DDRE BY C, EVERETT KOOP, M.D., SC.D, SURGEON GENERAL OF THE U, S, PUBLIC HEALTH SERVICE U.S, DEPARTMENT OF HEALTH AND HUMAN SERVICES PRESENTED TO ALLSTATE FOUNDATION FORUM ON PUBLIC ISSUES CHICAGO, ILLINOIS OCTOBER 13, 1987 /o/ 13 (GREETINGS TO HOSTS, GUESTS, FRIENDS, ETC.) IT’S MY PLEASURE TO BE HERE THIS MORNING TO ADDRESS YOU CONCERNING OUR EFFORTS AT CONTROLLING THE SPREAD OF AIDS, ONE OF THE DEADLIEST AND ALSO ONE OF THE MOST MYSTERIOUS DISEASES TO STRIKE MANKIND IN MANY, MANY YEARS, FIRST OF ALL, SINCE THERE’S BEEN SO MUCH INTERPRETATION AND MISINTERPRETATION OF THE FACTS ABOUT AIDS, LET ME QUICKLY RUN THROUGH THEM NOW. THIS IS HOW THINGS STAND...AND I SHOULD ADD, AS OF TODAY. IT’S HARD TO BELIEVE, BUT IT HAS BEEN ONLY 6 YEARS SINCE THE FIRST REPORTS OF THIS STRANGE DISEASE WERE RECEIVED BY OUR CENTERS FOR DISEASE CONTROL IN ATLANTA, YET, IT SEEMS LIKE AN ETERNITY. SINCE 1981 WE’VE SEEN THE OFFENDING VIRUS UNDER A MICROSCOPE AND WE’VE NAMED AND RENAMED IT, IT’S CURRENT BIOMEDICAL NAME IS "HUMAN IMMUNODEFICIENCY VIRUS,” OR H,1,V, ONCE WE HAD THE VIRUS WE COULD DETECT ANTIBODIES TO THAT VIRUS AND THAT MADE IT POSSIBLE TO DEVELOP A SCREENING TEST FOR BLOOD, THE FIRST GREAT ADVANTAGE WAS THE ABILITY TO MAKE THE BLOOD SUPPLY FOR TRANSFUSION - SAFE. BEFORE WE HAD THE SCREENING TEST, AIDS ANTIBODIES WERE TURNING UP IN 4 OR 5 UNITS OF BLOOD PER 10,000, NOW THE FIGURE HAS SETTLED DOWN TO BETWEEN 4 AND 10 PER 1,000,000. AND AS I'M SURE YOU KNOW THAT’S ABOUT AS CLOSE TO PERFECT AS YOU CAN GET IN THIS KIND OF SERVICE. IN THE PAST 6 YEARS WE’VE BEEN ABLE TO GALVANIZE A LARGE. INTERNATIONAL ARMY OF BIOMEDICAL RESEARCHERS TO WORK ON UNLOCKING THE SECRETS OF THIS DISEASE. HERE IN THE UNITED STATES, THE FEDERAL GOVERNMENT ALONE IS SPENDING 317 MILLION IN AIDS RESEARCH THIS YEAR. NEXT YEAR THE FEDERAL FIGURE WILL BE 413 MILLION OUT OF A TOTAL FEDERAL AIDS EXPENDITURE OF MORE THAN ONE BILLION. IN ADDITION, OVER THE PAST 6 YEARS WE’VE DEVELOPED A WAY OF MONITORING THE SPREAD OF THE DISEASE THROUGH AN INTRICATE NATIONAL AND INTERNATIONAL SYSTEM OF EPIDEMIOLOGICAL REPORTING, THIS IS EXTREMELY IMPORTANT, BECAUSE IT PROVIDES US WITH OUR ONLY BASIS FOR ESTIMATING WHAT THE IMPACT OF THIS DISEASE IS -- AND WILL BE -- UPON OUR HEALTH CARE SYSTEM AND UPON OUR SOCIAL INSTITUTIONS THEMSELVES...NOW AND, I’M AFRAID, FOR YEARS TO COME. IT’S BECOMING QUITE CLEAR TO US THAT THE DISEASE OF AIDS --. AS IT CONTINUES TO SPREAD THROUGHOUT OUR POPULATION -- WILL BE DRAWING EVER MORE HEAVILY NOT ONLY UPON THIS COUNTRY’S MEDICAL AND FINANCIAL CAPITAL, BUT ALSO UPON OUR SOCIAL AND POLITICAL CAPITAL. JUST HOW SERIOUS IS THIS EPIDEMIC ANYWAY? ONE LOOK AT THE NUMBERS SHOULD LEAVE YOU PROFOUNDLY DEPRESSED. IT ALL BEGAN WITH ONLY 5 CASES IN LOS ANGELES. THESE WERE REPORTED IN JUNE 1981, PRIOR TO 1987, THE CUMULATIVE TOTAL OF AMERICANS WITH AIDS PASSED THE 37,000 MARK, AS OF NOW 43,000 CASES HAVE BEEN DIAGNOSED, 25,000 OF THEM HAVE DIED AND THE REST WILL. BY THE END OF 1991 -- A DECADE AFTER THOSE FIRST 5 REPORTS CAME IN FROM LOS ANGELES -- WE EXPECT THAT APPROXIMATELY 270,000 AMERICANS WILL HAVE CONTRACTED AIDS -- AND 170,000 WILL HAVE DIED. IN ADDITION TO THOSE WHO SHOW EVIDENCE OF AIDS -- AND CAN BE DIAGNOSED AS SUCH -- THERE ARE CONSIDERED TO BE 1 - 1,5 MILLION CARRIERS OF THE VIRUS, IN GOOD HEALTH, BUT INFECTIOUS TO OTHERS. INDEED MANY DO NOT EVEN KNOW THEY ARE INFECTED, THIS IS A TERRIBLE DISEASE, FOR WHICH WE DO NOT YET HAVE A CURE, NOR DO WE HAVE A VACCINE -- AND WE PROBABLY WON’T HAVE ONE GENERALLY AVAILABLE BEFORE THE END OF THE CENTURY, MAKE NO MISTAKE ABOUT IT. AIDS JS FATAL AND IT IS SPREADING, AND THE ONLY THING WE HAVE THAT MAY WORK AGAINST IT IS EDUCATION, . .EDUCATION...AND MORE EDUCATION IN OUR HOMES, OUR SCHOOLS, OUR HEALTH CARE FACILITIES, AND OUR WORK ENVIRONMENTS, WORKSITES IN PARTICULAR CAN SERVE AS EFFECTIVE SETTINGS IN WHICH TO PROVIDE AIDS EDUCATION. AND THE IDEAL TIME TO EDUCATE YOUR EMPLOYEES ABOUT AIDS IS BEFORE YOUR CORPORATION HAS ITS FIRST AIDS CASE. SOME OF YOU HAVE ALREADY PASSED THAT MARK; FOR OTHERS THE TIME TO START IS NOW T HAD THE WORKSITE IN MIND WHEN I WROTE THE SURGEON GENERAL’S REPORT ON AIDS AND PRESENTED IT TO THE PUBLIC IN OCTOBER 1986, I HAD CONSULTED WITH THE WASHINGTON BUSINESS GROUP ON HEALTH AND MORE SPECIFICALLY MET WITH THE DAYTON-HUDSON COMPANY. THE CONCLUSION WAS TO TREAT AIDS AT THE WORKSITE LIKE ANY OTHER CHRONIC ILLNESS, oO) EMPLOYERS NOT ONLY HAVE AN OPPORTUNITY TO PROVIDE EDUCATION GENERALLY WHICH WILL HAVE SPIN OFFS WITH EMPLOYEE’S FAMILY AND SOCIAL CONTACTS. BUT EMPLOYERS ALSO HAVE THE OPPORTUNITY -- INDEED IT MAY BE AN OBLIGATION -- TO PROVIDE INFORMATION ON: o HOW AIDS IS SPREAD o HOW AIDS IS NOT SPREAD o WHO IS AT RISK -- AND HOW THEY CAN CHANGE THEIR BEHAVIOR o WHO IS NOT AT RISK -- AND HOW THEY STAY THAT WAY o WHY AIDS IS NOT CONTAGIOUS AT THE WORKSITE o WHY THE STIGMA THAT ACCOMPANIES THE DIAGNOSIS LEADS TO IRRATIONAL AND UNFAIR BEHAVIOR. AND, BELIEVE ME, THAT INFORMATION PASSED ON TO YOUR EMPLOYEES WILL STAND YOU -- THE EMPLOYER IN GOOD STEAD, LET'S JUST TICK THESE OFF--ONE AT A TIME, AIDS IS SPREAD BY SEMEN OR BLOOD THROUGH SEXUAL CONTACT OR BY SHARING DIRTY EQUIPMENT SHOOTING DRUGS, AIDS IS NOT SPREAD BY WORKING SIDE BY SIDE WITH A PERSON WHO HAD AIDS OR WHO CARRIES THE VIRUS IN YOUR PLANT OR OFFICE SETTING. YOU DON'T GET AIDS FROM SHAKING HANDS, SHARING OFFICE MACHINES OR TELEPHONES, EATING TOGETHER. OR SHARING THE SAME LOCKER. YOU DONT GET AIDS FROM TOILET SEATS, TOWELS, SNEEZING AND COUGHING, DRINKING FOUNTAINS, OR DOOR KNOBS, THE PEOPLE WHO ARE AT RISK FOR AIDS IN YOUR COMPANY ARE THOSE WHO PRACTICE HIGH RISK BEHAVIOR,--HOMOSEXUAL OR BISEXUAL MEN WHO ENGAGE IN SEXUAL BEHAVIOR WITH OTHERS WHO CARRY THE VIRUS, HETEROSEXUALS WHO ARE NOT IN A MUTUALLY FAITHFUL MONOGAMOUS RELATIONSHIP WITH A PARTNER FREE OF THE VIRUS; THOSE WHO HAVE MULTIPLE SEXUAL PARTNERS, VISIT PROSTITUTES, OR SHOOT DRUGS, THE BEHAVIOR CHANGES ARE OBVIOUS -- ABSTINENCE IS 100% EFFECTIVE, MUTUALLY FAITHFUL MONOGAMOUS RELATIONSHIPS ARE TOO IF NEITHER PARTNER IS CARRYING THE VIRUS, FOR THOSE WHO ARE NEITHER ABSTINENT NOR MONOGAMOUS, PROTECTED SEXUAL INTERCOURSE -- A CONDOM -- IS THE BEST WE HAVE TO OFFER -- ALTHOUGH NOT 100% EFFECTIVE. IN GENERAL CONDOMS, HOWEVER, ARE MORE RELIABLE THAN THE PEOPLE WhO USE THEM, I THINK THOSE ANSWERS ALSO COVER WHO IS NOT AT RISK AND HOW THEY STAY THAT WAY AND WHY AIDS IS NOT CONTAGIOUS AT THE WORKSITE, A WORD ABOUT THE STIGMA. AIDS IS USUALLY CONTRACTED BY BEHAVIOR WHICH MOST AMERICANS DO NOT PRACTICE AND OF WHICH MOST AMERICANS DO NOT APPROVE. THAT COLORS EVERYTHING WE SEE AND HEAR IN REFERENCE TO AIDS, WE HAVE TO AFFIRM AND REAFFIRM THAT WE ARE FIGHTING A DISEASE AND NOT PEOPLE. WE HAVE TO RECOGNIZE THAT MANY WHO CARRY THE VIRUS DO SO THROUGH NO BEHAVIOR THAT COULD BE CRITICIZED BY ANYONE -- THE RAY CHILDREN IN FLORIDA IS A POIGNANT EXAMPLE, HEMOPHILIAC CHILDREN REQUIRING BLOOD AND BLOOD PRODUCTS TO STAY ALIVE CONTRACTED THE VIRUS IN THAT WAY, THEY ARE TO BE SINCERELY PITIED YET THEY WERE DENIED SCHOOL, OSTRACIZED, DENIED ACCESS TO STORES, BARBER, CHURCH AND EVENTUALLY THEIR HOME DESTROYED BY FIRE, IF YOUR EDUCATION PROGRAM COULD PREVENT JUST ONE SUCH INCIDENT FROM HAPPENING, IT WOULD BE WORTHWHILE. ABOUT 4 PERCENT OF ALL REPORTED AIDS VICTIMS ARE HETERSEXUALS -- MEN AND WOMEN WHO ARE NEITHER HOMOSEXUAL NOR BISEXUAL NOR 1.V. DRUG ABUSERS. APPARENTLY THEIR ONLY HIGH-RISK ACTIVITY WAS TO HAVE HAD SEXUAL RELATIONS WITH SOMEONE ELSE WHO HAD AIDS. 10 A COMMON EXAMPLE COULD BE THAT OF A HETERSEXUAL MAN WHO HAS SEX WITH AN AIDS-INFECTED PROSTITUTE, THEN GOES HOME AND HAS SEX WITH HIS UNSUSPECTING WIFE OR WITH OTHER WOMEN. ALL OF WHOM COULD RECEIVE THE VIRUS FROM HIM, NOTHING VERY KINKY ABOUT IT -- NOTHING VERY EXOTIC. BUT ALL VERY TRAGIC, THE TRAGEDY IS THEN COMPOUNDED WHEN ONE OF THESE WOMEN BECOMES PREGNANT AND PASSES THE VIRUS ON TO HER NEW-BORN INFANT EITHER IN UTERO OR IN THE BIRTH CANAL DURING DELIVERY, IT’S TRUE THAT THE NUMBER OF CHILDREN BORN WITH AIDS IS STILL QUITE SMALL. THEY CONSTITUTE JUST OVER 1 PERCENT OF THE TOTAL NUMBER OF ALL PERSONS WITH AIDS ll A COUPLE OF YEARS AGO. HOWEVER. THERE WEREN'T ANY. BY MARCH OF 1987 THERE WERE 471, IN FACT, SOME HOSPITALS -- IN NEW YORK, NEW JERSEY, AND WASHINGTON, D.C,, FOR EXAMPLE -- HAVE HAD TO SET ASIDE WARDS TO TAKE CARE OF THE RISING NUMBER OF INFANTS INFECTED WITH THE AIDS VIRUS AND USUALLY ABANDONED BY THEIR MOTHERS, I SHOULD ADD THAT, BECAUSE OF THE STIGMA OF AIDS, THERE ARE FAR FEWER FOSTER HOMES OPEN TO THESE CHILDREN. AND, IN FACT. THE STIGMA HAS BEEN AN INVISIBLE BUT VIRTUALLY IMPENETRABLE BARRIER BETWEEN THEM AND A WHOLE VARIETY OF SOCIAL AND PUBLIC HEALTH SERVICES, THIS INTER-SEXUAL AND INTER-GENERATIONAL CHAIN OF INFECTION IS NOT A NEW STORY. IT’S THE SAME STORY WE IN PUBLIC HEALTH HAVE BEEN TELLING FOR YEARS IN REGARD TO THE TRANSMISSION OF HERPES, SYPHILIS, GONORRHEA, CHLAMYDIA. AND OTHER SEXUALLY TRANSMITTED DISEASES. 12 BUT AIDS HAS PUT A NEW TWIST ON THAT OLD STORY. THE AIDS INFECTION DOESN’T END WITH A SHOT OF AN ANTIBIOTIC. IT ENDS IN DEATH, TO PREVENT THESE AIDS DEATHS WE NEED YOU AS ENLIGHTENED MANAGERS TO TAKE ACTION, WE NEED YOU TO SET THE EXAMPLE FOR BEING FAIR AND OBJECTIVE AND FOR NOT SUCCUMBING TO GROUNDLESS HYSTERIA. WE NEED YOU TO BE INFORMED ABOUT AIDS, TO INFORM YOUR EMPLOYEES ABOUT AIDS AND TO ENCOURAGE YOUR EMPLOYEES TO EXERCISE APPROPRIATE PREVENTIVE MEASURES, THERE ARE A NUMBER OF ISSUES INVOLVED IN ESTABLISHING AN EFFECTIVE AIDS EDUCATION PROGRAM IN THE WORKPLACE. WHAT INFORMATION IS APPROPRIATE TO DISSEMINATE? WHAT ARE EFFECTIVE WAYS TO CONVEY INFORMATION? WHAT COMMUNITY RESOURCES ARE AVAILABLE? SHOULD THERE BE A CORPORATE POLICY ON AIDS? 13 IN CALIFORNIA, IN THE SPRING OF 1987, THE ORANGE COUNTY BUSINESS LEADERSHIP TASK FORCE ON AIDS AND ALCOHOL AND DRUG ABUSE ISSUED A MANUAL ON “FACILITATING AIDS EDUCATION IN THE WORK ENVIRONMENT.” THIS EXCELLENT MANUAL WILL HELP YOU DEVELOP AN AIDS EDUCATION PROGRAM FOR YOUR WORKSITE, OTHER HIGH-QUALITY RESOURCE MATERIALS ARE AVAILABLE FROM THE PUBLIC HEALTH SERVICE, STATE AND LOCAL HEALTH AGENCIES, THE MEDIA AND THE MANY PRIVATE SECTOR ORGANIZATIONS CONCERNED WITH AIDS EDUCATION, IT CANNOT BE EXHAUSTIVE IN MY SUGGESTION OF WHAT SHOULD BE INCLUDED IN YOUR COMPANY’S AIDS POLICY BUT LET ME SUGGEST AT LEAST THE FOLLOWING: O TREATMENT OF AIDS SHOULD BE WITHIN EXISTING POLICY FOR ILLNESS. 14 EMPLOYEES WITH AIDS SHOULD BE OFFERED THE OPPORTUNITY TO WORK AS LONG AS THEY CAN -- BEARING IN MIND THE RISK TO THE PERSON WITH AIDS IN SOME HIGH RISK AREAS SUCH AS HIGH STEEL OR TO OTHERS AS WITH A CRANE OPERATOR. AIDS PATIENTS SHOULD PERFORM SATISFACTORILY OR BE OFFERED LESSER RESPONSIBILITY. ENCOURAGE EMPLOYEES TO BE SENSITIVE TO THE NEEDS OF A COLLEAGUE WITH AIDS, EMPLOYEES SHOULD NOT BE GRANTED TRANSFER REQUESTS INCONSISTENT WITH OTHER TRANSFER POLICY BECAUSE THERE ARE PERSONS WITH AIDS AT THEIR WORKSITE, CONFIDENTIALITY OF HEALTH RECORDS OF PERSONS WHO CARRY THE VIRUS BUT ARE NOT ILL MUST BE MAINTAINED. 15 Oo RESPECT FOR THE INDIVIDUAL -- CONSISTENT WITH THE COMPANY'S EXPERIENCE MUST BE STRESSED BY MANAGEMENT AND SUBORDINATES, o AN EDUCATIONAL PROGRAM MUST BE IMPLEMENTED, BECAUSE OF ECONOMICS YOU MAY WISH TO CONSIDER CASE MANAGEMENT. THE COST OF THE AVERAGE AIDS PATIENT NATIONALLY IS $147,000, THE COST IN SAN FRANCISCO IS $25,000 TO $47,000 BECAUSE OF SKILLFUL CASE MANAGEMENT, CASE MANAGEMENT IS DESIGNED TO CUSTOMIZE CARE FOR INDIVIDUALS WITH CATASTROPHIC ILLNESS. THE PROCESS REQUIRES COST ANALYSIS AND COORDINATION BY AN INDIVIDUAL CASE MANAGER, OFTEN A NURSE. THE CASE MANAGER COMPARES COST AND QUALITY OF CARE PROVIDED BY DIFFERENT HEALTH CARE PROVIDERS AND TAILORS THEM 10 PATIENT NEEDS IN CONSULTATION WITH THE PATIENT, HIS FAMILY. AND HEALTH CARE PROFESSIONALS, THE RESULT IS AN INDIVIDUAL HEALTH CARE PLAN PRESENTED TO PURCHASERS FOR APPROVAL. 16 WE“VE GOT A MAJOR TASK AHEAD OF US,..AND WE’VE GOT TO DO IT TOGETHER. ..OR IT WON’T GET DONE AT ALL. GOVERNMENT CANNOT DO THE JOB ALONE. WE NEED THE FULL COLLABORATION AND COMMITMENT OF AMERICAN BUSINESS AS WELL. NONE OF US CAN DEFAULT ON THIS RESPONSIBILITY, TOO MANY LIVES DEPEND ON US, WE’RE TALKING NOT ONLY ABOUT THE HEALTH AND WELL-BEING OF AMERICA’S 100 MILLION WORKING PEOPLE...WE’RE ALSO TALKING ABOUT THE HEALTH AND WELL- BEING OF THEIR FAMILIES AND THEIR COMMUNITIES. IN THE “AGE OF AIDS” OUR SCIENCE MAY BE GOOD...OUR STRATEGIC PLANNING MAY BE INNOVATIVE... BUT IF WE CAN'T GET THE AIDS PREVENTION MESSAGE ACROSS TO OUR FELLOW MANAGERS AND OUR EMPLOYEES -- THEN WE’VE FAILED, AND OUR FAILURE WILL BE MEASURED IN HIGHER HEALTH CARE COSTS AND IN THE LOSS OF PRODUCTIVE MEMBERS OF OUR WORKFORCE, AND NOW, LET ME THANK YOU AGAIN FOR HAVING ME AS YOUR GUEST AND BEST WIShES FOR A MOST SUCCESSFUL MEETING. I KNOW THAT YOU ARE IN GOOD HANDS WITH ALLSTATE,”