ORIGINAL

 

Arps AND AMERICAN VALUES

By
C, Everett Koop, MD, ScD
SURGEON GENERAL
OF THE
U. S, PupLic HEALTH SERVICE
U, S, DEPARTMENT OF HEALTH AND HUMAN SERVICES

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PRESENTED TO THE Cosmos CLUB

a

WASHINGTON, D.C,
Octosper 19, 1987
(GREETINGS TO HOSTS, FRIENDS, COLLEAGUES, ETC.)

I’M SURE YOU’VE HEARD A GREAT DEAL ABOUT THE EPIDEMIC OF AIDS
SO FAR -- ESPECIALLY THE BIOMEDICAL INFORMATION -- SO I HAVE CHOSEN
TO SPEND THE NEXT FEW MOMENTS SHARING WITH YOU A NUMBER OF OTHER,
NON-MEDICAL CONCERNS THAT HAVE BEEN BROUGHT TO MY ATTENTION, AS I
HAVE TRAVELED ABOUT THIS COUNTRY AND ALSO OVERSEAS.

FIRST, LET ME EMPHASIZE THAT THE THREE ASPECTS OF AIDS THAT
COLOR EVERYTHING DONE AND SAID ABOUT THE DISEASE ARE...ONE, THAT IT
1S STILL A MYSTERY...TWO, THAT IT 1S FATAL...AND THREE, THAT YOU GET
AIDS CHIEFLY BY DOING THINGS THAT THE MAJORITY OF PEOPLE DON'T DO

AND DON'T LIKE.
THESE THREE ASPECTS OF THE AIDS EPIDEMIC PRESENT THE PEOPLE OF
THE UNITED STATES WITH AN EXTREMELY DIFFICULT AND COMPLEX TEST OF
OUR NATIONAL CHARACTER. IN SOME WAYS THE SCIENTIFIC ISSUES PALE IN
COMPARISON TO THE HIGHLY SENSITIVE ISSUES OF LAW, ETHICS, ECONOMICS,
MORALITY, AND SOCIAL COHESION THAT ARE BEGINNING TO SURFACE.

[ BELIEVE WE’RE ALREADY AT A SENSITIVE STAGE CONCERNING THE
ETHICAL FOUNDATION OF HEALTH CARE ITSELF,

DESPITE THE SENSIBLE AND RATHER ELEMENTARY GUIDELINES FROM
C.D.C. TO THE HEALTH PROFESSIONS, WE STILL HEAR -- EVERY DAY -- OF
PHYSICIANS, DENTISTS, NURSES, AND OTHER HEALTH PERSONNEL WHO REFUSE
TO TREAT PERSONS WITH AIDS OR EVEN PERSONS WHOM THEY SUSPECT OF
HAVING AIDS.
THEY ARE AFRAID OF CATCHING THE DISEASE THEMSELVES, THAT'S
CERTAINLY UNDERSTANDABLE, EQUALLY UNDERSTANDABLE IS THE FACT THAT

IT IS VERY UNLIKELY THAT A HEALTH WORKER WILL CATCH THE DISEASE AT
ALL.

THUS FAR, OF THE 5 MILLION PERSONS IN SOME KIND OF HEALTH WORK
IN THIS COUNTRY, ONLY 10 HAVE CONTRACTED AIDS ON THE JOB. IN ALMOST
EVERY CASE, THE INDIVIDUAL SIMPLY DID NOT FOLLOW THE ROUTINE
INSTRUCTIONS FOR SELF-PROTECTION THAT THE CENTERS FOR DISEASE
CONTROL PUBLISHED OVER A YEAR AGO,
LET ME QUICKLY ADD THAT THIS REJECTION OF AIDS PATIENTS IS NOT
CHARACTERISTIC OF THE HEALTH PROFESSIONALS BY ANY MEANS. ON THE
CONTRARY, THE OVERWHELMING MAJORITY OF MY COLLEAGUES HAVE PROVIDED
-- AND CONTINUE TO PROVIDE -- QUALITY, COMPASSIONATE CARE TO PERSONS
WITH EVERY KIND OF ILLNESS... INCLUDING AIDS,

BUT THE GOOD CONDUCT OF THE MAJORITY DOES NOT IN ANY WAY
RELEASE US FROM FACING THE UN-PROFESSIONAL CONDUCT OF A FEARFUL AND
IRRATIONAL MINORITY,

WHAT SHOULD WE DO ABOUT THAT? I SUBMIT THAT IT’S AN IMPORTANT
QUESTION, BECAUSE HEALTH CARE IN THIS COUNTRY HAS ALWAYS BEEN
PREDICATED ON THE ASSUMPTION THAT -- SOMEHOW -- EVERYONE WILL BE
CARED FOR AND NO ONE WILL BE TURNED AWAY.
AS A PHYSICIAN AND AN AMERICAN, I’M PROUD TO BE PART OF A
TRADITION OF CARE THAT WILL NOT ABANDON THE SICK AND THE DISABLED...
WHOEVER THEY ARE.

HENCE, THE REPORTS OF A FEW PHYSICIANS AND OTHERS WITHHOLDING
CARE FROM PERSONS WITH AIDS ARE, THEREFORE, EXTREMELY SERIOUS. SUCH
CONDUCT THREATENS THE VERY FABRIC OF HEALTH CARE IN THIS COUNTRY.

BUT THIS ISSUE HAS YET ANOTHER WRINKLE OR TWO,

I’M TOLD THAT THOSE HOSPITALS WITH NATIONAL REPUTATIONS FOR
PROVIDING CARE FOR AIDS PATIENTS ARE NOW BEING BY-PASSED BY MANY
MEDICAL AND NURSING STUDENTS LOOKING FOR A RESIDENCY, AN INTERNSHIP,
OR A PRACTICUM TO COMPLETE THEIR PROFESSIONAL TRAINING.
IN ADDITION, MANY NON-AIDS PATIENTS -- ESPECIALLY THOSE WITH
GOOD INSURANCE COVERAGE -- ARE ASKING THEIR PHYSICIANS TO CHECK THEM
INTO HOSPITALS THAT DO NOT HAVE MANY -- OR ANY -- AIDS PATIENTS,

I THINK THIS IS A SERIOUS MATTER BECAUSE THE ACTUAL DIRECT
IMPACT OF AIDS THUS FAR ON OUR HOSPITAL SYSTEM 1S QUITE SMALL... BUT
THIS INDIRECT IMPACT CAN BE QUITE LARGE,..DISPROPORTIONATELY SO. IT
TS AN IMPACT THAT COULD WELL LEAD TO THE DEVELOPMENT OF DE FACTO
MEDICAL GHETTOS FOR AIDS PATIENTS,

HOW CAN WE PREVENT THAT FROM HAPPENING? WE NEED SOME ANSWERS
BEFORE THIS DEADLY VIRUS FURTHER WEAKENS THE ETHICS OF MEDICAL
PRACTICE IN THE UNITED STATES,
A RELATED ISSUE IS THE COST OF CARE FOR AIDS PATIENTS, THOSE
COSTS ARE NOW RUNNING AT ABOUT $2 BILLION A YEAR. BY 1991, WE
ANTICIPATE THE ANNUAL BILL FOR PATIENT CARE FOR AIDS VICTIMS WILL
RANGE ANYWHERE FROM A LOW OF $8 BILLION TO A HIGH OF $16 BILLION,

WHO SHOULD PAY THAT?

RIGHT NOW, THE AMERICAN TAXPAYER IS COVERING ABOUT 25 PERCENT
OF THAT COST, POSSIBLY MORE. IS THAT FAIR?

AS YOU KNOW, WE HAVE A MIXED SYSTEM OF SUPPORT FOR HEALTH CARE
IN THIS COUNTRY: PRIVATE METHODS OF PAYMENT EXIST SIDE-BY-SIDE WITH
PUBLICLY SUPPORTED SYSTEMS OF REIMBURSEMENT FOR CARE.
THERE IS, HOWEVER, A CURIOUS TWIST TO THIS PARTICULAR QUESTION,

FOR EXAMPLE, THE AMERICAN TAXPAYER SUPPORTS MATERNAL AND CHILD
HEALTH PROGRAMS, AS WELL AS PROGRAMS FOR ALCOHOLICS, DRUG ADDICTS,
AND SYPHILITICS.

THOSE PROGRAMS AREN’T REALLY EXPENSIVE. IN ADDITION. THEY ARE
GEARED TO BRING -- OR BRING BACK -- MEN, WOMEN, AND CHILDREN TO A
STATE OF GOOD HEALTH.

BUT AIDS IS QUITE DIFFERENT, HEALTH AND MEDICAL CARE FOR AN
AIDS PATIENT 1S VERY EXPENSIVE, THE JOURNAL OF THE AMERICAN MEDICAL
ASSOCIATION JUST PUBLISHED A STUDY INDICATING THAT THE AVERAGE
INPATIENT COST PER AIDS PATIENT PER YEAR IS $20,320,
AND WHAT’S THE OUTCOME? AFTER CONSUMING THREE TO FOUR YEARS‘
WORTH OF COSTLY MEDICAL CARE AND SOCIAL SERVICES... THE AIDS PATIENT
DIES,

SO WE MUST ASK THIS QUESTION: AS THE AIDS CASE-LOAD CLIMBS AND
THE COSTS RISE, WILL THE AMERICAN PEOPLE CONTINUE TO SUPPORT SUCH
CARE? WILL THEY ASK FOR RELIEF? OR WILL THEY SUPPORT ONLY SECOND-
CLASS CARE FOR AIDS PATIENTS?

HOW SHOULD WE RESPOND TO THAT POSSIBILITY? IT’S A VERY
TROUBLING QUESTION FOR AMERICAN MEDICINE AND AMERICAN DOMESTIC
PUBLIC POLICY,
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ANOTHER ISSUE THAT HAS ARISEN QUITE FAST OVER THE PAST YEAR OR
SO 1S THE ISSUE OF INDIVIDUAL PRIVACY versus THE NEED TO PROTECT THE
COMMUNITY FROM DANGER.

 

NEITHER SIDE OF THIS EQUATION REQUIRES AN ABSOLUTE RESPONSE,
BUT HOW MUCH LEEWAY DO WE REALLY HAVE, AS A FREE YET RESPONSIBLE
PEOPLE?

ANOTHER WAY OF PUTTING THAT IS TO ASK, “HOW MUCH RISK CAN THE
COMMUNITY TOLERATE IN ORDER TO PRESERVE THE RIGHTS OF INDIVIDUALS?”

THIS, OF COURSE, IS THE HEART OF THE DEBATE OVER CONFIDENTI-
ALITY IN RECORDS,
1]

FOR THOSE OF YOU WHO DON’T KNOW ABOUT IT, 1 WILL ADD THAT
CONFIDENTIALITY HAS BEEN A LONG-STANDING PRACTICE IN PUBLIC HEALTH
WORK, THE PROMISE OF CONFIDENTIALITY HELPS US GET A GREAT DEAL OF
SENSITIVE, HEALTH-RELATED INFORMATION FROM THE INDIVIDUAL. WITHOUT
SUCH A SYSTEM, THIS COUNTRY WOULD NEVER HAVE SUCCEEDED IN CONTAINING
MOST INFECTIOUS DISEASES, AS WE HAVE DONE.

HOWEVER, NO PREVIOUS DISEASE HAS BEEN AT ONCE SO MYSTERIOUS, SO
FATAL. AND SO RESISTANT TO THERAPY AND PREVENTION.

THOSE OF US IN PUBLIC HEALTH BELIEVE THAT THE ASSURANCE OF
TOTAL CONFIDENTIALITY 1S THE KEY TO HAVING POTENTIAL -- AND ACTUAL
-- CARRIERS OF THE AIDS VIRUS PRESENT THEMSELVES FOR VOLUNTARY
TESTING AND COUNSELING,
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BUT AGAIN. WE MUST BE CAREFUL NOT TO TAKE AN ABSOLUTIST’S
POSITION, LET ME GIVE YOU A RECENT EXAMPLE INVOLVING THE WORK OF MY
OWN OFFICE,

EARLIER THIS YEAR I WAS ASKED BY THE DEPARTMENT OF JUSTICE TO
LOOK AT THE ISSUE OF CHILD SEXUAL ABUSE. WITH THE HELP OF A NUMBER
OF HEALTH AND LAW ENFORCEMENT EXPERTS FROM AROUND THE COUNTRY, I‘VE
BEEN DEVELOPING A DRAFT STATEMENT TO THE HEALTH PROFESSIONS GENERAL-
LY, WITH SPECIAL ATTENTION TO THE CARE AND TREATMENT OF VICTIMS,

AMONG THE RECOMMENDATIONS IS ONE THAT ADVISES HEALTH PERSON-
NEL TO ADMINISTER A NUMBER OF TESTS...INCLUDING A TEST FOR THE
PRESENCE OF AIDS, IN OTHER WORDS, WE BELIEVE A HEALTH WORKER SHOULD
CHECK TO SEE IF THE PERPETRATOR PASSED THE AIDS VIRUS ON TO THE
CHILD VICTIM DURING A SEXUAL ATTACK,
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WE NEED TO KNOW THAT BECAUSE, FOR EXAMPLE, A CHILD WITH THE
AIDS VIRUS SHOULD NOT RECEIVE THE ROUTINE SERIES OF VACCINATIONS
THAT NEARLY EVERY CHILD IN AMERICA NOW GETS, INDEED, FOR SOME
CHILDREN WITH AIDS, VACCINATION ITSELF COULD BE LIFE-THREATENING.

NATURALLY, PARENTS SHOULD BE TOLD IF THEIR CHILD 1S SERO-
POSITIVE. AND THE FAMILY PHYSICIAN SHOULD BE TOLD, ALSO,

BUT SHOULD THE SCHOOL BE TOLD? SHOULD THE CHILD’S RELIGIOUS
CONGREGATION BE TOLD? IN OTHER WORDS, HOW MUCH OF THE PUBLIC HAS A
TRUE “NEED TO KNOW” ABOUT THE RESULTS OF A CHILD‘S TEST FOR AIDS?
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T MAINTAIN THAT THE ISSUE OF CONFIDENTIALITY WOULD NEVER HAVE
COME UP, IF IT WERE NOT FOR A NUMBER OF INSTANCES IN WHICH PERSONS
KNOWN TO HAVE AIDS WERE FIRED FROM THEIR JOBS ,..LOST THEIR INSUR-
ANCE,,.WERE EVICTED FROM HOUSING...WERE SENT HOME FROM SCHOOL... AND
SO ON,

SUCH REACTIONS ARE IRRATIONAL, UNFAIR, AND DISCRIMINATORY.
WELL, WHAT SHOULD WE DO ABOUT THEM? HOW CAN WE DEAL WITH THESE
INCLINATIONS TOWARD DISCRIMINATION?

SOME PEOPLE ARGUE THAT IT IS NOT DISCRIMINATORY TO DENY HOUSING
OR MEDICAL CARE OR ANY OTHER ESSENTIAL SERVICE TO A PERSON WHO
CONTRACTED AIDS WHILE SHOOTING DRUGS OR ENGAGING IN SODOMY.
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BUT THE GREAT MARCH OF PUBLIC POLICY FOR OVER A CENTURY IN THIS
COUNTRY HAS BEEN TO REDUCE OR ELIMINATE ALTOGETHER THE CRITERIA FOR
ELIGIBILITY TO RECEIVE ESSENTIAL PUBLIC SERVICES.

IS AIDS GOING TO BE THE EXCEPTION? IF SO, WHY?

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.

 
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THIS COUNTRY IS ONLY NOW EMERGING FROM TWO DECADES OF TURMOIL,
DURING WHICH WE TRIED TO CORRECT THE SOCIAL INJUSTICES OF THE
PAST, WE HAVE FINALLY EXTENDED TO ALL AMERICANS -- REGARDLESS OF
RACE, COLOR, CREED, ETHNIC ORIGIN, RELIGION, AGE. OR SEX -- THE
BIRTHRIGHT OF FREEDOM THAT IS THEIRS,

WILL THE DISEASE OF AIDS -- BY ITSELF -- REVERSE THIS TREND OF
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,
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HOW CAN YOU...AND I,,.AND EVERY AMERICAN INSURE THAT OUR
COUNTRY WILL NOT RETURN IN FEAR AND HATRED TO THE WAYS OF A SHAMEFUL
PAST?

THE PRESIDENT HAS SAID THAT WE MUST COME TOGETHER TO FIGHT THIS
DISEASE WITH EVERYTHING AT OUR COMMAND, BUT WE MUST NOT FIGHT THE
PEOPLE WHO HAVE IT.

CAN WE DO THAT? CAN WE, FOR EXAMPLE, REMAIN COLOR-BLIND IN
THIS WAR AGAINST AIDS? HOW DO WE MAKE SURE WE CAN?

THESE AND OTHER ISSUES LIE BEFORE OUR COUNTRY...AND BEFORE THE
WORLD. LET ME TALK ABOUT THAT FOR A MINUTE,
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AMONG MY OTHER JOBS IS THAT OF DIRECTOR OF THE OFFICE OF
INTERNATIONAL HEALTH, IN THAT ROLE I HAVE MANY OCCASIONS TO SPEAK
WITH HEALTH MINISTERS OF OTHER NATIONS ON THEIR VISITS HERE OR ON MY
TRAVELS OVERSEAS. AND I AM CONSTANTLY REMINDED OF THE EXTENT TO
WHICH THE UNITED STATES IS A BEACON OF GOOD SENSE AND GOOD SCIENCE
FOR THE REST OF THE WORLD,

AND TODAY ESPECIALLY, THE WORLD SORELY NEEDS US,

AS OF AUGUST, THE REPORTED AIDS CASE-LOAD IN COUNTRIES OTHER
THAN THE UNITED STATES HAD REACHED 14,600. THAT SEEMS TO BE A VERY
LOW FIGURES, WE HAVE EVERY REASON TO BELIEVE THAT IT IS SO LOW
BECAUSE OF SEVERE UNDER-REPORTING OF THE DISEASE OF AIDS,
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IN AFRICA, FOR EXAMPLE, WHERE THE DISEASE IS RAGING AMONG THE
HETEROSEXUAL POPULATION, OVER A DOZEN AFRICAN NATIONS REPORT NO
CASES OF AIDS AT ALL...ZERO, OBVIOUSLY THAT’S A POLITICAL AND NOT
AN EPIDEMIOLOGICAL FACT OF THEIR NATIONAL LIFE,

DESPITE SUCH NON-REPORTS, THE WORLD HEALTH ORGANIZATION NOTES
THAT THE NUMBER OF AIDS VICTIMS IS CLIMBING STEEPLY AND THAT, OVER
THE NEXT 5 YEARS, THE WORLD COULD ADD ANYWHERE FROM ANOTHER HALF-
MILLION TO 3 MILLION NEW CASES OF AIDS,

AND RIGHT HERE LET ME EMPHASIZE A POINT THAT WE MUST NOT
FORGET: DISEASE KNOWS NO NATIONAL BOUNDARIES.
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THE DISEASE OF AIDS ITSELF APPARENTLY CAME TO THESE SHORES FROM
AFRICA BY WAY OF THE CARIBBEAN OR OF CANADA. CLEARLY PART OF OUR
SUCCESS IN CONTAINING THE DISEASE HERE WILL DEPEND ON HOW WELL IT IS
CONTAINED ELSEWHERE.

SO WE MUST STAND TOGETHER WITH OUR NEIGHBORS ON THIS TINY
PLANET.

YES, AIDS IS A TRAGEDY FOR EACH PERSON WHO IS INFECTED, BUT IT
IS ALSO A TRAGEDY FOR HUMANITY ITSELF,
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THEREFORE, WE MUST BE CONCERNED NOT ONLY WITH THE DEATH OF THE
FLESH OF THOSE STRICKEN WITH AIDS, BUT ALSO WITH THE DEATH OF THE
SPIRIT OF THOSE WITHOUT AIDS WHO LIVE IN FEAR AND ANGER,

THANK YOU,

htt dH #