Human behavior, according to Surgeon General David Satcher, M.D., Ph.D., is the most important factor in the public health challenges facing the nation. In conversations with students and in a speech to library associates this spring, Satcher said that smoking, poor nutrition and physical inactivity are responsible for hundreds of thousands of deaths each year. Half of all deaths derive from nine behaviors, he said in his keynote address, “Toward a Balanced Community Health System: Opportunities and Challenges,” delivered March 24 at the 51st annual meeting of the Associates of the Cushing/Whitney Medical Library. And medicine expends a disproportionate amount of its resources on treatment of late-stage disease rather than health promotion and disease prevention, he said.

Treatment, he pointed out, fails to reach all social groups and classes equally. “We have the most sophisticated health care system in the world,” he said. “Yet there are tremendous disparities on the basis of race and ethnicity. An African-American baby born in this country is two times as likely to die in the first year of life as a majority baby.”

Over lunch he took questions from medical, public health and nursing students who had traveled abroad on research fellowships or spent time working in inner-city hospitals and homeless shelters. What, asked Kebba Jobarteh, did Satcher think about controversial AZT trials designed to reduce vertical transmission of HIV in the Third World? “We were criticized by people I respect a lot,” answered Satcher, who, as director of the Centers for Disease Control and Prevention, endorsed the trials that used placebos in a control group. The study found that use of AZT could reduce the spread of AIDS from pregnant mother to child, even if the first dose is administered during labor. “That controversial study is saving thousands of lives every day,” Satcher said.

Did he foresee, asked Rachel Lovins, any changes in the nation’s health insurance system? “There is no way we are going to control costs as long as we focus on treatment of patients after they are sick,” he said. “There is not enough incentive for health promotion and disease prevention.” Satcher expressed hope that frustration with the current system would pave the way for his balanced approach.