BY C. EVERETT KOOP, MD, ScD SURGEON GENERAL OF THE U- S- PUBLIC HEALTH SERVICE PRESENTED TO THE NATIONAL ASSOCIATION OF ELEMENTARY SCHOOL PRINCIPALS CRYSTAL CITY, VIRGINIA JULY 26, 1987 NATIONAL ASSOCIATION OF ELEMENTARY SCHOOL PRINCIPALS IT’S MY SPECIAL PLEASURE TO BE WITH YOU THIS MORNING BECAUSE THERE IS A NATURAL KINSHIP AMONG US THAT MANIFESTS ITSELF BY DEVOTING OUR SUNDAY MORNING TO THE WELL BEING OF CHILDREN- I, AS A PEDIATRIC SURGEON AND HEALTH OFFICER, AND YOU AS TEACHERS AND PRINCIPALS HAVE DEDICATED OUR PROFESSIONAL LIVES TO THE DEVELOPMENT OF THIS NATIONS CHILDREN INTO HEALTHY, WELL ADJUSTED, WELL EDUCATED CITIZENS. IN MY FORTY YEARS OF WORKING WITH CHILDREN I HAVE FOUND NO GREATER REWARD IN THIS LIFE THAN BEING ABLE TO HELP A CHILD - IN MEDICINE OR EDUCATION. WHAT WE ARE HERE TODAY TO TALK ABOUT IS ACQUIRED IMMUNE DEFICIENCY SYNDROME, OR AIDS. THERE IS PRESENTLY NO CURE FOR AIDS- THERE IS PRESENTLY NO VACCINE TO PREVENT AIDS- OUR ONLY DEFENSE AGAINST AIDS IS EDUCATION, AND THATS WHAT YOU DO BEST. IT IS FOR THAT REASON THAT I CONSULTED WITH THE NATIONAL ASSOCIATION OF PRINCIPALS OF ELEMENTARY SCHOOLS IN PREPARING THE SURGEON GENERAL’S REPORT ON AIDS WHICH I RELEASED OCTOBER 22 LAST YEAR. SAM SAVA AND HIS COLLEAGUES WERE EXTREMELY HELPFUL AND YOUR ASSOCIATIONS CONCERNS AND IDEAS ARE REFLECTED IN THE REPORT. -2- AS OF JUNE 15, 1987 THE CENTERS FOR DISEASE CONTROL REPORTED JUST OVER 500 CHILDREN WHO HAVE BEEN DIAGNOSED AS HAVING AIDS, - OR ABOUT 1-4% OF ALL PERSONS WITH THE SYNDROME. WHERE CHILDREN ARE CONCERNED, THE DEFINITION AND DIAGNOSIS OF AIDS PROBABLY RESULTS IN UNDER - REPORTING. SO THE NUMBERS FOR THE MOMENT ARE SMALL. THE NUMBERS THAT DO CONCERN US ARE THE 21% OF ALL CASES OF AIDS THAT OCCUR IN THE 20-29 YEARS OF AGE GROUP. WE KNOW THAT SOME PROPORTION OF THIS INFECTION TOOK PLACE DURING THE TEENAGE YEARS AND THAT IT WAS DUE TO BEHAVIOR THAT YOU CAN HELP PREVENT - FIRST A LITTLE BACKGROUND: WE KNOW THAT THE AIDS VIRUS IS TRANSMITTED FROM ONE PERSON TO ANOTHER EITHER IN BLOOD OR IN SEMEN- NO OTHER BODILY FLUIDS --TEARS, SALIVA, OR PERSPIRATION, FOR EXAMPLE -- HAVE THE CONCENTRATION THAT THE VIRUS SEEMS TO REQUIRE - WE HAVE NOT ONE SUBSTANTIATED CASE OF THE VIRUS BEING TRANSMITTED BY COUGHING OR SNEEZING. . -BY FOOD UTENSILS OR WATER GLASSES. . -BY TOILET SEATS, AND SO ON ~- OR MOSQUITOES. -3- IN THIS COUNTRY, THE AIDS VIRUS IS SPREAD BY INTIMATE SEXUAL CONTACT AND THE SHARING OF NEEDLES, SYRINGES, AND OTHER PARAPHERNALIA IN THE INTRAVENOUS ABUSE OF ILLICIT DRUGS. THIS IS WHY THE U.S. PUBLIC HEALTH SERVICE HAS ADVISED THE EDUCATIONAL COMMUNITY THAT THERE IS NO SCIENTIFIC, MEDICAL, OR PUBLIC HEALTH REASON FOR BARRING OR ISOLATING A PERSON WITH THE VIRUS FROM ANY ROUTINE SCHOOL ACTIVITY- I HAVE TO SAY, THEREFORE, THAT A DECISION TO BAR A CHILD FROM SCHOOL BECAUSE HE OR SHE HAS TESTED POSITIVE FOR AIDS IS NOT A PUBLIC HEALTH DECISION. SOME OF YOU MAY FEEL YOU HAVE TO MAKE SUCH A DECISION AND THAT IT IS WISE AND NECESSARY TO DO SO- THAT MAY OR MAY NOT BE SO- BUT THE REASON HAS TO BE SOMETHING OTHER THAN HEALTH BECAUSE -- PURELY ON THE GROUNDS OF PUBLIC HEALTH -- IT WOULD NOT BE A VERY GOOD DECISION AT ALL- AS I STATED IN MY REPORT, SUCH DECISIONS SHOULD BE MADE ON AN INDIVIDUAL CASE-BY-CASE BASIS. IT IS A BALANCING ACT BETWEEN THE NEEDS OF MANY CHILDREN AND THE RIGHTS OF A FEW. RESPECTING AND HONORING THE CONFIDENTIALITY OF THE CHILD AND HIS OR HER FAMILY ARE PARAMOUNT ACTIONS. - -BUT THEY DO CONFLICT, AT TIMES, WITH THE NEED TO PROTECT THE JUVENILE VICTIM. -4- I KNOW THIS IS MUCH EASIER FOR ME, TRAINED IN SCIENCE AND MEDICINE, TO EXPLAIN TO YOU THAN IT MAY BE FOR YOU -- AND FOR PARENTS AND SCHOOL PERSONNEL -- TO UNDERSTAND. - -AND ACCEPT. BUT THE TRUTH IS THE TRUTH. - -AND WE AMERICANS HAVE ALWAYS CHOSEN TO FOLLOW THE TRUTH, NO MATTER HOW UNCOMFORTABLE THAT MAY BE, RATHER THAN FOLLOW AN UNTRUTH, NO MATTER HOW EASY THAT MIGHT BE. SECOND, MY REPORT ON AIDS MAKES CLEAR THAT, IN ORDER TO END THE CHAIN OF TRANSMISSION OF THIS DISEASE ONCE AND FOR ALL, WE NEED TO TEACH OUR YOUNG PEOPLE THE FACTS ABOUT AIDS AND BEFORE THAT, ABOUT THEIR OWN SEXUALITY. THE OBJECTIVE IS TO MAKE THEM A LOT MORE RESPONSIBLE IN THEIR RELATIONSHIPS THAN THEIR ELDERS HAVE BEEN. WHAT MIGHT SUCH AN EDUCATION PROGRAM SAY? WHO SHOULD SAY IT? WHO SHOULD HEAR IT? AND WHEN SHOULD THEY HEAR IT? THOSE ARE THE KEY QUESTIONS. AND LET ME ASSURE YOU THAT WE IN PUBLIC HEALTH AND IN THE FEDERAL GOVERNMENT LOOK TO YOU -- NOT TO OURSELVES -- FOR ANSWERS. -5- MAY I, HOWEVER, BE PERMITTED A PERSONAL STATEMENT? BEFORE AIDS EDUCATION BEGINS, A CHILD SHOULD BE GIVEN INFORMATION RELATIVE TO HIS OR HER OWN SEXUALITY. AND INSTEAD OF CALLING IT “SEX EDUCATION,” I’D LIKE IT CALLED SOMETHING LIKE “STUDIES IN HUMAN DEVELOPMENT.” I THINK CHILDREN SHOULD BE LEARNING ALL ABOUT THEMSELVES. - -THEIR UNBELIEVABLE COMPLEXITY, AND ESPECIALLY OF THEIR OWN GREAT VALUE. IF THEY ARE PROPERLY TAUGHT THEIR OWN WORTH, WE CAN EXPECT THEM TO TREAT THEMSELVES. . -AND OTHERS. - -WITH GREAT RESPECT. HUMAN DEVELOPMENT INSTRUCTION SHOULD KEEP PACE WITH -- AND NOT ANTICIPATE -- THEIR INDIVIDUAL DEVELOPMENT AND CURIOSITY AND I BELIEVE SUCH INFORMATION CAN BE TAUGHT AS LOVING, CARING, KIND, AND CONSIDERATE RELATIONSHIPS IN THE CONTEXT OF THE FAMILY. IT NEED NOT, AND SHOULD NOT, BE FRIGHTENING AND THREATENING. EDUCATION IN THIS COUNTRY HAS BEEN AND MUST CONTINUE TO BE A CONCERN AND RESPONSIBILITY OF STATES AND COMMUNITIES. WHAT I OFFER YOU TODAY -- I SINCERELY HOPE -- IS INFORMATION FOR YOUR GUIDANCE. WHAT YOU DO WITH IT IS ~~ LITERALLY AND LEGALLY -- YOUR BUSINESS. -6§- THE FEDERAL ROLE, HOWEVER, IS IMPORTANT AS FAR AS GETTING FACTUAL, SCIENTIFICALLY ACCURATE INFORMATION INTO THE HANDS OF YOUR TEACHING STAFFS. AND 1 CAN TELL YOU THAT THIS YEAR THE PUBLIC HEALTH SERVICE IS INVESTING OVER 200 MILLION DOLLARS IN JUST SUCH AN ACTIVITY: GETTING YOU THE FACTS. IN THE FOREWORD TO OUR OVERALL EDUCATION PLANNING DOCUMENT, WHICH IS AVAILABLE TO ANYBODY WHO REQUESTS IT. OUR SECRETARY, DR- OTIS BOWEN EXPRESSLY SAYS THAT. - - “ANY HEALTH INFORMATION DEVELOPED BY THE FEDERAL GOVERNMENT THAT WILL BE USED FOR EDUCATION SHOULD ENCOURAGE RESPONSIBLE SEXUAL BEHAVIOR -~ BASED ON FIDELITY, COMMITMENT, AND MATURITY, AND PLACING SEXUALITY WITHIN THE CONTEXT OF MARRIAGE.” HE GOES ON TO SAY THAT SUCH INFORMATION “PROVIDED BY THE FEDERAL GOVERNMENT” FOR SCHOOLS “SHOULD TEACH THAT CHILDREN SHOULD NOT ENGAGE IN SEX” AND THAT SUCH INFORMATION “SHOULD BE USED WITH THE CONSENT AND INVOLVEMENT OF PARENTS.” I THOROUGHLY AGREE WITH SECRETARY BOWEN. AND I HOPE YOU DO, 100 -7J- BUT I’VE SAID IT ANOTHER WAY- I BELIEVE CHILDREN SHOULD BE TAUGHT TO BE ABSTINENT UNTIL THEY GROW UP, ASSUME THE ROLE OF A RESPONSIBLE ADULT, AND FIND A MUTUALLY MONOGAMOUS RELATIONSHIP. THAT DOESN’T SEEM TO BE 100 FAR-FETCHED. IN FACT, IT WAS ONCE THE NORM FOR THIS COUNTRY AND A RETURN TO SUCH A NORM WOULD INSURE THE END OF SEXUALLY TRANSMITTED AIDS- CONTINUING WITH OUR EDUCATION PLAN, WE ALSO WANT TO ESTABLISH COOPERATIVE AGREEMENTS WITH STATE EDUCATION DEPARTMENTS AND LOCAL SCHOOL DISTRICTS TO SUPPORT THEIR EFFORTS IN MOUNTING PROGRAMS TO THAT TEACH ABOUT AIDS. THE PAPERWORK FOR THAT PROGRAM IS MOVING THROUGH THE BUREAUCRACY EVEN AS I SPEAK- THE ENCOURAGING THING ABOUT AIDS EDUCATION IS THAT THIS IS AN AREA WHERE SCIENCE AND MORALITY ARE WALKING THE VERY SAME PATH TOWARDS THE CONTAINMENT OF THE EPIDEMIC. FROM A PUBLIC HEALTH POINT OF VIEW, THE BEST DEFENSE AGAINST AIDS IS TOTAL ABSTINENCE. AND THAT IS CERTAINLY THE MESSAGE WE SHOULD GET ACROSS TO QUR CHILDREN, AIDS OR NO AIDS. -8- AND DR- BOWEN HAS MADE IT QUITE CLEAR THAT HIS DEPARTMENT PERCEIVES EDUCATION AS AN ACTIVITY THAT IS “LOCALLY DETERMINED” AND “CONSISTENT WITH PARENTAL VALUES” EXPRESSED WITHIN EACH COMMUNITY. I] HAVE ALWAYS FELT THAT SEX EDUCATION WAS PRIMARILY A JOB FOR PARENTS. THEY‘RE THE ONES WHO SHOULD BE THE TEACHERS OF SEXUALITY AND HUMAN RELATIONS TO THE CHILDREN OF THIS COUNTRY. IF ONE SET OF PARENTS TEACHES THEIR CHILD WITH THE SAME SET OF VALUES AND GOALS THAT ANOTHER SET OF PARENTS USES WITH THEIR CHILD, - THATS REINFORCEMENT. IF THE SCHOOLS FURTHER REINFORCE THAT TEACHING WE COULD HAVE THE NEXT GENERATION OF ADOLESCENTS REMAINING ABSTINENT UNTIL MONOGAMOUS . WHEN I WAS IN PRACTICE PARENTS AGREED THAT SUCH EDUCATION WAS THEIR RESPONSIBILITY. BUT I KNOW THAT MOST PARENTS EITHER COULD NOT OR WOULD NOT DO IT- WE NEED COMMUNITY COALITIONS THAT CAN TEACH PARENTS T0 FACE TEACHING THEIR CHILDREN COMFORTABLY - SOME OF YOU WILL FACE PROBLEMS OF THE DISPROPORTIONATE NUMBERS OF AIDS PATIENTS AMONG SOME MINORITIES. -9- BLACKS MAKE UP 12% OF THE POPULATION BUT 24% OF AIDS PATIENTS ARE BLACK - WITH HISPANICS IT IS 14% OF AIDS BUT 7% OF THE POPULATION. THE SPREAD OF AIDS IN THESE ETHNIC GROUPS IS LARGELY THRU IV DRUG ABUSE BUT ALSO SEXUALLY TO PARTNERS OF IV DRUG ABUSERS. I KNOW, TOO, THAT IN SOME PARTS OF URBAN AMERICA THE TASK IS COMPLICATED BY THE FACT THAT YOUR JUVENILE CHARGES COME FROM SETTINGS WHERE OLDER SIBLINGS AND OTHERS WITH WHOM THEY LIVE ARE DISADVANTAGED, WITH LOW SOCIOECONOMIC STATUS, LOW EDUCATIONAL LEVEL, A SENSE OF POWERLESSNESS AND HELPLESSNESS, ARE UNEMPLOYED AND PERHAPS ABUSING DRUGS. FROM THE POINT OF VIEW OF AIDS PREVENTION SUCH ENVIRONMENTS PRESENT US WITH THE GREATEST CHALLENGE AND WE ARE ATTEMPTING TO FIND INNOVATIVE AND CREATIVE WAYS OF EDUCATION THAT MIGHT BE EFFECTIVE- HAVING SAID ALL OF THAT WHAT CAN ELEMENTARY SCHOOLS UNIQUELY CONTRIBUTE TO AIDS EDUCATION? -10- FIRST, YOU HAVE CHARGE OF THE CHILDREN WHEN THEY ARE CURIOUS ABOUT SEX, BUT BEFORE THEY ARE PERSONALLY INVOLVED. YOU CAN BUILD THE BASIC KNOWLEDGE ABOUT HUMAN DEVELOPMENT WITHIN A FRAMEWORK OF SOLID VALUES THAT ENHANCE FEELINGS OF SELF WORTH- I BELIEVE THAT SUCH BASIC EDUCATION CAN BEGIN AS EARLY AS THE THIRD GRADE, - AND WITH INNOVATIVE PROGRAMS, PERHAPS EARLIER - WITH SPECIFIC INFORMATION ABOUT AIDS PREVENTION BEGINNING AROUND THE FIFTH GRADE. THE TIMING WILL VARY DEPENDING ON THE TYPE OF COMMUNITY IN WHICH THE SCHOOL IS LOCATED- SECOND, IN ADDITION TO PREVENTING THE SPREAD OF AIDS YOU CAN HELP PREVENT THE 2 1/2 TO 5 MILLION PERSONS UNDER AGE 25 WHO CONTRACT OTHER SEXUALLY TRANSMITTED DISEASES FROM DOING SQ. THE SAME EDUCATION WOULD GO A LONG WAY TO PREVENTING OVER 1 MILLION TEENAGE PREGNANCIES EACH YEAR. -lji- ALCOHOL AND DRUG USE CAN BE PREVENTED. YOU SAY THESE ARE LARGE SOCIAL PROBLEMS THAT WERE AROUND BEFORE AIDS, WHAT CAN I DO ABOUT IT? YOU CAN, AS OPINION LEADERS, WORK WITH YOUR ADMINISTRATION, YOUR SCHOOL BOARD, YOUR COMMUNITY, - AND YES ITS DOCTORS AND CLERGY, - TO BRING TO ELEMENTARY SCHOOLS THE KIND OF HUMAN DEVELOPMENT EDUCATION THAT GIVES OUR CHILDREN A SET OF VALUES AND SKILLS THAT WILL FACILITATE THE RIGHT DECISIONS ABOUT THEIR SEXUALITY, ABOUT THEIR RELATIONSHIP WITH DRUGS AND ALCOHOL - IT IS GOOD TO TEACH CHILDREN TO SAY NO TO EXTRA-MARITAL SEX AND DRUGS, BUT YOU CAN’T DO IT UNLESS YOU MAKE SURE THEY KNOW WHY TO SAY NO AND HOW TO SAY NO AND HAVE THE POSITIVE SELF IMAGE TO BE MOTIVATED TO SAY NO- IT CAN BE DONE AND YOU ARE THE LEADERS T0 DO IT-