AIDS lecture May 4, 1988
15/9
Remarks
By
C. Everett Koop, MD, ScD
Surgeon General
U.S. Public Health Service
U.S. Department of Health and Human Services

Press Conference
The AIDS Brochure and the National Mailing
Presented at
Press Conference
Washington, DC
May 4, 1988
It had been sixteen days since I had last spoken in public about the AIDS epidemic.

Reference has been made in this archive previously on several occasions to the effort that went
into the Surgeon General’s Report on Acquired Immuno Deficiency Syndrome. That was a
sixteen-page brochure released to the public on October 22, 1986 and had been many months in
the making with consultation between my office and each of 26 separate groups representing
major institutions in this country — political, civic, religious, and fraternal. Everything in that
report, as I have said previously in this archive, is true today except for the treatment. The
lectures on AIDS up to this point have all been discouraging as to treatment, mentioning only the
use of AZT — also mentioned in that report — but that has fortunately been superceded by
complicated therapy, which if undertaken early might give the person who is HIV positive a
chance for his or her otherwise normal life expectancy. Millions of copies of that report were
made available through the offices of congressmen and senators — many of whom sent one to
each of their known constituents — other countries copied the report in whole or part; France and
Australia probably lifted the most, which pleased me greatly.

Yet, there was a feeling on the part of us in the Public Health Service that we were not reaching
enough people and although we were the first country to put out a report on AIDS, other
countries had since that time sent much more widely distributed information to their citizens. I
had, before this date, mentioned my disappointment that we had not undertaken such a move
before a congressional committee during the question and answer session. That body acted by
appropriating money for a national mailer. Congress felt that the Department of Health and
Human Services had been slow in responding to this perceived need and expressed their ire by
stipulating that the national mailer had to be approved at a level no higher than the Director of
the Centers for Disease Control. That would have ordinarily been a slap at the Secretary, but the
Director of CDC, at that time, James Mason, kicked the approval process up to the level of the
Secretary.

The small staff and I that had prepared the First Surgeon General’s Report on AIDS worked
diligently with a nationally known public relations firm and turned out the mailer. It was
designed in such a way that it opened into a large sheet, almost the size of an opened newspaper
double page, and if one read it where the reader was supposed to start, it was a letter to the
public, which had to be signed by someone. To my way of thinking, there were just a handful of
people who could appropriately sign such a document, but the number of people who thought
that they should be the signatory to the mailer far exceeded that number.

The day came when Otis Bowen assembled his staff and enough others to include most of the
individuals who thought they should be the signatory. Otis Bowen was not only an excellent
Secretary, but also a very wise politician. He asked an open question, “Who do you think should
sign the mailer?” Several people responded, nominating themselves or others and then Secretary
Bowen specifically asked me who I thought should sign the mailer. I replied that I thought he
should. ‘My reasoning was that he was the Director of the entire Department of Health and
Human Services and it was at his desk that the buck stopped and in as much as he was ultimately
held responsible, he should be the signatory.

Dr. Bowen’s response was classical for him. He said, “I have had some focus groups put
together to which we posed this same question and we have their answer. We asked them who
they would like to see as the signatory of a document of this importance about a disease as
dreadful as AIDS. Now, if a physician asked for a consultation and gets it and doesn’t take the
advice he has requested, he just might look like a fool. The focus groups were overwhelmingly
in favor of this document being signed by the Surgeon General and so, Chick, you will sign the
mailer.”

This document was sent to 107 million households in America and was the largest mailing ever
undertaken by the federal government, including information about income tax.

Although AIDS isn’t the least bit humorous, this mailer produced a lot of political humor that is
available elsewhere in this archive as political cartoons. In general, we all considered the effort
to be a great success. There was one other humorous episode. We wanted to make it clear in the
mailer to the public audience that you couldn’t look at somebody and tell whether he or she was
HIV positive. So, we had one little part of the mailer, which was laid out somewhat like a
newspaper, with a headline that said, “This is what AIDS looks like.” And then, we went on to
describe the fact that there was nobody stereotypical of AIDS and you couldn’t tell by looking.
Somehow or other, inadvertently, in the layout of the page, no one noticed that the picture of
Tony Fauci, the director of the National Institute of Allergy and Infectious Disease and
considered the number one scientists in the United States on the subject of AIDS, was pictured in
an adjacent column in the mailer in reference to something entirely different. However, when
one read the headline, “This is what AIDS looks like,” attention was immediately drawn to the
juxtaposed portrait of Tony Fauci. He took it in good grace and we still are good friends.

I opened the press conference by stating that 19.2 million copies of the first report issued on
October 22, 1986 had been distributed. It had been printed and reprinted in magazines and
newspapers about 20 million times. I then described the process whereby the mandate came
from Congress to the Department of Health and Human Services through the Public Health
Services Center for Disease Control to distribute a national mailing of information to all United
States households. That was enacted on December 22, 1987.
This was the first time the federal government had ever sent information on a sexually
transmitted disease to every home in America. I indicated we took this step because the
epidemic of misunderstanding on how AIDS was spread and how it was not spread, seemed at
times, as difficult to control as the epidemic itself. In addition, the American public had been
whipsawed by publications from the private sector accusing the government of circulating
inaccurate information and suggesting that either we had seriously overestimated the problem on
the one hand, or that we had withheld information on the transmission of AIDS on the other.

I expressed confidence in the fact that we had made substantial progress on our educational
campaign, but amazingly enough, studies still told us that there were millions of Americans who
believe you can get AIDS from mosquitos, blood donations for transfusion to others, toilet seats,
and sitting next to a child in school who might be HIV positive.

The mailer was designed to provide facts, to quiet fears, and to lessen discrimination against
those who have AIDS or carry the virus. The language was clear and told the reader that AIDS
was not transmitted from insects, by donating blood, from a kiss, or from saliva, sweat, tears,
urine or bowel movements. The mailer also addressed a serious problem that too many people
still believed that there was an imaginary wall that protected certain groups of individuals from
the AIDS virus through sexual intercourse or the sharing of paraphernalia in the abuse of illegal
drugs. The mailer endeavored to make everyone understand that who you are had nothing to do
with the dangers faced with becoming infected with the AIDS virus. What did matter was that
person’s behavior.

I was very frank about descriptions of sexual intercourse and sharing needles and syringes in
shooting drugs as the cause of the spread of AIDS. I reminded he public that trying to estimate
chances of catching the virus based on the latest magazine article or newspaper story was like
playing Russian roulette.

I made no excuses for the fact that we spoke frankly about vaginal and anal intercourse as well as
the proper use of condoms. We believed that this was information that every sexually active
American should know. Many people say truthfully, that the AIDS epidemic will eventually
affect everyone. What these well meaning people were trying to say was that the effects of the
AIDS epidemic, such as discrimination and the cost, as well as the ethics of the disease would
affect everyone. So, the brochure made it clear that it was not AIDS that would affect everyone,
but the affect of the epidemic would affect everyone. Certainly, the brochure enabled the reader
to separate health information that was true from various political agendas promoted at the
expense of the public’s health.

We entitled the mailer, “Understanding AIDS”, hoping that it could come close to required
reading in every American home. My hope was that parents, grandparents, children and
teenagers would set a time when they could sit down together and review the information in
those eight pages. It was my hope that schools would do the same thing in classrooms that were
appropriate. The technique of the release of this brochure was totally different than usual
procedure of delivering such a brochure to the press with its contents under embargo until a
certain time or date. With this mailer, we did something entirely new by giving the press
advance copies long before it would appear in the mail slots of the homes of America and asked
the opposite of our usual request, which was to give it as much publicity as they possibly could.
We wanted the public to be aware that the brochure would eventually be found in their mailbox
and wanted them to be interested, concerned, and curious enough to read it carefully and discuss
it with others. I challenged the press by saying that no one could do it as well as they could.

I then gave a little background to the press on what went on behind the scenes with Olgilvy and
Mather, the public relations firm, and those of us who were concerned about the content of the
brochure.

There is a paradox about consumer attention. People are concerned about AIDS and want
definitive information, but on the other hand, that’s not a true priority in the lives of most people,
so everything about the brochure had to encourage readership and review.

Secondly, people in general, are reluctant readers. Therefore, we attempted to develop a layout
with an appeal to glancing readers that were not just serious students of AIDS to make it say,
“We know what you’re interested in — here it is, read it.”

Third, AIDS is a complex subject; and it is really scores of subjects in one. It’s not like saying,
“Don’t drink and drive.” Therefore, we had the difficult task of not arbitrarily assigning
importance to one topic over another, nor to bury information, such as hiding the facts in small
type and long paragraphs, when that information might be exactly what the reader needed to
know. In a sense, we put the choice of what to read in the reader’s hands.

Finally, we wanted this to be a chatty document, neither a medical seminar, nor a sermon.

I’m pleased to say that I think we succeeded in simple language, simple words, and used them in
a caring, conversational counseling tone.

Each topic had been given relatively equally importance. Nothing was buried. It had appeal to
the glancing reader. When one thinks about it very few illustrations are relevant to the needs of
the reader, we thought the layout acknowledged the difficulty in handling a primarily verbal
presentation through variety, informality, and attractiveness.

Finally, I reminded the press that I had been lavish in my praise in the way they had handled the
subject of AIDS in the past and congratulated them once again on the way they sustained the
interest of the public as long as they had and then made the plea that we needed them once again.
We wanted the press to tell everybody that it was on the way, but not to call us for an advance

copy.

Because this introduction has been so detailed, there is no index.