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ADDRESS

BY
C, EVERETT KOOP, M.D. Sc.D,
SURGEON GENERAL
OF THE
U.S. PUBLIC HEALTH SERVICE

PRESENTED TO THE
PHILADELPHIA COUNTY MEDICAL SOCIETY

OCTOBER 16, 1987

PHILADELPHIA, PENNSYLVANIA
ALTHOUGH IT IS A PLEASURE TO BE BACK IN MY HOME TOWN, I’M
SORRY IT HAS TO BE TO DISCUSS TOGETHER THE IMPLICATIONS OF AIDS.

WHEN I SAW YOUR PROGRAM AND THE MANNER IN WHICH YOU
APPROACHED THE SUBJECT, I REALLY WONDERED WHAT I MIGHT SAY
BECAUSE YOU REALLY HAVE COVERED THE SUBJECT,

AND I KNOW YOU DIDN'T BEGIN TO THINK ABOUT IT JUST IN
PREPARATION FOR TODAY. THAT PLEASES ME BECAUSE IN THE SURGEON
GENERAL’S REPORT ON AIDS WHICH I RELEASED A YEAR AGO, I SAID THAT
"AIDS WILL IMPACT ALL OF US. THE CHANGES IN OUR SOCIETY WILL BE
ECONOMIC AND POLITICAL AND WILL AFFECT OUR SOCIAL INSTITUTIONS,
OUR EDUCATIONAL PRACTICES, AND OUR HEALTH CARE.”
| IT FURTHER SUGGESTED THAT "STATE AND LOCAL TASK FORCES SHOULD
PLAN AHEAD AND WORK COLLABORATIVELY WITH OTHER JURISDICTIONS TO
REDUCE TRANSMISSION OF AIDS” AND SO ON,

WHEN WE FIRST BEGAN TO CONFRONT THE AIDS EPIDEMIC, THE
PEOPLE AT HIGHEST RISK WERE EITHER HOMOSEXUALS AND BISEXUAL MEN
AND I.V¥, DRUG ABUSERS, MALE AND FEMALE. I’M AFRAID THEY STILL
ARE: 9 OF EVERY 10 CASES INVOLVE THESE KINDS OF INDIVIDUALS,

BUT NOWADAYS WE'RE RECEIVING MORE AND MORE REPORTS OF THE

AIDS VIRUS OCCURRING AMONG HETEROSEXUAL MEN AND WOMEN WHO ARE NOT
IT,V. DRUG ABUSERS, IN FACT, THEIR HETEROSEXUAL ACTIVITY SEEMS TO

BE THEIR ONLY RISK FACTOR,
AS OF LAST WEEK, 4 PERCENT OF ALL REPORTED AIDS CASES IN THE
U.S, HAD BEEN CONTRACTED THROUGH HETEROSEXUAL BEHAVIOR...A
PERCENTAGE, BY THE WAY, THAT’S CLIMBING ONLY SLOWLY.

ANOTHER CONCERN IS THE RISE IN AIDS AMONG BLACKS AND
HISPANICS, BLACKS ACCOUNT FOR 12 PERCENT OF THE U.S. POPULATION,
BUT THEY ACCOUNT FOR 25 PERCENT OF ALL AIDS CASES, SIMILARLY,
HISPANICS ACCOUNT FOR 6 PERCENT OF THE U.S, POPULATION, BUT THEY
ACCOUNT FOR 14 PERCENT OF ALL AIDS CASES. 95% OF THE BABIES BORN
WITH AIDS ARE BLACK OR HISPANIC.

SO THE DEMOGRAPHY OF THIS DISEASE IS BECOMING AS COMPLEX AS
THE DISEASE ITSELF,
OUR SINGLE DEFENSE AGAINST THIS DISEASE FROM THE VERY
BEGINNING HAS BEEN INFORMATION AND EDUCATION, AND IT STILL IS,

OVER THE PAST 5 YEARS, WE’VE BEAMED INFORMATION ALMOST
EXCLUSIVELY TO HOMOSEXUALS AND BISEXUAL MEN AND, WHEREVER
POSSIBLE, TO DRUG ABUSERS. AMONG HOMOSEXUALS, THIS CAMPAIGN
SEEMS TO HAVE BEEN EFFECTIVE... THEIR SEXUAL BEHAVIOR HAS
APPARENTLY CHANGED,

THERE'S BEEN A NOTICEABLE SHARP DROP IN THE NUMBERS OF MEN
TAKING PART IN WHOLESALE, ANONYMOUS, PROMISCUOUS SEX,

AS A RESULT, A DECLINE HAS ALREADY OCCURRED IN THE INCIDENCE
OF OTHER SEXUALLY TRANSMITTED DISEASES AMONG HOMOSEXUAL MEN, SUCH
AS GONORRHEA, HEPATITIS B.. AND SYPHILIS.
BUT NOW WE NEED TO DIRECT OUR INFORMATION AND EDUCATION
EFFORTS OUT TO HETERSEXUAL MEN AND WOMEN...WHICH IS TO SAY, TO
SOCIETY AT LARGE.

THAT WAS THE BASIS FOR THE SURGEON GENERAL’S REPORT ON AIDS,
WHICH I RELEASED LAST OCTOBER.

I WANT TO ASSURE YOU THAT AT NO TIME HAVE I HAD ANY
MISGIVINGS ABOUT ANYTHING I WROTE,

THERE IS MUCH SCIENTIFIC AND PUBLIC HEALTH INFORMATION IN
THAT REPORT, BUT ON THE BEHAVIOR SIDE, THERE WERE JUST THREE
MESSAGES THAT ARE VITALLY IMPORTANT:
THE FIRST MESSAGE IS SIMPLE ENOUGH. IT SAYS THAT THE BEST
DEFENSE AGAINST AIDS IS TOTAL ABSTINENCE FROM SEXUAL RELATIONS,

[ THINK THAT'S PRECISELY THE RIGHT MESSAGE TO GIVE TO OUR
CHILDREN -- AIDS OR NO AIDS, BUT ADULTS ARE AT RISK. ALSO. AND A
RECOMMENDATION OF TOTAL ABSTINENCE FOR THE ENTIRE POPULATION IS,
TO SAY THE LEAST, UNREALISTIC.

HENCE, MY SECOND MESSAGE IS THIS:

FIND SOMEONE WHO IS WORTHY OF YOUR RESPECT AND YOUR
LOVE...GIVE THAT PERSON BOTH,..AND STAY FAITHFUL TO HIM OR HER,

IN OTHER WORDS, SHORT OF TOTAL ABSTINENCE, THE BEST DEFENSE

AGAINST AIDS IS TO MAINTAIN A FAITHFUL, MONOGAMOUS RELATIONSHIP

IN WHICH YOU HAVE ONLY ONE CONTINUING SEXUAL PARTNER...AND THAT
PERSON IS AS FAITHFUL AS YOU ARE,
MY THIRD MESSAGE IS FOR PEOPLE WHO AREN'T ABSTINENT BUT
DON’T YET HAVE A FAITHFUL MONOGAMOUS RELATIONSHIP...FOR WHATEVER
REASON, UNLESS YOU KNOW WITH ABSOLUTE CERTAINTY (AND HOW CAN YOU
KNOW) THAT NEITHER YOU NOR YOUR PARTNER IS CARRYING THE AIDS

VIRUS, YOU MUST USE CAUTION.

FROM THE VIEWPOINT OF EPIDEMIOLOGY, WHEN YOU HAVE SEX WITH
SOMEONE, YOU'RE ALSO HAVING SEX WITH EVERYONE ELSE WITH WHOM THAT
PERSON HAS HAD SEX,

AND, WHEN YOU CONSIDER THE LONG INCUBATION PERIOD FOR THE
AIDS VIRUS, WE'RE TALKING ABOUT THAT PERSON'S HISTORY OF SEXUAL
RELATIONS SOING BACK 5 YEARS OR PERHAPS LONGER. IF YOU DON’T
LISTEN TO THOSE 2 GOOD HEALTH MESSAGES AND IF YOU DO DECIDE TO
HAVE SEX WITH SOMEONE AND YOU ARE NOT ABSOLUTELY CERTAIN ABOUT
HIS OR HER SEXUAL HISTORY, THEN -- IF YOU’RE A MAN -- USE A
CONDOM FROM START TO FINISH. IF YOU’RE A WOMAN, MAKE SURE YOUR
MALE PARTNER USES A CONDOM...AGAIN, FROM START TO FINISH,
A CONDOM WON’T PROVIDE 100 PERCENT PROTECTION -- FEW THINGS
IN LIFE DO -- BUT SO FAR IT SEEMS TO BE THE BEST PROTECTION
AVAILABLE. WE KNOW VERY LITTLE ABOUT THE FAILURE RATE FOR
CONDOMS AS FAR AS SEXUALLY TRANSMITTED DISEASES ARE CONCERNED,
WE KNOW ENOUGH ABOUT CONDOMS AND CONTRACEPTION TO SAY THAT
CONDOMS ARE PROBABLY MORE RELIABLE THAN THE PEOPLE WHO USE
THEM, A SPERMICIDE -- NONOXINOL 9 -- ADDS FURTHER PROTECTION,

| IN MARCH THE USPHS PUBLISHED AN INFORMATION-EDUCATION PLAN
TO HELP CONTROL AIDS IN THE U.S. LET ME TOUCH THE HIGHLIGHTS OF
THAT PROGRAM,

OCTOBER IS AIDS AWARENESS MONTH AND AT THIS MOMENT MUCH OF
THIS PLAN IS BEING IMPLEMENTED BY A MEDIA BLITZ,
ONE FEATURE -- THE PRINTING OF 40 MILLION LEAFLETS FOR
DISTRIBUTION TO INDIVIDUALS BY ANY GOVERNMENT OR PRIVATE AGENCY
THAT WISHES TO SEND TO THEIR OWN CONSTITUENTS. IT IS NOT AS
COMPLETE AS THE SURGEON GENERAL’S REPORT -- BUT IT COVERS THE
FACTS, YOU MAY WANT TO CONSIDER SOME DISTRIBUTION IN
PHILADELPHIA,

THE DIFFERENCES OF OPINION IN THE U.S. AT THE MOMENT SWIRL
AROUND:

Oo HOW TO BEST PROTECT INDIVIDUALS WHO ARE HIV POSITIVE. OR
HAVE AIDS, FROM UNWARRANTED DISCLOSURE AND
DISCRIMINATION, WHILE PROTECTING THE PUBLIC FROM
INFECTION,
10

I WOULD LIKE TO SUMMARIZE BRIEFLY,

FROM A PUBLIC HEALTH PERSPECTIVE, THE PRIMARY PURPOSE OF ANY
ACTION RELATED TO THE AIDS EPIDEMIC IS TO PREVENT THE SPREAD OF
THE DISEASE. THERE ARE A BROAD RANGE OF OPTIONS, SOME REFLECTING
TRADITIONAL FEDERAL AND STATE ROLES. SOME GO BEYOND THE PUBLIC
HEALTH PURPOSE AND WOULD HAVE BROADER EFFECTS ON INSURANCE,
EMPLOYMENT. AND OTHER PRACTICES,

THE CURRENT PROTECTION FROM DISCLOSURE OF PERSONS WHO ARE
HIV POSITIVE INCLUDE PRIVATE ACTIONS SUCH AS PHYSICIAN
DISCRETION, THE HIPPOCRATIC OATH, ETC,, STATE LAWS AND FEDERAL
LAWS AND REGULATIONS,
ll

THE PROBLEM WITH ALL OF THIS IS THAT POTENTIAL OR ACTUAL
DISCLOSURE MAY “CHILL” VOLUNTARY TESTING, STIGMATIZE THE INFECTED
AND POSSIBLY LEAD TO ACTUAL DISCRIMINATION,

INSOFAR AS DISCRIMINATION IS CONCERNED, PROPER OR IMPROPER
DISCLOSURE BY CUSTODIANS OF INFORMATION MAY RESULT IN ACTIONS
BEING TAKEN AGAINST PERSONS WHO ARE HIV POSITIVE OR WHO HAVE
PROGRESSED TO FULL BLOWN AIDS. THE PITIFUL SITUATION OF THE RAY
CHILDREN IN FLORIDA IS AN EXAMPLE,

THERE IS ALSO CONTROVERSY BETWEEN THOSE WHO FAVOR MANDATORY
TESTING AND THOSE WHO DO NOT. THE MOTIVATION OF THE FORMER GROUP
TS MIXED, MOST OF THE PUBLIC HEALTH PEOPLE ADHERE TO THE LATTER

STANCE, |
12

THE TWO AREAS OF MOST HEATED CONTROVERSY ARE PREMARITAL
TESTING AND THE TESTING OF HOSPITAL ADMISSIONS.

HIGH RISK PEOPLE ARE USUALLY NOT GETTING MARRIED IN THE
UNITED STATES. THE OLD LAWS PERTAINING TO MARRIAGE LICENSES AND
TESTING FOR SYPHILIS ARE NOT APPLICABLE BECAUSE FOR SYPHILIS
THERE WAS A CURE; THERE IS NO SUCH THING AVAILABLE FOR AIDS,
SEVENTY-FIVE PERCENT OF THOSE GETTING MARRIED HAVE ALREADY BEEN
LIVING TOGETHER. THE COSTS OF SUCH TESTING IS EXORBITANT IN
REFERENCE TO THE NUMBER OF CASES FOUND, AFTER WHICH THERE IS NO
PROGRAM AVAILABLE EXCEPT EDUCATION.
13

A RECENT HARVARD SHOOL OF PUBLIC HEALTH STUDY:

3.8 MILLION MARRIAGES

9,000 WOULD SCREEN POSITIVE

1,200 WOULD BE WESTERN BLOT POSITIVE

100 POSITIVE WOULD BE MISSED

COST: $100,000,000

WOULD NOT PREVENT INFECTION OR PREGNANCY
WOULD NOT PROTECT BABIES

INCREASED HOSPITAL TESTING WILL UNDOUBTEDLY COME BUT FOR THE
MOMENT IT REMAINS A LOCAL HOSPITAL OPTION -- AND ALWAYS
VOLUNTARY, PRESENTLY. IT REMAINS IN THE REALM OF TRUST BETWEEN
PATIENT AND PHYSICIAN,
14

TO BUSINESS AND INDUSTRY, LET ME SAY THAT WORKSITES IN
PARTICULAR CAN SERVE AS EFFECTIVE SETTINGS IN WHICH TO PROVIDE
AIDS EDUCATION. AND THE IDEAL TIME TO EDUCATE YOUR EMPLOYEES
ABOUT AIDS 1S 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. 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,
15

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

Oo WHY AIDS IS NOT CONTAGIOUS AT THE WORKSITE

o WHY THE STIGMA THAT ACCOMPANIES THE DIAGNOSIS LEADS TO
IRRATIONAL AND UNFAIR BEHAVIOR, —
16

AND, BELTEVE ME. THAT INFORMATION PASSED ON TO YOUR
EMPLOYEES WILL STAND YOU -- THE EMPLOYER IN GOOD STEAD,

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,
17

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?
18

IN CALIFORNIA, 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 CF AIDS SHOULD BE WITHIN EXISTING POLICY FOR
ILLNESS,
19

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 NGT 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,
20

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,
21

LET ME SHIFT GEARS AND TALK ABOUT AIDS IN A DIFFERENT
VEIN. WHAT IS AIDS GOING TO DO TO OUR SOCIAL ORDER? AND BEING
AWARE OF SOME OF THE PROBLEMS OF THE FUTURE, CAN FORETHOUGHT AND
PLANNING BE PROPHYLACTIC?

I WANT TO SPEND A FEW MOMENTS REVIEWING FOR YOU, ALBEIT IN A
BRIEF MANNER, SOME OF THE CHOICES THAT LIE AHEAD OF US,

FIRST, LET ME REMIND YOU THAT IN THE U.S, THE THREE ASPECTS
OF AIDS THAT COLOR EVERYTHING DONE AND SAID ABOUT THE DISEASE
ARE, ONE, THAT IT IS STILL A MYSTERY,..TWO, THAT IT IS
FATAL...AND THREE, THAT PEOPLE GET AIDS BY DOING THINGS THAT THE.
MAJORITY OF PEOPLE DON’T DO AND DON’T LIKE,
22

WE NEED TO KEEP THESE THREE ASPECTS OF THE DISEASE IN MIND,
BECAUSE THEY, IN COMBINATION, TRULY OBSCURE THE MANY SCIENTIFIC
ISSUES SURROUNDING AIDS AND, INSTEAD, SWING OUR ATTENTION TO THE
MORE VOLATILE ISSUES OF LAW, ETHICS, ECONOMICS, MORALITY, AND
SOCIAL COHESION THAT SURROUND AIDS,

WE CAN SEE THIS MOST CLEARLY IN THE WAY THE EPIDEMIC OF AIDS
HAS AFFECTED THE WORLDWIDE SYSTEM OF MEDICAL INTELLIGENCE ITSELF,
WHICH HAS BEEN A MAJOR ADVANCE FOR THE: CAUSE OF PUBLIC HEALTH,

THE PRESENCE OF AIDS IN THEIR MIDST IS A PROFOUND
EMBARRASSMENT -- TO SAY THE LEAST -- FOR MANY NATIONS OF THE
WORLD,
23

WORSE, ITS PRESENCE CAN BE AN AFFRONT TO THE MORAL STANDARDS
OF MANY SOCIETIES. AND I SUSPECT THAT SOME OF THESE HAVE CHOSEN
TO MAKE THE DISEASE DISAPPEAR BY SIMPLY NOT PUBLICLY REPORTING
ITS PREVALENCE. THIS GLOBAL PROBLEM MAY NOT EFFECT PHILADELPHIA
FOR THE MOMENT, BUT WE MUST CONTINUE TO PROVIDE ENCOURAGEMENT AND
SUPPORT TO THE TOTAL EPIDEMIOLOGICAL EFFORT, BEGINNING WITH THE
INDIVIDUAL HEALTH WORKERS WHO ARE ON THE FRONT-LINE OF DATA
COLLECTION, THESE ARE THE PEOPLE WHO MUST BE PROFESSIONALLY
COMMITTED TO MAINTAINING THE INTEGRITY.OF HEALTH DATA. THEY MUST
NOT COMPROMISE THOSE DATA FOR ANY REASON,

BUT I AM PERSUADED THAT THE UNDER-REPORTING OF THE
PREVALENCE OF AIDS IS A FACTOR RETARDING OUR PROGRESS IN THE
FIGHT AGAINST THIS DISEASE.
24

THE DISEASE OF AIDS IS ALSO TESTING THE DEGREE TO WHICH
HEALTH WORKERS -- PHYSICIANS, NURSES, TECHNICIANS, AND OTHERS --
UNDERSTAND AND ARE TRULY DEDICATED TO THE ETHICAL FOUNDATION OF
HEALTH CARE ITSELF,

WE ARE HEARING EVERY DAY SOME STORY OR OTHER INVOLVING A
HEALTH PROFESSIONAL -- OR A GROUP OF PROFESSIONALS -- WHO REFUSE
TO TREAT PERSONS WITH AIDS...OR EVEN TO TREAT PERSONS WHOM THEY

SUSPECT OF HAVING AIDS,

I DO NOT FOR A MOMENT BELIEVE THAT THIS IS THE
CHARACTERISTIC BEHAVIOR OF HEALTH PROFESSIONALS. THE
OVERWHELMING MAJORITY OF OUR COLLEAGES HAVE PROVIDED -- AND WILL
CERTAINLY CONTINUE TO PROVIDE -- QUALITY, COMPASSIONATE CARE TO
PERSONS DYING OF AIDS WHEREVER THEY ARE,
25

BUT THE GOOD CONDUCT OF THE MAJORITY SHOULD NOT IN ANY WAY
SHIELD THE POOR CONDUCT OF A FEARFUL AND IRRATIONAL MINORITY,

I MUST REMIND YOU, HOWEVER, THAT THE RECORD OF THE SEVERAL
HEALTH PROFESSIONALS IS NOT VERY GOOD ON THIS MATTER OF HOLDING
COLLEAGUES TO A CLEAR STANDARD OF ETHICAL CONDUCT. I DON’T THINK
THAT’S A PROBLEM UNIQUE TO ANY ONE COUNTRY EITHER. IT’S ONE
THAT, UNFORTUNATELY, EVERY ONE OF US MUST STRUGGLE WITH,

NOR WILL I SAY THAT THE PROBLEM REGARDING AIDS PATIENTS IS
MORE SERIOUS THAN ANY OTHER. THAT’S NOT TRUE BECAUSE WHENEVER A
HEALTH PROFESSIONAL COMPROMISES THE ETHICS OF THE HEALING ART --
INVOLVING WHATEVER DISEASE OR CONDITION -- IT IS A SERIOUS
MATTER,
26

BUT THE DENIAL OF SERVICES TO PEOPLE WITH AIDS IS ESPECIALLY
SIGNIFICANT BECAUSE OF THE OFTEN PROTRACTED AND EXTREMELY
DEBILITATING NATURE OF THE AIDS-RELATED TERMINAL ILLNESSES.

THESE ARE ILLNESSES WHICH ARE LABOR-INTENSIVE. IN OTHER WORDS,
WE NEED ALL THE COMMITMENT OF ALL THE HEALTH PROFESSIONS TO GET
US THROUGH THE NEXT DECADE OR SO, AS THE DISEASE PROGRESSES,

IT IS ALSO ESSENTIAL THAT PHYSICIANS, DENTISTS, NURSES, AND
OTHERS ESTABLISH A DE MINIMIS LEVEL OF. RATIONALITY THAT THE REST
OF SOCIETY CAN FOLLOW, RELATIVE TO OUR CONDUCT TOWARD THE CLASSES
OF PEOPLE AMONG WHOM THE DISEASE SEEMS TO BE MAKING THE MOST
HEADWAY.
2/

AS WE IN MEDICINE KNOW FULL WELL, THE DISEASE OF AIDS IS NOT
INTRINSIC TO HOMOSEXUALITY, AS IT IS NOT INTRINSIC TO
HETEROSEXUALITY. YET, THAT DISTINCTION IS LOST ON SOME PEOPLE,
WITH THE RESULT THAT WE ARE SEEING -- IN OUR COUNTRY AND
ELSEWHERE IN THE WORLD -- A RISE IN HOMOPHOBIA, THAT IS THE

HATRED OF -- AND VIOLENCE AGAINST -- HOMOSEXUALS AND BISEXUAL
MEN,

HEALTH PROFESSIONALS MUST NOT IN ANY WAY CONTRIBUTE TO SUCH
IRRATIONAL BEHAVIOR. AND DENYING HEALTH SERVICES TO HOMOSEXUALS
OR BISEXUAL MEN -- WHETHER THEY HAVE AIDS OR NOT -- IS ALSO
IRRATIONAL AND CANNOT BE EXCUSED OR CONDONED,
28

WE MUST NOT LET THIS ISSUE FURTHER WEAKEN THE ETHICS OF
MEDICAL PRACTICE. THAT WOULD BE ANOTHER AND JUST AS DEADLY AN
EPIDEMIC,

ANOTHER ISSUE CONCERNS THE COST OF CARE FOR AIDS PATIENTS:
WHAT MIGHT THOSE COSTS BE? AND WHO SHOULD PAY THEM? AND WHAT
SPECIAL PROBLEMS DOES HIV PRESENT TO INSURANCE COMPANIES?

AS YOU KNOW. WE HAVE A MIXED SYSTEM OF SUPPORT FOR HEALTH
CARE IN THE U.S.: PRIVATE METHODS OF PAYMENT EXIST SIDE-BY-SIDE
WITH PUBLICLY SUPPORTED SYSTEMS OF REIMBURSEMENT FOR CARE,
29

AT THIS POINT THE TOTAL ANNUAL EXPENDITURE FOR THE MEDICAL
CARE OF AIDS PATIENTS IS ABOUT $1.6 BILLION. HOWEVER, OF THAT
TOTAL. THE AMERICAN TAXPAYER CONTRIBUTES ABOUT 1 DOLLAR OF EVERY
4, OR SOMETHING ON THE ORDER OF $400 MILLION THIS YEAR,

OF COURSE, THE AMERICAN TAXPAYER SUPPORTS A GREAT RANGE OF
PUBLIC HEALTH PROGRAMS, MOST OF THEM EITHER HELP PROMOTE OR

MAINTAIN AN INDIVIDUAL’S GOOD HEALTH, OR THEY HELP RETURN THE
INDIVIDUAL TO A STATE OF GOOD HEALTH.

BUT AIDS IS DIFFERENT.
30

IT’S VERY EXPENSIVE...WELL OVER $600 A DAY ON THE AVERAGE
FOR IN-PATIENT CARE. BUT THEN, AFTER CONSUMING TENS OF THOUSANDS
OF DOLLARS WORTH OF MEDICAL CARE AND SOCIAL SERVICES...THE AIDS
PATIENT DIES,

WE ANTICIPATE THAT. OVER THE NEXT FOUR YEARS, THE ANNUAL
AIDS CASE-LOAD WILL MORE THAN DOUBLE AND THE ANNUAL COST OF CARE
WILL MORE THAN TRIPLE.

WILL THE AMERICAN PEOPLE CONTINUE TO SUPPORT HIGH-COST
PATIENT CARE FOR PEOPLE WITH AIDS, OR WILL THEY ASK FOR RELIEF?
AND IF THEY DO, WHAT WILL THAT DO TO THE ACCESSIBILITY OF MEDICAL
CARE,..OR THE QUALITY OF MEDICAL CARE...FOR AIDS PATIENTS IN OUR
COUNTRY? |
31

17D LIKE TO THINK THAT THE AMERICAN TAXPAYER WILL DO THE
RIGHT THING AND CONTINUE TO SUPPORT QUALITY, ACCESSIBLE CARE FOR
ALL AIDS PATIENTS, BUT I DON’T KNOW,

T‘VE BEEN CALLING FOR ACTION ON THIS SUBJECT AT FEDERAL,
STATE, AND MUNICIPAL LEVELS FOR THE ENTIRE YEAR. THE HCFA
SUPPORT OF THE RAND STUDY IS A STEP IN THE RIGHT DIRECTION,

ANOTHER ISSUE IS THE HEALTH PROFESSIONALS’ EVENTUAL DECISION
ON WHAT COMPONENTS OF MEDICAL PRACTICE, IF ANY, ARE DANGEROUS TO
PATIENTS IF A PHYSICIAN, NURSE, OR WHATEVER IS°HIV POSITIVE,
wt
ho

PHYSICIANS IN THE U.S, HAVE VOLUNTARILY GIVEN UP THEIR
PRACTICES WHEN HIV POSITIVE. OTHERS HAVE BEEN PROHIBITED BY
VARYING AUTHORITIES FROM PRACTICING IN PART OR TOTALLY. THESE
DECISIONS REST ON THE LIKEIHOOD, OR LACK THEREOF, FOR
TRANSMISSION OF THE VIRUS FROM HEALTH WORKER TO PATIENT. I THINK
YOU MUST TURN SOME ATTENTION TO THAT.

A RELATED QUESTION -- RELATIVE TO HIV NEUROLOGICAL DISEASE
-- HAS TO DO WITH WHO SHOULD BE DISQUALIFIED FROM PERFORMING
CERTAIN JOBS IF HIV POSITIVE?

AND THIS CERTAINLY HAS TO BE A CONCERN OF THOSE WHO WORRY
ABOUT THE PUBLIC SAFETY OF A CITY LIKE THIS,
33

] HOPE GUIDELINES WILL SOON EMERGE FROM CDC TO PRESENT
PRECIPITIOUS AND UNFAIR ACTION BEING TAKEN IN THIS REGARD.

WE SEE MORE EVIDENCE EVERY DAY THAT THIS DISEASE 1S BECOMING
THE PARTICULAR SCOURGE OF PEOPLE WHO ARE YOUNG. BLACK, AND
HISPANIC,

HOW TRAGIC FOR THEM.

AND HOW TRAGIC FOR ALL OF US.

IN VIRTUALLY EVERY EPIDEMIC OR PLAGUE IN HUMAN HISTORY,
SOCIETY HAS FOUND A CONVENIENT SCAPEGOAT. THE SCAPEGOAT IS

USUALLY POOR, A MINORITY OF SOME KIND -- RACIAL. RELIGIOUS, OR
ETHNIC -- AND TOO WEAK TO FIGHT BACK,
34

DURING THOSE PERIODS OF THE GREAT EPIDEMICS, THE MAJORITY
GAINED A FEELING OF SECURITY AND SATISFACTION, IF IT COULD
SOMEHOW PUNISH A WEAKER AND VERY VISIBLE MINORITY BY OSTRACISM,
QUARANTINE, OR THE DENIAL OF BASIC HUMAN RIGHTS,

THE MARK OF MATURITY OF A PEOPLE, OF COURSE. IS THE DEGREE
TO WHICH THEY REJECT THIS KIND OF BEHAVIOR. AND I AM PROUD OF
THE WAY THE UNITED STATES HAS TACKLED THE ISSUE OF FAIRNESS TO
ITS MINORITIES,

WILL THE DISEASE OF AIDS -- ALL BY ITSELF’-- REVERSE THIS
TREND IN RECENT HUMAN 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 THE GOVERNMENT AND
THROUGHOUT ALL SOCIAL AND POLITICAL INSTITUTIONS TO REINFORCE

THOSE HOPES AND PRAYERS.

YES, IT IS TRUE THAT THE GREAT MAJORITY OF AIDS PATIENTS SO
FAR HAVE BEEN HOMOSEXUALS, DRUG ADDICTS, BLACKS, AND HISPANICS.
ABOUT 43,000 OF THEM,

SO WE MUST ASK IF WE ARE TRULY MATURE ENOUGH TO BE COLOR-
BLIND IN THIS WAR AGAINST AIDS? AND CAN WE OVERLOOK THE SOCIAL
STATUS OF THE INDIVIDUAL WITH AIDS?
36

ARE WE SECURE ENOUGH TO EXTEND OUR VERY BEST MEDICAL CARE
EVEN TO THE VERY LEAST OF OUR CITIZENS?

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

1 HOPE WE WILL NOT STUMBLE TOWARD IT AND ARRIVE UNPREPARED
FOR THE CHALLENGES THAT LIE BEYOND.

I HOPE THAT, INSTEAD, WE WILL MOVE FORWARD WITH GOOD SENSE
AND GOOD SCIENCE AND, TOGETHER, GIVE THE WORLD.SOMETHING EVERY
BIT AS PRECIOUS AS THE MUCH-DESIRED AIDS VACCINE: WE WILL SHOW
THE WORLD HOW COMPASSION AND JUSTICE CAN TRIUMPH OVER DISEASE.

ONCE AGAIN... THANK YOU,