With his beard and armor-piercing gaze, Dr. C. Everett Koop resembles an Old Testament prophet who has discovered his neighbors making graven images. Actually, he is not fierce, but is determined to be heard, which is good because that is his job. He is surgeon general of the United States.
The surgeon general's job includes monitoring the health of the American people, publicizing significant findings and using information to change behavior, as has been done with several reports on smoking. Having saved millions of lives and billions of dollars, the surgeon general's office has done more good per dollar spent than any other federal office.
Recently Koop expanded slightly the scope of his office's monitoring. Speaking to the American Academy of Pediatrics, Koop, a pediatrician, urged physicians generally but pediatricians especially to consider violence as a treatable public health problem. Statistics show that there are periods when there are striking changes in the incidence of violence. We now are in one, which began in the late 1960s. Koop thinks it unlikely that mortality rates from violent acts will return to the levels of the early 1960s.
For example, for 15- to 24-year-olds, the homicide rate went from 5.9 per 100,000 in 1960 to 11.7 in 1970 to 13.2 in 1978. For black males, the rates were 46.4 in 1960, 102.5 in 1970, 72.5 in 1978.
Among all 15- to 24-year-olds, the suicide rate rose from 5.2 per 100,000 in 1960 to 12.4 in 1978. For white males, that rate went from 8.2 to 20.8.
We have neither the historical distance nor, perhaps, the analytic capability to say what has happened to cause the increased violence. But Koop believes that violence is "treatable" in this sense: we know enough about the symptoms of violent personality in children and parents to make diagnostic, predictive and preventative decisions.
Clues include the fact that homicidal children tend to have histories of attempted suicides and of psychomotor seizures. Many have seen or been victims of family violence. Many have mothers who have had inpatient psychiatric care. High- risk families tend to be socially isolated, lacking strong friendships and subject to stress from even such common social transactions as shopping and using public transportation.
Koop wants physicians to be sensitive to the signals of personal and family stress, and to master the growing literature about the predisposition to violence. He believes there should be "the same kind of counseling or referral service as if the patient showed a predisposition to cardiovascular disease, obesity or diabetes." Physicians, he notes, do not hesitate to counsel patients with hypertension to avoid salt or certain sugars. "Similarly, if we have a patient with a predisposition for violent behavior, especially against family members, I think we need to advise that patient to get some professional counseling and also suggest that he or she monitor their entertainment 'menu' and avoid the kinds of television or motion-picture fare that stimulates and contributes to the violence in their personalities."
There is controversy about "desensitization" -- about what is known or knowable about the effect of entertainment that depicts violence short of murder as a common, semi-acceptable response to frustration, insult or injury. Koop believes the evidence "strongly suggests that physicians ought to recognize that a diet of violent entertainment for the violence-prone individual is as unhealthy as a diet of sugar and starch is for the obesity-prone individual."
But it is one thing for a doctor practicing physical medicine to diagnose and treat a proneness that is, say, metabolic; it is quite different and more problematic for him even just to diagnose a predisposition that is part of the patient's disposition. Such dispositions may reflect metabolic or other physical disorders, but our understanding is currently slight.
Violence is, unquestionably, a health problem, and there is much more to improving health than practicing medicine. But many physicians are inclined, by temperament and training, to confine themselves to administering medicine. They understandably resist being pulled into the periphery of social problems. Koop understandably wants to expand somewhat the physicians' sense of what the practice of medicine should encompass.
He argues that medicine and the social services have similar ethical imperatives, and that pediatricians, especially, have special relationships with, and insights about, the irreducible social units that shape citizens -- families. He may have a misplaced confidence in research about the causes -- biological, psychological, social--of violence. But a surgeon general, like an Old Testament prophet, cannot do his job without starting an occasional argument.