bran flakes with skim milk and coffee, and that would usually be it. For lunch I'll have something like tuna fish salad or broiled chicken with broccoli or something like that.

Dr. C.S.: Broccoli?

Dr. L.S.: Of course.

Dr. C.S.: If you can find any in Washington. Is it getting scarce?

Dr. L.S.: Yes, I told the President that he was making my job difficult. I'm afraid I didn't convince him that he should eat his broccoli.

In the evening, we will tend to have chicken or seafood. First of all, we happen to love vegetables and fruit. Red meat--we might consume it three times a year, if that. Usually it might be when we're out someplace and there's almost no other choice. I also tend to watch desserts. I love ice cream. That's where I'll fall off the wagon, but other things like pastries and baked goods I don't bother with. In the evening, I used to have one or two glasses of wine when I got home, but I stopped that for three reasons one, calories; the second is that it would make me sleepy; and the third is that it would make me hungry so I would eat more. So I now will have a glass of sparkling water with lime because basically I found, for me at least, that I simply wanted to have something in my hand.

Dr. C.S.: What about caffeine? Are you into coffee drinking?

Dr. L.S.: Right. Caffeine. I have to admit I take it. I frankly don't care for decaffeinated coffee, so that's one of those things that I haven't given up. I used to also take in a fair amount of salt, but I have now gotten away from that, though my blood pressure is normal, it has never been a problem.

Dr. C.S.: Do you take any kinds of supplemental vitamins?

Dr. L.S.: Yes.

Dr. C.S.: Magnesium, calcium?

Dr. L.S.: Yes. And usually I'll take a multivitamin, you know, and B complex with C, in the morning.

Dr. C.S.: What about NutraSweet? Do you feel comfortable with that?

Dr. L.S.: I don't use artificial sweeteners.

Dr. C.S.: I read of your sickle cell research in the New England Journal [of Medicine]. I was wondering if you see in the future a time when we might be able to do bone marrow transplants on a seriously ill sickle cell patient.

Dr. L. S.: Yes, I think that that is certainly feasible, as well as our great capacity that will be coming out of our human genome project of possibly even correcting the genetic error in patients with sickle cell disease. Now that's yet to be determined, but I think that from what we are learning in terms of the human genome, as well as our tremendous capabilities in gene splicing, that that is entirely feasible. So I would not be surprised before the turn of the century to see a cure for sickle cell anemia from either bone marrow transplants or from genetic gene splicing, or both. And I think that would be a very exciting time.

Dr. C. S.: As technology advances and we have so many things that we can do for people, do you worry at all that we will have to ration what we do and for whom? We understand that in England now, if you're 55, you can't get kidney dialysis; they won't do it after 55. These people must die with their uremic poisoning. Do you foresee that if we don't control our health costs we will have similar medical care rationing in this country?

Dr. L. S.: Well, that's something I am very concerned about, of course. We already see some efforts of that in Oregon. And what I'm hoping is that by stressing health promotion and disease prevention, we will be able to avoid a number of the problems we now have. My staff, for example, has data suggesting that between 50 and 70 percent of the causes of premature death and disability in our society could be alleviated by control of only ten risk factors.

Dr. C. S.: Smoking . . . drinking?

Dr. L. S.: Right. Use of seat belts, proper diet, avoiding illicit drugs and eliminating teenage pregnancy and other high-risk pregnancies causing high infant mortality. I think we need to focus on more health promotion and disease prevention. The tobacco effort is part of that.

Dr. C. S.: As a means of cutting health costs, would you go so far as to look at routine neonatal circumcision as being a cosmetic or religious practice without valid medical indications?

In England, when the government stopped paying for circumcisions, the number of babies being circumcised dropped from 90 percent to 10 percent. And of course circumcision isn't done in South American countries. The Japanese and Chinese don't circumcise their babies. Neither do the Norwegians. Eighty percent of the males in the world aren't circumcised. Considering that the surgery is not without risk and that it could eliminate a billion dollars in our budget in the next ten years, is it something that you'll be thinking about in your drive to cut costs?

Dr. L. S.: We really would look at any procedure where the question is: What is the effectiveness of this? What do we really accomplish? If it's simply cosmetic procedure, I think there's a question: Should we be using public funds for that when we have so many other dire needs in the health field? So I think we would certainly look at any option like that.

We have a budget this year of $50 million to look at the effectiveness of things like coronary bypass operations versus other procedures, balloon angioplasty, or even medical treatment because with medical treatment we may be looking at a cost of $800 or $1,000 versus $20,000 or more. We're also looking at such things as prostatic surgery for benign prostatic hypertrophy. What is the best approach there? Hip fractures, and a few other things. Those are just a few that we're starting now. But the idea is what are the procedures where our healthcare financing is spending a lot of money, and if there are alternatives, then what is most effective? We want both to control costs as well as to be sure that we're getting value for the dollars we are spending, and to make sure that what we are doing is having some effect.

Dr. C. S.: Statistically, Blacks have twice as much prostate cancer as whites. So instead of trying to do a lot of exotic things, if we could do digital rectal exams on all males, we might reduce the costs and catch prostate cancer early.

Dr. L. S.: Right, exactly.

Dr. C. S.: And wouldn't it help if we could make Nicorette a nonprescription drug, as it is all over Europe? Even in Poland one can buy Nicorette without a prescription. Do you know why we can't? Is it because of the tobacco industry?

Dr. L. S.: I don't know. That's something I'll look at, because I was not aware of that.

Dr. C. S.: The need for a prescription slows down use of the product. We have mobile units that dispense free preventive healthcare. But nurses aren't permitted to give out Nicorette samples unless there's a doctor on board.

Dr. L. S.: It may be because nicotine is addicting.

Dr. C. S.: But they're already addicted to nicotine. They're not going to chew it except to quit smoking, because it tastes terrible. A piece of Nicorette has one-tenth as much nicotine as a pack of cigarettes.

Dr. L. S.: I was not aware of that.

Dr. C. S.: I'd like to know how you decided to go into medicine. It's said you have a mission--was your mother religious? Was there a lot of religion in your home, and do you have a mission from above?

Dr. L. S.: Yes. Right. First of all, I wanted to be a doctor as far back as I can remember, and I'm sure that this was greatly influenced by my parents. Yes. Both my parents were quite religious. My mother actually was the organist for the church we attended in the small town of Blakely.

Dr. C. S.: Was that Episcopalian?

Dr. L. S.: In Georgia? Not at that time. No, that was Methodist. I became Episcopalian under the influence of my wife. When we met in Boston, where I was in medical school, she was Episcopalian, so I went to church where she went.

Dr. C. S.: Did you meet her in church?

Dr. L. S.: No, I met her through a fraternity brother. After moving to Boston from Atlanta when I went to medical school, I knew no one in Boston. So through members of my national fraternity office, I went to a meeting in Boston. One of the members of the fraternity then introduced me to my wife. She was also new to Boston, having recently come down to Boston University from Pittsfield, Massachusetts, where she lived. So that's how we met. And I became very active in the Episcopal church and was a member of the vestry of our church in Boston, Christ Church in Cambridge, actually. So that's how that happened.

Dr. C. S.: And your children were all brought up in that same kind of environment?

Dr. L. S.: Yes, in fact my oldest son, who's in Atlanta as a general physician, is very active with the Episcopal Church, St. Luke's church there in Atlanta. He was on a search committee for the new rector there, so he's being very active there.

Dr. C. S.: You met the [then] vice president and Mrs. Bush when they came down to Atlanta on a literacy project? So your interest in literacy is really the reason you're here today?

Dr. L. S.: Well, let me say this first: in terms of education, my parents were highly committed to providing my brother and myself--there were two of us--with an education. There was a strong conviction that the way to a better life was through education, so that was inculcated into us from the beginning. Wanting to be a doctor was also part of my parents' belief that one should really strive to have a role in life that was meaningful in terms of serving other people, so that's how medicine appealed to me. It was really combining my interest in science and biology with a way to serve other people.

But when I was developing the medical school there at Morehouse--having raised the funds for our first building, which included a $5 million federal grant--I invited Vice President Bush to come down to speak at the dedication of that building. That was in July of '82. Mrs. Bush wasn't with him then, but he subsequently invited me to go with him to Africa in November of '82 to visit seven sub-Sahara African countries and Mrs. Bush was on that trip. As we visited places like Zimbabwe and Zambia and Zaire, she was always speaking to literacy groups, and that's how I learned about her interest in the subject. I remember her going to a meeting with an adult women's literacy group in Zimbabwe and Harar that met at the school of social work at the University of Zimbabwe there in Harar. And I was able to convince her that literacy being education was the same business I was in--only medical education--and so we invited her to come on the board and she accepted. She came on the board in January of '83.

Dr. C. S.: And she's currently on the board, isn't she?

Dr. L. S.: She's an honorary member of the board. It was felt by the White House General Council that perhaps it would be better when the President was elected to make her an honorary member. But she's still very interested and very supportive of the school.

Dr. C. S.: That's wonderful. Morehouse was the first all-black medical school?

Dr. L. S.: In this century, yes. There were two that existed at that time, Howard Medical School here in Washington, which opened in 1868 right after the Civil War, and then Meharry Medical College in Nashville in 1876. But Morehouse was the first in this century.

Dr. C. S.: That took a lot of courage. Anyone with that kind of courage is surely going to do a lot of wonderful things as Secretary of Health and Human Services. We're so glad you're here.
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Author:SerVaas, Cory
Publication:Saturday Evening Post
Article Type:interview
Date:Sep 1, 1990
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