Bows PATE &'OS WO TIME FOR IGNORANCE THE AIDS CRISIS BY C, EVERETT KOOP, M.D.. SC.D. OF THE U.S, PUBLIC HEALTH SERVICE PRESENTED TO THE ST, FRANCIS CENTER WASHINGTON, D.C. OCTOBER 21, 1987 FIRST...A LITTLE HISTORY, ALMOST SIX YEARS AGO, IN JUNE 1981, THE PUBLIC HEALTH SERVICE PUBLISHED THE FIRST REPORTS OF FIVE CASES OF PNEUMOCYSTIS CARINIL PNEUMONIA IN LOS ANGELES, NOW, FIVE CASES AREN’T MUCH,..BUT THIS LETHAL DISEASE IS SO RARE THAT A HANDFUL OF CASES IN A SINGLE YEAR IS LIKE AN EPIDEMIC, SOON, THERE WERE SIMILAR REPORTS TRICKLING IN FROM OTHER CITIES AS WELL, THEN, A MONTH LATER, WE PUBLISHED A REPORT THAT 26 YOUNG MEN HAD BEEN RECENTLY DIAGNOSED AS HAVING KAPOSI’S SARCOMA, “AN UNCOMMONLY REPORTED MALIGNANCY” USUALLY FOUND -- IF AT ALL -- AMONG ELDERLY MEN. THESE 26 YOUNG MEN, LIKE THOSE FIRST 5 IN LOS ANGELES WITH PNEUMOCYSTIS. WERE YOUNG HOMOSEXUALS, AND, IN THAT SAME JULY ISSUE. THE EDITOR PUBLISHED 10 NEW REPORTS OF PNEUMOCYSTIS...AND ALL OF THEM INVOLVED YOUNG HOMOSEXUALS, ALSO. PUBLIC HEALTH INVESTIGATORS THEN REPORTED THAT PEOPLE WERE NOT ONLY SICK WITH THESE VERY DANGEROUS DISEASES... THEY WERE DYING OF THEM, FOR SOME MYSTERIOUS REASON, THEIR BODIES WERE NOT FIGHTING BACK. APPARENTLY THESE VICTIMS HAD ACQUIRED SOME KIND OF “BUG” -- A VIRUS. MOST LIKELY -- THAT ATTACKED AND DESTROYED THEIR NATURAL IMMUNE SYSTEMS, MEDICINE HAD NEVER COME UPON A SYNDROME QUITE LIKE IT BEFORE. WE GAVE IT A LONG TITLE: THE “ACQUIRED IMMUNE DEFICIENCY SYNDROME.” BUT WE SOON SETTLED JUST FOR THE INITIALS - A.I.D.S. - OR “AIDS”. AND IT'S BEEN AIDS EVER SINCE. YOUVE READ THE STORIES AND HAVE SEEN IT ON TELEVISION, 1°M SURE, SO I WON’T GO THROUGH THE WHOLE HISTORY ALL OVER AGAIN. INSTEAD, I’LL JUST TOUCH ON A FEW KEY POINTS: FIRST OF ALL, WE’RE TALKING ABOUT A DISEASE THAT IS SPREADING AND IS FATAL. IT NOW TAKES A LITTLE OVER A YEAR IN THE U.S, FOR THE NUMBER OF CASES TO DOUBLE, FOR EXAMPLE, AT THE END OF 1985, WE HAD A CUMULATIVE TOTAL OF ABOUT 19,000 REPORTED CASES, TODAY THE TOTAL NUMBER OF AIDS VICTIMS IS CLOSE 10 43,000. | 25,000 OF THEM HAVE ALREADY DIED OF THE DISEASE...AND THE REST PROBABLY WILL. BY THE END OF 1990 THE CUMULATIVE TOTAL WILL BE OVER A QUAR ON. 170,000 WILL HAVE DIED -- 54,000 IN 1991, SECOND POINT: EVEN THOUGH SCIENTISTS HAVE HAD A LOOK AT THE AIDS VIRUS, WE STILL DON’T KNOW PRECISELY WHAT IT IS. IN 1984, THE SEARCH WAS NARROWED DOWN TO SOMETHING CALLED A “HUMAN RETROVIRUS.” THE SCIENTISTS AT THE NATIONAL CANCER INSTITUTE WERE EVEN ABLE TO PIN-POINT A SPECIFIC ONE. THEY CALLED IT THE "HUMAN T-CELL LYMPHOTROPIC VIRUS TYPE III,” OR SIMPLY “HTLV-II1.” THE SAMZ VIRUS SHOWED UP IN THE WORK OF THE PASTEUR INSTITUTE, WHERE IT BECAME KNOWN AS THE "LYMPHADENOPHATHY- ASSOCIATED VIRUS,” OR mUAV,"” SCIENTISTS NOW AGREE TO CALL IT BY THE SINGLE COMMON NAME OF “HUMAN IMMUNODEFICIENCY VIRUS", OR "HAV." THE ABILITY TO RECOGNIZE THE VIRUS WAS A VERY IMPORTANT DEVELOPMENT. ONCE YOU KNOW WHERE THE AIDS VIRUS IS, YOU CAN THEN RECOGNIZE THE PRESENCE OF ANTIBODIES SPECIFIC TO IT. OF COURSE, THOSE ANTIBODIES AREN’T VERY EFFECTIVE, BUT THEY'RE PRESENT NEVERTHELESS. AS OF 1985 WE'VE HAD A TEST THAT CAN DETECT THE PRESENCE OF THESE ANTIBODIES IN A PERSON’S BLOODSTREAM, BEFORE THE TEST WAS DEVELOPED, THE AIDS ANTIBODIES WERE TURNING UP IN ABOUT 4 OR 5 UNITS OF BLOOD PER 10,000 UNITS, NOW, SINCE BLOOD SCREENING WAS BEGUN, THAT FIGURE HAS SETTLED AT BETWEEN 4 AND 10 PER 1 MILLION UNITS OF TRANSFUSED BLOOD. AND, AS YOU KNOW, 1’M SURE, THAT'S AS CLOSE TO PERFECT AS YOU CAN GET IN THIS KIND OF SERVICE. ON THE BASIS OF SUCH TESTING, PLUS OTHER EPIDEMIOLOGICAL DATA, WE THINK THERE ARE BETWEEN A MILLION AND A MILLION-AND-A- HALF AMERICANS WALKING AROUND WITH THE AIDS VIRUS IN THEIR SYSTEMS, ALTHOUGH. HONESTLY, IT COULD BE 400,000 TO 4 MILLION. THEY HAVE THE VIRUS...BUT THEY AREN’T YET SICK WITH AN AIDS- RELATED DISEASE. SUCH AS PNEUMOCYSTIS CARINII PNEUMONIA OR KAPOSI’S SARCOMA OR ANY OTHER OPPORTUNISTIC INFECTION. ONE MAJOR COMPLICATION FOR MAKING ESTIMATES FOR THE FUTURE IS THE LENGTH OF THE INCUBATION PERIOD. IT CHANGES. APPARENTLY IT CAN BE ANYWHERE FROM A YEAR OR SO IN SOME PEOPLE TO 10 YEARS IN OTHERS, SO WE STILL CAN’T PREDICT WHICH PERSON CARRYING THE AIDS VIRUS WILL OR WILL NOT GET AN AIDS-RELATED DISEASE. BUT IT’S NOT A 50-50 RISK. THE ODDS ARE WORSE THAN THAT, THE POSSIBILITY OF BEING OVERCOME BY AN INFECTIOUS DISEASE OF SOME KIND IS VERY, VERY HIGH. IN FACT, SOME RESEARCHERS NOW FEEL THAT ANYONE WITH THE AIDS VIRUS WILL EVENTUALLY CONTRACT AN AIDS- RELATED DISEASE IF HE LIVES LONG ENOUGH...AND WILL DIE FROM IT. THERE’S OTHER RESEARCH GOING ON AS WELL, IN THE AREA OF DRUG THERAPY AND VACCINE DEVELOPMENT. IN FACT, RESEARCH NOW COMMANDS ABOUT 317 MILLION IN U.S, FEDERAL FUNDS THIS YEAR, PLUS MANY MILLIONS MORE IN STATE AND PRIVATE SECTOR FUNDS. NEXT YEAR ~ RESEARCH FUNDING WILL BE 413 MILLION OUT OF A TOTAL FEDERAL AIDS EXPENDITURE OF 71 BILLION, ONE NEW EXPERIMENTAL DRUG -- AZIDOTHYMIDINE. OR A.Z.1. -- HAS GONE THROUGH A SO-CALLED “FAST-TRACK” APPROVAL PROCESS AND IS NOW BEING USED TO PROLONG THE LIVES OF AIDS VICTIMS DYING OF PNEUMOCYSTIS CARINII PNEUMONIA, BUT I’M AFRAID THAT’S ALL A.Z.T. DOES...17 PROLONGS SOME LIVES, IT DOES NOT SAVE THEM. FOR SAVING LIVES, WE NEED A VACCINE. AND EVERYBODY WANTS TO KNOW WHEN AN EFFECTIVE VACCINE MIGHT BE AVAILABLE, 1 HAVE TO TELL THEM THAT I DON’T SEE ONE IN THE NEAR FUTURE. 10 NATURALLY, WE’RE MOVING AHEAD ON THIS FRONT AS QUICKLY AS WE CAN, BUT. AS YOU KNOW, VACCINE DEVELOPMENT IS ONE THING THAT CANNOT BE RUSHED WITHOUT CREATING MORE PROBLEMS THAN WE ALREADY HAVE. WE NEED TO REMEMBER, FOR EXAMPLE, THAT IT TOOK 17 YEARS T0 DEVELOP THE HEPATITIS B VACCINE...AND THAT WAS A COMPARATIVELY EASY VIRUS TO UNDERSTAND. NOW FOR MY THIRD POINT: WE DON’T KNOW VERY MUCH ABOUT AIDS,..BUT WE DO KNOW -- WITH COMPLETE CERTAINTY -- THAT THE AIDS VIRUS TENDS TO CONCENTRATE IN BODY FLUIDS WHICH ALSO CARRY LARGE CONCENTRATIONS OF INFECTED LYMPHOCYTES, | 1] IN MOST BODY FLUIDS -- SUCH AS TEARS, SALIVA, AND PERSPIRATION, FOR EXAMPLE -- THE VIRUS PARTICLE COUNT IS VERY LOW OR ABSENT ALTOGETHER. ON THE OTHER HAND, LARGE NUMBERS OF VIRUS PARTICLES ARE FOUND IN BLOOD AND SEMEN, THIS IS ONE OF THE MOST IMPORTANT PIECES OF INFORMATION WE HAVE SO FAR. IT EXPLAINS, FOR EXAMPLE, WHY THE INITIAL ALARM ABOUT AIDS WAS SOUNDED AMONG HOMOSEXUALS AND BISEXUAL MEN, SOME SEX PRACTICES AMONG THESE MEN NOT ONLY PRODUCE SEMEN BUT MAY ALSO CAUSE SOME BLEEDING. AND, AGAIN, BLOOD AND SEMEN ARE THE ONLY TWO-BODY FLUIDS THAT CARRY -- AND TRANSMIT -- H1GH ENOUGH CONCENTRATIONS OF THE LIVE AIDS VIRUS. 12 THE BIOPHYSICAL PECULIARITIES OF THE AIDS VIRUS ALSO EXPLAIN WHY 25 PERCENT OF ALL AIDS CASES ARE INTRAVENOUS DRUG ABUSERS WHO USE CONTAMINATED NEEDLES AND OTHER PARAPHERNALIA THEY‘VE BORROWED EROM OTHER ADDICTS WHO HAVE AIDS. THIS GROUP INCLUDES DRUG ABUSERS WHO ARE HOMOSEXUALS, ALSO. WHEN WE FIRST BEGAN TO CONFRONT THE AIDS EPIDEMIC, THE PEOPLE AT HIGHEST RISK WERE EITHER HOMOSEXUALS AND BISEXUAL MEN AND 1.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 1.V, DRUG ABUSERS. IN FACT, THEIR HETEROSEXUAL ACTIVITY SEEMS 10 BE THEIR ONLY RISK FACTOR, 13 AS OF LAST WEEK, 4 PERCENT OF ALL REPORTED AIDS CASES IN THE U.S. WERE OF SUCH HETEROSEXUAL MEN AND WOMEN...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. SQ THE DEMOGRAPHY OF THIS DISEASE IS BECOMING AS COMPLEX AS THE DISEASE ITSELF. 14 AND THAT LEADS ME TO MY FOURTH POINT: 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 NOTICEABLY SHARP DROP IN THE NUMBERS OF MEN TAKING PART IN WHOLESALE. ANONYMOUS, PROMISCUOUS SEX. 15 AS A RESULT, A DECLINE IS ALREADY OCCURRING IN THE INCIDENCE OF OTHER SEXUALLY TRANSMITTED DISEASES AMONG HOMOSEXUAL MEN, SUCH AS GONORRHEA. HEPATITIS B.. AND SYPHILIS. LAST MONTH FOR THE FIRST TIME THERE WAS A DROP IN THE INCIDENCE OF AIDS IN HOMOSEXUALS. BUT NOW WE NEED TO DIRECT OUR INFORMATION AND EDUCATION EFFORTS OUT TO HETEROSEXUAL MEN AND WOMEN...WHICH IS TO SAY, 10 SOCIETY AT LARGE, THAT WAS THE BASIS FOR THE SURGEON GENERAL'S REPORT ON AIDS. WHICH I RELEASED LAST OCTOBER. LET ME TAKE JUST A MINUTE HERE TO EXPLAIN HOW THAT REPORT CAME ABOUT. 16 EARLY IN FEBRUARY 1986, PRESIDENT REAGAN INSTRUCTED ME TO PULL TOGETHER EVERYTHING WE KNEW ABOUT AIDS AND PUT IT INTO A PLAIN-ENGLISH REPORT TO THE AMERICAN PEOPLE. THE PRESIDENT WAS CONCERNED THAT THERE WAS STILL TOO MUCH CONFUSION AMONG THE AMERICAN PEOPLE ABOUT THE NATURE OF THIS THREAT TO PUBLIC HEALTH. HE ASKED ME TO DO WHAT { COULD TO SET THE RECORD STRAIGHT AND I RELEASED THE REPORT TO THE AMERICAN PEOPLE ON OCTOBER 22, 1986. 1 WANT TO ASSURE YOU THAT AT NO TIME HAVE I HAD ANY MISGIVINGS ABOUT ANYTHING I WROTE. 17 THERE 1S MUCH SCIENTIFIC AND PUBLIC HEALTH INFORMATION IN THAT REPORT, BUT ON THE BEHAVIORAL SIDE, THERE WERE JUST THREE MESSAGES THAT ARE VITALLY IMPORTANT : IT SAYS THAT THE BEST THE FIRST MESSAGE 1S SIMPLE ENOUGH. OM SEXUAL RELATIONS. DEFENSE AGAINST AIDS IS TOTAL ABSTINENCE FR 1 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: 18 FIND SOMEONE WHO 1S 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 1S 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 1S CARRYING THE AIDS VIRUS, YOU MUST USE CAUTION. EROM 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, 19 AND, WHEN YOU CONSIDER THE LONG INCUBATION PERIOD FOR THE AIDS VIRUS, WE’RE TALKING ABOUT THAT PERSON'S HISTORY OF SEXUAL RELATIONS GOING BACK 5 YEARS OR PERHAPS LONGER -- IF YOU DON’T LISTEN TO THOSE 2 GOOD HEALTH MESSAGES AND IF YOU DO 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. A SPERMICIDE -- NONOXINOL 9 -- ADDS FURTHER PROTECTION. 20 THEN THERE IS THE ISSUE OF “INDIVIDUAL PRIVACY VERSUS THE NEED TO PROTECT THE COMMUNITY FROM DANGER.” J DON’T BELIEVE EITHER SIDE OF THIS QUESTION REQUIRES AN ABSOLUTE RESPONSE. BUT HOW MUCH LEEWAY DO WE REALLY HAVE, AS A FREE BUT RESPONSIBLE PEOPLE? HOW MUCH RISK CAN THE COMMUNITY REALLY TOLERATE IN ORDER TO PRESERVE THE RIGHTS OF EACH INDIVIDUAL WITHIN THAT COMMUNITY? IT SEEMS TO ME THAT THIS IS THE HEART OF THE DEBATE OVER CONFIDENTIALITY IN RECORDS. AS MANY OF YOU KNOW, IT’S BEEN A LONG-STANDING PRACTICE IN PUBLIC HEALTH TO GET AS MUCH SENSITIVE. HEALTH-RELATED INFORMATION AS POSSIBLE FROM THE INDIVIDUAL. IN EXCHANGE, WE ROUTINELY GUARANTEE CONFIDENTIALITY. 21 WITHOUT SUCH A SYSTEM, WE WOULD NEVER HAVE SUCCEEDED IN CONTAINING MOST INFECTIOUS DISEASES, AS WE HAVE DONE, BUT NO PREVIOUS DISEASE HAS BEEN AT ONCE SO MYSTERLOUS, SO FATAL, AND SO RESISTANT TO THERAPY AND VACCINE DEVELOPMENT. NEARLY ALL PUBLIC HEALTH PROFESSIONALS WITH WHOM I'VE DISCUSSED THIS MATTER 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. BUT IS TOTAL-CONFIDENTIALITY EVEN POSSIBLE? 22 IF, FOR EXAMPLE, A HEMOPHILIAC CHILD BECOMES HIV POSITIVE. NATURALLY, THE PARENTS SHOULD BE TOLD IF THEIR CHILD IS SERO-POSITIVE. AND THE FAMILY PHYSICIAN, ALSO, IF THERE IS ONE. BUT SHOULD THE SCHOOL BE TOLD? SHOULD THE CHILD’S RELIGIOUS CONGREGATION BE TOLD? HOW MUCH OF THE PUBLIC REALLY HAS A “NEED TO KNOW” WHETHER OR NOT THE CHILD VICTIM 1S SERO-POSITIVE? I MAINTAIN THAT THE ISSUE OF CONFIDENTIALITY WOULD NEVER HAVE COME UP. HAD IT NOT BEEN FOR A NUMBER OF INSTANCES IN WHICH PERSONS KNOWN TO HAVE AIDS HAVE BEEN FIRED FROM THEIR JOBS, . HAVE BEEN SENT HOME FROM SCHOOL...AND SO ON. 23 THESE REACTIONS HAVE BEEN IRRATIONAL, UNFAIR, AND DISCRIMINATORY, WHAT SHOULD WE DO ABOUT 1T? HOW SHOULD WE DEAL WITH THESE INCLINATIONS TOWARD DISCRIMINATION? SOME PEOPLE ARGUE THAT IT IS NOT DISCRIMINATORY 10 DENY HOUSING OR MEDICAL CARE OR ANY OTHER ESSENTIAL SERVICE TO A PERSON WHO CONTRACTED AIDS WHILE SHOOTING DRUGS OR ENGAGING IN SODOMY. BUT AMERICAN PUBLIC POLICY OVER THE PAST CENTURY HAS ALWAYS BEEN IN THE DIRECTION OF REDUCING -- OR ELIMINATING ALTOGETHER -- ANY ELIGIBILITY CRITERIA TO RECEIVE ESSENTIAL PUBLIC SERVICES, SHOULD AIDS BE THE EXCEPTION? AND WHY? 24 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. HOW TRAGIC FOR THEM. AND HOW TRAGIC FOR AMERICA. THE UNITED STATES IS ONLY NOW EMERGING FROM TWO DECADES OF TURMOIL, DURING WHICH WE HAVE TRIED TO CORRECT THE SOCIAL INJUSTICES OF THE PAST, WE HAVE FINALLY EXTENDED TO ALL AMERICANS -- REGARDLESS OF RACE, COLOR. CREED. ETHNIC ORIGIN. RELIGIOUS, AGE, OR SEX -- THE BIRTHRIGHT OF FREEDOM THAT IS THEIRS. 25 WILL THE DISEASE OF AIDS -- ALL BY ITSELF -- REVERSE THIS TREND IN OUR NATION’S 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, IT'S APPROPRIATE TO ASK THAT QUESTION OF OUR GOVERNMENT. BUT WE CANNOT STOP THERE. WE NEED TO MAKE SURE THAT EVERY AMERICAN UNDERSTANDS JUST WHAT IS AT STAKE HERE AND THAT HE OR SHE WILL DO WHATEVER IS NECESSARY TO MAKE SURE THAT OUR COUNTRY NEVER RETURNS IN FEAR AND HATRED TO THE WAYS OF A SHAMEFUL PAST. 26 AS THE PRESIDENT HAS SAID, WE MUST COME TOGETHER AND FIGHT THIS DISEASE WITH EVERYTHING AT OUR COMMAND. BUT WE MUST NOT BE THE ENEMIES OF THE PEOPLE WHO HAVE IT. BUT ARE WE TRULY MATURE ENOUGH A SOCIETY TO REMAIN COLOR- BLIND IN THIS WAR AGAINST AIDS? HOW DO WE KNOW? THESE AND OTHER ISSUES LIE ON THE HORIZON BEFORE US. BUT THE HORIZON 1S NOT THAT FAR AWAY, 1 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 TO BE. 27 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...NOT SCIENCE ALONE... CAN TRIUMPH OVER DISEASE, A CONCLUDING WORD ABOUT THE INTERNATIONAL SCENE, NOT ONLY AS YOUR SURGEON GENERAL, BUT ALSO IN MY ROLE AS DIRECTOR OF THE P.H.S, OFFICE OF INTERNATIONAL HEALTH, I HAVE VISITED OVERSEAS MANY TIMES AND I AM CONSTANTLY REMINDED OF THE EXTENT TO WHICH THE UNITED STATES IS REGARDED AS A BEACON OF GOOD SENSE AND GOOD SCIENCE BY THE REST OF THE WORLD, AND THE OTHER NATIONS OF THE WORLD SORELY NEED US...AS, INDEED. WE NEED THEM, ALSO, IN OUR COLLECTIVE AND CONTINUING BATTLE AGAINST DISEASE. THIS IS ESPECIALLY EVIDENT IN REFERENCE TO THE WORLD PANDEMIC OF THE ACQUIRED IMMUNE DEFICIENCY SYNDROME. OR “AIDS.” 28 AS OF AUGUST, THE REPORTED AIDS CASE-LOAD IN COUNTRIES OTHER THAN THE UNITED STATES HAD REACHED 14,600, IT’S FAIR TO SAY THAT THIS FIGURE IS WELL BELOW WHAT THE TRUE FIGURE MIGHT BE, SINCE AIDS IS VERY UNDER-REPORTED., FOR INSTANCE, ABOUT 17 COUNTRIES IN AFRICA REPORT EITHER 1 CASE OR NO CASES AT ALL. WHILE OTHER COUNTRIES -- SOME SHARING COMMON BORDERS -- REPORT 300,..700,..AND 1,100 CASES OF AIDS. | W.H.0, SAYS, HOWEVER, THAT THE NUMBERS ARE CLIMBING STEEPLY AND THAT. OVER THE NEXT 5 YEARS, THE WORLD COULD ADD ANYWHERE FROM ANOTHER HALF-MILLION TO ANOTHER 3 MILLION NEW CASES OF AIDS, 1 SHOULD ADD THAT THIS IS ONE MAJOR REASON WHY THE PRESIDENT HAS ASKED THE CONGRESS TO APPROPRIATE THE FULL U.S. CONTRIBUTION TO THE UNITED NATIONS, AND ESPECIALLY TO THE WORLD HEALTH ORGANIZATION, 29 DISEASE KNOWS NOT BORDERS, IN FACT, IT WOULD APPEAR THAT THE DISEASE OF AIDS ITSELF MAY HAVE COME TO THESE SHORES FROM AFRICA BY WAY OF THE CARIBBEAN, WHETHER THAT'S THE WAY IT HAPPENED OR NOT, WE WILL NEVER FULLY CONTAIN THE DISEASE HERE IN THE UNITED STATES, AS LONG AS IT IS NOT ALSO CONTAINED ELSEWHERE IN THE WORLD. AND THAT TAKES MONEY, IT WILL BE TERRIBLY SELF-DEFEATING, IF THE UNITED STATES DOES NOT PAY ITS FULL ASSESSMENT TO THE UNITED NATIONS AND THUS, WILL NOT ENABLE THE WORLD HEALTH ORGANIZATION TO BE AN EFFECTIVE WORLD LEADER IN THE FIGHT AGAINST AIDS. 30 WE MUST STAND TOGETHER IN THE FIGHT AGAINST AIDS WITH ALL OUR NEIGHBORS ON THIS TINY PLANET.: AIDS IS CERTAINLY A PERSONAL TRAGEDY FOR EVERYONE WHO IS INFECTED. BUT IT’S ALSO A TRAGEDY FOR HUMANITY ITSELF. J BELIEVE THAT THE UNITED STATES MUST BE A FULL PARTNER WITH ALL OTHER COUNTRIES, IN THIS FIGHT AGAINST AIDS, THAT’S A MORAL CHOICE THAT WE MUST MAKE, IT MUST NOT BE DECIDED BY EITHER POLITICS OR ECONOMICS, OUR ONLY HOPE AS A NATION -- INDEED AS A CIVILIZATION -- IS THAT WE ALL DO OUR PART TO STOP THE SPREAD OF AIDS... THAT WE WILL PROTECT AND SAVE THE LIVES OF PEOPLE AT RISK. THAT’S A TALL ORDER? -- AND THERE ARE MANY SAYING IT CAN‘T BE DONE, | 31 BUT, THEY'RE WRONG. 1 THINK WE WILL EVENTUALLY AGREE ON THE TASKS THAT REALLY MATTER -- AND GET THEM DONE. MY PERSONAL HOPE IS THAT I’LL STILL BE AVAILABLE TO HELP! THANK YOU,