ORIGINAL
"3 “fab!

ADDRESS.

BY
C, Everett Koop, MD, ScD
SURGEON GENERAL
OF THE
U. S, Pupiic HEALTH SERVICE
U, S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

OD
BJ
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PRESENTED TO THE AMERICAN ACADEMY oF MEDICAL ADMINISTRATORS
Las VEGAS, NEVADA
NovemBer, 12, 1987
——

(GREETINGS TO HOSTS, FRIENDS, COLLEAGUES, ETC.)

THANK YOU VERY MUCH FOR THE HONOR YOU'VE BESTOWED UPON ME. I’M
DELIGHTED TO BE COUNTED AMONG YOUR NUMBER, BECAUSE I KNOW THAT WHERE
YOU LABOR -- DAY IN AND DAY OUT -- IS WHERE THE HEALTH CARE SYSTEM
OF THIS COUNTRY WORKS....OR DOESN’T WORK,

BUT I BELIEVE IT IS WORKING,...17 MAY NEED SOME HELP HERE AND
THERE...BUT THE AMERICAN SYSTEM OF HEALTH CARE IS WORKING NEVERTHE-
LESS,

AND YOUR CONTRIBUTION, OF QUALITY HOSPITAL-BASED CARE, IS A
CRICUAL ELEMENT OF OUR UNIQUE SYSTEM OF CARE.
IT’S A SYSTEM OF HEALTH CARE THAT HAS MET A MULTITUDE OF
CHALLENGES IN THE PAST, IT HAS WEATHERED THEM ALL,

BUT ONE OF THE MOST DIFFICULT CHALLENGES WE’VE EVER FACED...IS
FACING US RIGHT NOW,

AND THAT CHALLENGE 1S THE CHALLENGE OF AIDS.

I’M SURE YOU’VE ALREADY HEARD A GREAT DEAL ABOUT THE EPIDEMIC
OF AIDS -- ESPECIALLY THE BIOMEDICAL INFORMATION -- SO I’VE CHOSEN
TO SPEND THE NEXT FEW MOMENTS SHARING WITH YOU A NUMBER OF OTHER,
NON-MEDICAL CONCERNS THAT HAVE BEEN BROUGHT TO MY ATTENTION, AS I
HAVE TRAVELED ABOUT THIS COUNTRY AND ALSO OVERSEAS.
THEY MAY BE NON-MEDICAL, BUT I THINK YOU WILL AGREE THAT THEY
STRIKE AT THE VERY HEART OF MEDICAL ADMINISTRATION.

FIRST, JUST TO ESTABLISH SOME COMMON GROUND IN THIS DISCUSSION,
LET ME EMPHASIZE THAT THERE SEEM TO BE THREE ASPECTS OF THE DISEASE
OF AIDS THAT COLOR EVERYTHING DONE AND SAID ABOUT THAT DISEASE.
THEY ARE...

ONE, THAT IT 1S STILL A MYSTERY...

TWO, THAT IT IS FATAL...

AND THREE, THAT YOU GET AIDS CHIEFLY BY DOING THINGS THAT JHE
MAJORITY OF PEOPLE DON’T DO AND DON’T LIKE TO SEE OTHER PEOPLE

DO EITHER.
THESE THREE ASPECTS OF THE AIDS EPIDEMIC PRESENT THE PEOPLE OF
THE UNITED STATES WITH A DIFFICULT AND COMPLEX TEST OF OUR NATIONAL
CHARACTER,

IN SOME WAYS THE SCIENTIFIC ISSUES PALE IN COMPARISON 10 THE
HIGHLY SENSITIVE ISSUES OF LAW, ETHICS, ECONOMICS. MORALITY, AND
SOCIAL COHESION THAT ARE BEGINNING TO SURFACE...SPAWNED BY THOSE
THREE ASPECTS OF AIDS THAT I JUST MENTIONED,

AND TO TELL THE TRUTH, WE MAY ALREADY BE AT A VERY SENSITIVE
STAGE IN REGARD TO THE ETHICAL FOUNDATION OF HEALTH CARE ITSELF.
FOR EXAMPLE, DESPITE THE SENSIBLE AND RATHER ELEMENTARY
GUIDELINES FROM THE CENTERS FOR DISEASE CONTROL. WE STILL HEAR --
EVERY DAY -- OF PHYSICIANS, DENTISTS, NURSES, AND OTHER HEALTH
PERSONNEL WHO REFUSE TO TREAT PERSONS WITH AIDS OR EVEN PERSONS WHOM
THEY SUSPECT OF HAVING AIDS.

THEY SAY THEY ARE AFRAID OF CATCHING THE DISEASE THEMSELVES.
THAT'S CERTAINLY UNDERSTANDABLE. BUT EQUALLY UNDERSTANDABLE IS THE
FACT THAT IT IS VERY UNLIKELY THAT A HEALTH WORKER WILL CATCH THE
DISEASE AT ALL.

THUS FAR, OF THE 5 MILLION PERSONS IN SOME KIND OF HEALTH WORK
IN THIS COUNTRY, ONLY 10 HAVE CONTRACTED AIDS ON THE JOB. IN ALMOST
EVERY CASE, THE INDIVIDUAL SIMPLY DID NOT FOLLOW THE ROUTINE
INSTRUCTIONS FOR SELF-PROTECTION THAT C.D,.C, PUBLISHED OVER A YEAR
AGO,
LET ME QUICKLY ADD THAT THIS REJECTION OF AIDS PATIENTS IS NOT
CHARACTERISTIC OF THE HEALTH PROFESSIONALS BY ANY MEANS. ON THE
CONTRARY, THE OVERWHELMING MAJORITY OF MY COLLEAGUES HAVE PROVIDED
-~ AND CONTINUE TO PROVIDE -- QUALITY, COMPASSIONATE CARE TO PERSONS
WITH EVERY KIND OF ILLNESS... INCLUDING AIDS.

BUT THE GOOD CONDUCT OF THE MAJORITY DOES NOT IN ANY WAY
RELEASE US FROM FACING THE UN-PROFESSIONAL CONDUCT OF A FEARFUL AND
IRRATIONAL MINORITY,

WHAT SHOULD WE DO ABOUT THAT? I SUBMIT THAT IT’S AN IMPORTANT
QUESTION, BECAUSE HEALTH CARE IN THIS COUNTRY HAS ALWAYS BEEN
PREDICATED ON THE ASSUMPTION THAT -- SOMEHOW -- EVERYONE WILL BE
CARED FOR AND NO ONE WILL BE TURNED AWAY,
AS A PHYSICIAN AND AN AMERICAN, I’M PROUD TO BE PART OF A
TRADITION OF CARE THAT WILL NOT ABANDON THE SICK AND THE DISABLED...
WHOEVER THEY ARE.

HENCE, THE REPORTS OF A FEW PHYSICIANS AND OTHERS WITHHOLDING
CARE FROM PERSONS WITH AIDS ARE, THEREFORE, EXTREMELY SERIOUS. SUCH
CONDUCT THREATENS THE VERY FABRIC OF HEALTH CARE IN THIS COUNTRY.

BUT THIS ISSUE HAS YET ANOTHER WRINKLE OR TWO,

I’M TOLD THAT THOSE HOSPITALS WITH NATIONAL REPUTATIONS FOR
PROVIDING CARE FOR AIDS PATIENTS ARE NOW BEING BY-PASSED BY MANY
MEDICAL AND NURSING STUDENTS LOOKING FOR A RESIDENCY, AN INTERNSHIP,
OR A PRACTICUM TO COMPLETE THEIR PROFESSIONAL TRAINING,
IN ADDITION, MANY NON-AIDS PATIENTS -- ESPECIALLY THOSE WITH
GOOD INSURANCE COVERAGE -- ARE ASKING THEIR PHYSICIANS TO CHECK THEM
INTO HOSPITALS THAT DO NOT HAVE MANY -- OR ANY -- AIDS PATIENTS.

I THINK THIS IS A SERIOUS MATTER BECAUSE THE ACTUAL DIRECT
IMPACT OF AIDS THUS FAR ON OUR HOSPITAL SYSTEM IS QUITE SMALL... BUT
THIS INDIRECT IMPACT CAN BE QUITE LARGE...DISPROPORTIONATELY SO. IT
1S AN IMPACT THAT COULD WELL LEAD TO THE DEVELOPMENT OF DE FACTO
MEDICAL GHETTOS FOR AIDS PATIENTS.

HOW CAN WE PREVENT THAT FROM HAPPENING? WE NEED SOME ANSWERS
BEFORE THIS DEADLY VIRUS FURTHER WEAKENS THE ETHICS OF MEDICAL
PRACTICE IN THE UNITED STATES,
LO

WE HAD HOPED THAT THIS SITUATION COULD HAVE BEEN SOMEHOW
BROUGHT UNDER CONTROL BY THE HEALTH PROFESSIONS THEMSELVES. BUT
THAT HASN’T HAPPENED, THEREFORE, THE DEPARTMENTS OF LABOR AND OF
HEALTH AND HUMAN SERVICES HAVE JOINTLY ISSUED GUIDELINES TO BE
FOLLOWED BY THE INDIVIDUAL AND BY THE INSTITUTION. IN ORDER TO
REDUCE THE POSSIBLITY OF ON-THE-JOB INFECTION BY EITHER THE AIDS
VIRUS OR THE HEPATITIS B VIRUS.

THE FULL NOTICE WAS IN THE OCTOBER 30 ISSUE OF THE THE FEDERAL
REGISTER, IN CASE ANY OF YOU MISSED IT,
10

I THINK YOU SHOULD BE AWARE THAT THE NOTICE SAYS, AMONG OTHER
THINGS, THAT “IT IS THE LEGAL RESPONSIBILITY OF EMPLOYERS TO PROVIDE
APPOPRIATE SAFEGUARDS FOR HEALTH-CARE WORKERS WHO MAY BE EXPOSED T0
DANGEROUS VIRUSES, FOR THAT REASON,” THE NOTICE SAYS, THE LABOR
DEPARTMENT “IS BEGINNING A PROGRAM OF ENFORCEMENT TO INSURE THAT
HEALTH-CARE EMPLOYERS ARE MEETING THOSE NEEDS.”

WHAT WILL THIS PROGRAM DO? THE OBVIOUS THING IS TO MAKE SURE
THAT HEALTH-CARE PERSONNEL ARE PROTECTED FROM ACCIDENTAL INFECTION,
THE NOT-SO-OBVIOUS THING IS TO TAKE THE ARGUMENT OF “HIGH-RISK” AWAY
FROM THOSE HEALTH-CARE WORKERS WHO NOW SHUN AIDS PATIENTS,
Il

AS YOU KNOW, THIS ADMINISTRATION HAS TENDED NOT RELY ON
REGULATIONS AND ENFORCEMENT ACTIVITIES, UNLESS THE SITUATION HAS
CLEARLY WARRANTED IT,

AS FAR AS AIDS IS CONCERNED -- AND IN PARTICULR THE ROLE OF
HELATH CARE WORKERS IN THE TREATMENT OF AIDS PATIENTS -- THAT TYPE
OF SITUATION HAS ALREADY ARRIVED,

AND THEREFORE. WE HAVE HAD TO MOVE IN THIS MANNER,

THIS FEDERAL REGISTER NOTICE, BY THE WAY, CONTAINS A GRET DEAL
OF VALUABLE, UP-TO-DATE BACKGROUND DATA ON THE AIDS EPIDEMIC. SO,
FOR A VAIRETY OF REASONS, I URGE EACH ONE OF YOU TO SECURE A COPY
AND READ IT ALL THE WAY THROUGH,
12

BUT WE’VE HAD REGULATIONS BEFORE IN MANY AREAS...AND BY THEM-
SELVES, THEY DON’T GET THE JOB DONE. THE ONLY THING THAT WILL
REALLY WORK IN THIS CURRENT SITUATION IS FOR EVERYONE IN THE HEALTH
PROFESSIONS -- WHETHER IN DIRECT PATIENT CARE OR IN ADMINISTRATION
-- TQ RE-COMMIT THEMSELVES TO THE PRINCIPLE OF "QUALITY CARE FOR

EVERYONE.” PERIOD.
IF WE CAN’T DO THAT,..WE WILL BE IN SERIOUS TROUBLE.

A RELATED ISSUE THAT I KNOW IS WORRYING MOST OF YOU RIGHT NOW
IS THE COST OF CARE FOR AIDS PATIENTS. THOSE COSTS ARE NOW RUNNING
AT ABOUT $2 BILLION A YEAR. THE JOURNAL OF THE AMERICAN MEDICAL
ASSOCIATION JUST PUBLISHED A STUDY INDICATING THAT THE AVERAGE
INPATIENT COST PER AIDS PATIENT PER YEAR IS $20,320,
13

BY 1991, WE ANTICIPATE THE ANNUAL BILL TO CARE FOR AIDS
PATIENTS WILL RANGE ANYWHERE FROM A LOW OF $8 BILLION TO A HIGH OF

$16 BILLION.

WHO SHOULD PAY THAT?

RIGHT NOW. THE AMERICAN TAXPAYER IS COVERING ABOUT 25 PERCENT
OF THAT COST, POSSIBLY MORE. IS THAT FAIR?

AS YOU KNOW, WE HAVE A MIXED SYSTEM OF SUPPORT FOR HEALTH CARE
IN THIS COUNTRY: PRIVATE METHODS OF PAYMENT EXIST SIDE-BY-SIDE WITH
PUBLICLY SUPPORTED SYSTEMS OF REIMBURSEMENT FOR CARE.

THERE 1S, HOWEVER, A CURIOUS TWIST TO THIS PARTICULAR QUESTION,
14

FOR EXAMPLE, THE AMERICAN TAXPAYER SUPPORTS MATERNAL AND CHILD
HEALTH PROGRAMS, AS WELL AS PROGRAMS FOR ALCOHOLICS, DRUG ADDICTS,
AND SYPHILITICS,

THOSE PROGRAMS AREN'T VERY EXPENSIVE... THEY WON’T ADD UP TO $8
BILLION, IN ANY CASE, IN ADDITION, THEY ARE GEARED TO BRING -- OR
TO BRING BACK -- MEN. WOMEN, AND CHILDREN TO A STATE OF GOOD HEALTH,

BUT AIDS 1S QUITE DIFFERENT. HEALTH AND MEDICAL CARE FOR AIDS
PATIENTS IS VERY EXPENSIVE.

AND WHAT'S THE OUTCOME? AFTER CONSUMING ONE, TWO, OR THREE
YEARS’ WORTH OF COSTLY MEDICAL CARE AND SOCIAL SERVICES...THE AIDS
PATIENT DIES,
15

SO WE MUST ASK THIS QUESTION: AS THE AIDS CASE-LOAD CLIMBS AND
THE COSTS RISE. WILL THE AMERICAN PEOPLE CONTINUE TO SUPPORT SUCH
CARE? OR WILL THEY ASK FOR RELIEF?

WILL THEY STILL EXPECT THE BEST POSSIBLE CARE FOR EVERYONE?
WILL THEY SUPPORT ONLY SECOND-CLASS CARE FOR AIDS PATIENTS?

HOW SHOULD WE RESPOND TO THE SECOND POSSIBILITY? IT’S A VERY
TROUBLING QUESTION FOR AMERICAN MEDICINE AND AMERICAN DOMESTIC
PUBLIC POLICY IN GENERAL.
lo

ANOTHER ISSUE THAT HAS ARISEN QUITE FAST OVER THE PAST YEAR OR
SO IS THE ISSUE OF INDIVIDUAL PRIVACY versus THE NEED TO PROTECT THE
COMMUNITY FROM DANGER,

NEITHER SIDE OF THIS EQUATION REQUIRES AN ABSOLUTE RESPONSE,
BUT HOW MUCH LEEWAY DO WE REALLY HAVE, AS A FREE YET RESPONSIBLE
PEOPLE?

ANOTHER WAY OF PUTTING THAT IS TO ASK, “HOW MUCH RISK CAN THE
COMMUNITY TOLERATE IN ORDER TO PRESERVE THE RIGHTS OF INDIVIDUALS?”

THIS, OF COURSE, IS THE HEART OF THE DEBATE OVER CONFIDENTI-
ALITY IN RECORDS,
17

AS YOU ALL KNOW, I’M SURE, THE PROMISE OF CONFIDENTIALITY HAS
BEEN A LONG-STANDING PRACTICE IN PUBLIC HEALTH WORK, IT HELPS US

GET A GREAT DEAL OF SENSITIVE, HEALTH-RELATED INFORMATION FROM THE
INDIVIDUAL,

WITHOUT SUCH A SYSTEM, THIS COUNTRY WOULD NEVER HAVE SUCCEEDED
IN CONTAINING MOST INFECTIOUS DISEASES, AS WE HAVE DONE.

HOWEVER. NO PREVIOUS DISEASE HAS BEEN AT ONCE SO MYSTERIOUS, SO
FATAL, AND SO RESISTANT TO THERAPY AND PREVENTION.

THOSE OF US IN PUBLIC HEALTH BELIEVE THAT THE ASSURANCE OF
TOTAL CONFIDENTIALITY IS THE KEY TO HAVING POTENTIAL -- AND ACTUAL

-- CARRIERS OF THE AIDS VIRUS PRESENT THEMSELVES FOR VOLUNTARY
TESTING AND COUNSELING.
18

AND IT’S AT THIS POINT THAT MEDICAL ADMINISTRATOR’S HAVE TO SIT
DOWN AND CAREFULLY ASSESS WHAT DIRECTION THEY SHOULD TAKE IN THE
FUTURE. SOME HOSPITALS, FOR EXAMPLE, ARE ALREADY TESTING PATIENT
BLOOD FOR THE PRESENCE OF THE AIDS ANTI-BODIES, THIS IS BEING DONE
USUALLY IN RESPONSE TO STRONG APPEALS BY STAFF,

BUT NOT ALL HOSPITALS HAVE INDICATED THAT THEY ARE PREPARED TO
SCRUPULOUSLY HONOR THE NEED FOR CONFIDENTIALITY OF THAT RECORD,

THIS IS A QUID PRO QUO THAT CANNOT BE LIGHTLY TURNED ASIDE.

WE MUST INDICATE TO THE PUBLIC THAT WE ARE CONCERNED ENOUGH
ABOUT ALL OUR CITIZENS TO WANT TO TAKE BLOOD TESTS..,.BUT WE ARE ALSO
CONCERNED ABOUT EACH ONE OF OUR CITIZENS TO MAKE THE RESULTS OF
THOSE TESTS ABSOLUTELY SECURE,
19

AGAIN, IT HAS BEEN THE POSITION OF THE ADMINISTRATION NOT TO
SUPPORT A FEDERAL LAW ON CONFIDENTIALITY. WE BELIEVE THIS IS
ESSENTIALLY A STATE RESPONSIBILITY. AND I SUSPECT THAT MOST OF YOU
WOULD AGREE.

BUT NOT ALL STATES HAVE DONE ANYTHING ABOUT IT YET...AND AMONG
THOSE WHO HAVE THE LAWS ARE ARE FAR FROM UNIFORM,

YES, THIS IS A LEARNING PERIOD FOR ALL OF US, BUT THAT'S
HARDLY A GOOD ANSWER FOR THE PERSON WHO TESTS SEROPOSITIVE AND WHO,
AS A RESULT OF THE SURFACING OF THAT INFORMATION, IS FIRED FROM A
JOB, IS SENT HOME FROM SCHOOL, IS EVICTED FROM HOUSING, LOSES
INSURANCE, AND SO ON.
20

SUCH REACTIONS ARE IRRATIONAL, UNFAIR, AND DISCRIMINATORY,
WELL, WHAT SHOULD WE DO ABOUT THEM? HOW CAN WE DEAL WITH THESE
INCLINATIONS TOWARD DISCRIMINATION?

SOME PEOPLE ARGUE THAT IT IS NOT DISCRIMINATORY TO DENY HOUSING
OR MEDICAL CARE OR ANY OTHER ESSENTIAL SERVICE TO A PERSON WHO
CONTRACTED AIDS WHILE SHOOTING DRUGS OR ENGAGING IN HIGH-RISK ANAL
INTERCOURSE,

BUT THE GREAT MARCH OF PUBLIC POLICY FOR OVER A CENTURY IN THIS

COUNTRY HAS BEEN TO REDUCE OR ELIMINATE ALTOGETHER THE CRITERIA FOR
ELIGIBILITY TO RECEIVE ESSENTIAL PUBLIC SERVICES.

IS AIDS GOING TO BE THE EXCEPTION? IF SO, WHY?
2]

FINALLY -- AND PROBABLY MOST IMPORTANT OF ALL -- WE SEE MORE
EVIDENCE EVERY DAY THAT THIS DISEASE IS BECOMING THE PARTICULAR
SCOURGE OF PEOPLE WHO ARE YOUNG, BLACK. AND HISPANIC.

IN FACT, ALMOST HALF OF ALL REPORTED AIDS VICTIMS BETWEEN THE
AGES OF ONE WEEK AND 29 YEARS ARE MINORITIES.

WHAT A TRAGEDY FOR THEM,

AND WHAT A TRAGEDY FOR AMERICA,

OUR COUNTRY HAS TRIED TO CORRECT THE SOCIAL INJUSTICES OF THE
PAST, AND SO WE ARE EXTENDING TO ALL AMERICANS -- REGARDLESS OF
RACE, COLOR, CREED, ETHNIC ORIGIN, RELIGION, AGE, OR SEX -- THE
BIRTHRIGHT OF FREEDOM THAT IS THEIRS,
22

WILL THE DISEASE OF AIDS -- BY ITSELF -- REVERSE THIS TREND OF
HISTORY? WE HOPE AND PRAY THAT IT WILL NOT.

BUT HOPES AND PRAYERS MAY NOT BE ENOUGH. WE WILL NEED
COURAGEOUS LEADERSHIP AT ALL LEVELS OF GOVERNMENT AND THROUGHOUT OUR
SOCIAL AND POLITICAL INSTITUTIONS TO REINFORCE THOSE HOPES AND
PRAYERS,

HOW CAN YOU,..AND 1...AND EVERY AMERICAN INSURE THAT OUR
COUNTRY WILL NOT RETURN IN FEAR AND HATRED TO THE WAYS OF A SHAMEFUL
PAST?

THE PRESIDENT HAS SAID THAT WE MUST COME TOGETHER TO FIGHT THIS
DISEASE WITH EVERYTHING AT OUR COMMAND. BUT WE MUST NOT FIGHT THE
PEOPLE WHO HAVE IT,
23

CAN WE DO THAT? CAN WE, FOR EXAMPLE, REMAIN COLOR-BLIND IN
THIS WAR AGAINST AIDS? HOW DO WE MAKE SURE WE CAN?

THESE AND OTHER ISSUES LIE ON THE HORIZON BEFORE US, BUT THE
HORIZON IS NOT THAT FAR AWAY,

I HOPE WE WILL NOT STUMBLE ACROSS THAT TERRAIN. UNPREPARED FOR
THE CHALLENGES THAT LIE BEYOND, 1 HOPE WE WILL BEGIN TO TALK ABOUT
THESE ISSUES AS THE WISE, 200-YEAR-OLD SOCIETY WE PROFESS 10 BE,
24

IF WE DO, WE MAY GIVE THE WORLD SOMETHING EVERY BIT AS PRECIOUS
AS THE MUCH-DESIRED AIDS VACCINE:

WE WILL SHOW THE WORLD HOW COMPASSION AND JUSTICE...IN ADDITION
TO FIRST-CLASS...CAN TRIUMPH OVER THIS MYSTERIOUS, FATAL
DISEASE,

ONCE AGAIN... THANK YOU...AND BEST WISHES FOR THIS MEETING.

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