ORIGINAL

6

“4 | Mine!

EMARKS
BY

C, Everett Koop. M.D., Sc.D,
SURGEON GENERAL
OF THE
U.S. PuBLic HEALTH SERVICE
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Gs

PRESENTED AT THE CENTENNIAL OF THE
UNIVERSITY OF MINNESOTA MEDICAL SCHOOL
MINNEAPOLIS, MINNESOTA
OcToBeR 5, 1988
1
(GREETINGS TO HOSTS, GUESTS, FRIENDS, ETC.)

THANK YOU VERY MUCH FOR THIS OPPORTUNITY TO SHARE WITH YOU
IN THE CENTENNIAL OF A GREAT INSTITUTION. FOR MANY YEARS, THE
STATE OF MINNESOTA, ITS UNIVERSITY, AND ITS MEDICAL SCHOOL HAVE
CONTRIBUTED NOT ONLY NEW INFORMATION TO HELP US IDENTIFY AND
TREAT THE DISEASES OF MANKIND, BUT YOU'VE SHOWN US THE HEART AND
THE SPIRIT THAT LIE AT THE BASIS OF ALL GOOD MEDICAL PRACTICE.

AND IN THAT CONNECTION LET ME ADD THAT I’M DELIGHTED TO
HAVE, AS A GUIDE AND TRAVELING COMPANION ON THIS TRIP TO
MINNESOTA, YOUR SENIOR SENATOR, DAVE DURENBERGER.
2
I‘VE KNOWN SENATOR DURENBERGER TO BE A MAN WITH A KEEN

INTEREST IN RAISING THE HEALTH STATUS OF ALL AMERICANS. THOSE OF
US IN PUBLIC HEALTH COUNT HIM “ON OUR SIDE.” AND TI FEEL
ENRICHED BY MY EXPOSURE TO MINNESOTANS OVER THE PAST 2 DAYS AS WE
DISCUSSED KEY MATTERS OF PUBLIC HEALTH IN 6 CITIES.

AND TO TELL YOU THE TRUTH, THE PUBLIC HEALTH OF THIS COUNTRY
NEEDS ALL THE UNDERSTANDING ALLIES IT CAN GET, BECAUSE WE'VE GOT
SOME MAJOR ISSUES TO DEAL WITH IN THE FUTURE.

YOUR FIRST CENTURY WAS EXCITING ENOUGH. OVER THE PAST
HUNDRED YEARS THE WORLD HAS HAD TO ABSORB THE DEVELOPMENT OF MANY
NEW DISCIPLINES AND PURSUITS IN THE LIFE SCIENCES: MODERN
SURGERY, FOR EXAMPLE, AND THE SULFONAMIDES AND ANTIBIOTICS,

AND WE’VE BEGUN TO DECIPHER THE BASIC CODE OF LIFE: DNA AND RNA.
3
THE MAJOR KILLERS OF MANKIND USED TO BE TUBERCULOSIS AND

SMALLPOX ... TYPHOID AND TYPHUS ... PELLAGRA AND YELLOW FEVER ...
SYPHILIS ... POLIO ... AND CHILDBIRTH.

WE WERE SURROUNDED BY MADNESS ... BY EPIDEMICS OF FEVERS AND
DEBILITATING DISEASES ... BY TOXINS IN THE AIR, THE WATER, THE
MILK WE DRANK AND THE MEAT WE ATE,

THE HUMAN INTELLECT RESPONDED WITH AN QUTPOURING OF
SCIENTIFIC KNOWLEDGE THAT HAS STILL NOT BEEN COMPLETELY
UNDERSTOOD OR DIGESTED: PSYCHOLOGY ... VIROLOGY ... GENETICS ...
TOXICOLOGY ... AND SO ON,
\
WELL, THAT'S SOME OF WHAT'S BEEN HAPPENING WHILE THIS

EXCELLENT INSTITUTION HAS FLOURISHED. BUT WHAT OF THE NEXT
CENTURY? WILL WE BE SEEING MORE OF THE SAME? NEW DISEASES? NEW
CURES? WHAT SEEMS TO BE ON OUR HORIZON BETWEEN NOW AND THE YEAR
2088?

FOR THE NEXT FEW MINUTES, THEREFORE, I’D LIKE TO SUGGEST
THREE AREAS IN WHICH WE ARE BOUND TO SEE SOME CHANGES AND FOR
WHICH WE OUGHT TO MAKE SOME PREPARATION -- INTELLECTUALLY, AT THE
VERY LEAST.
5
THE FIRST AREA HAS TO DO WITH THE RELATIONSHIP BETWEEN

TECHNOLOGY AND HEALTH CARE.

T DON’T THINK THERE’S ANY QUESTION BUT THAT HEALTH CARE AND
MEDICAL PRACTICE HAVE BEEN PROFOUNDLY INFLUENCED BY TECHNOLOGY,
WHICH LET'S SAY -- FOR SHORT-HAND PURPOSES -- IS THE APPLICATION
OF NEW SCIENTIFIC KNOWLEDGE TO REAL EVENTS. IT HAS ALSO
PROFOUNDLY AFFECTED PUBLIC EXPECTATIONS AS WELL.

RECENTLY I TOOK PART IN A SERTES ON PUBLIC BROADCASTING
CALLED “MANAGING OUR MIRACLES.” ESSENTIALLY THEY WERE NEW
TECHNOLOGICAL SOLUTIONS TO CERTAIN PROFOUNDLY DISTURBING MEDICAL
AND ETHICAL QUESTIONS.
6
BUT THEY WERE CALLED “MIRACLES” BECAUSE THAT IS CERTAINLY

THE PUBLIC PERCEPTION OF WHAT MEDICAL PEOPLE SEEM TO ACCOMPLISH
ON A DAILY OR EVEN HOURLY BASIS.

BUT WILL IT ALWAYS BE SO? IS THE PRE-EMINENT ROLE OF
TECHNOLOGY NOW FIXED IN THE MEDICAL PANTHEON?

TEN YEARS AGO I WOULD HAVE SAID “YES” WITHOUT A MOMENT’S
HESITATION, BUT TEN YEARS FROM TODAY, WE MIGHT WELL BE SAYING
“NO ' a“
/
FOR A GOOD MANY YEARS THE PUBLIC HAS ASSUMED THAT THE

CONTINUED IMPROVEMENT OF ITS HEALTH STATUS WAS CLOSELY LINKED TO
THE CONTINUED EXPANSION OF OUR BIOMEDICAL TECHNOLOGIES.

MAYBE YOU CAN RECALL THE DEBATES THAT TOOK PLACE EVERY TIME
A LOCAL INSTITUTION ANNOUNCED IT WAS GOING TO BUY A “CAT”
SCANNER. “WE NEED 17,” PEOPLE SAID, “IF WE WANT TO AVOID
DISEASE AND MAINTAIN OUR HEALTH.”

HOWEVER, IN RECENT YEARS, THERE’S BEEN A DISTINCT COUNTER-
TREND, IN WHICH THE PUBLIC -- AND EVEN SOME MEMBERS OF THE
MEDICAL PROFESSION ITSELF -- QUESTION THE HIGH COST AND LIMITED
RESULTS OF NEW MEDICAL TECHNOLOGIES ... INCLUDING THE SECOND AND
SUBSEQUENT GENERATIONS OF IMAGING TECHNOLOGY ITSELF.
8
AND MOST RECENTLY WE’VE ALL BEEN EXPOSED, I’M SURE, TO THE

LIVELY PUBLIC DEBATE OVER THE USE OF SO-CALLED “EXTRAORDINARY”
MEASURES TO SAVE OR PROLONG THE LIVES OF PERSONS PROFOUNDLY
TRAUMATIZED OR TERMINALLY ILL. AGAIN, I SENSE THAT THE PUBLIC,
ALTHOUGH STILL VERY EAGER TO PROLONG LIFE, IS LEANING MORE AND
MORE AGAINST THE USE OF WHAT IT SEES AS HEROIC, LIFE-SAVING, BUT
IMPERSONAL TECHNOLOGIES.

THIS IS THE BASIS -- IS IT NOT? -- OF THE SO-CALLED “LIVING
WILL” AND THE ASSUMPTION BEHIND THE ORGAN DONOR CARD AND SO ON,
9
I WOULDN'T SAY MOST PEOPLE FEEL THIS WAY, BUT I BELIEVE A

SUBSTANTIAL MINORITY DOES AND THEY DO NOT WANT MEDICINE TO
PROLONG THEIR LIVES, IF THERE’S ANY CHANCE THAT THOSE ADDITIONAL
MONTHS OR YEARS WILL BE QUALITATIVELY INFERIOR TO WHAT THEY’VE
HAD SO FAR.

THERE ARE MANY DEFINITIONS THAT WE HAVE YET TO MAKE
UNEQUIVOCALLY CLEAR. BUT IT IS CLEAR TO ME THAT MANY AMERICANS
DON’T WANT LONGEVITY AT ANY COST, AND THEY SEE TECHNOLOGY, IN A
SENSE, “PERPETRATING” LONGEVITY UPON A DUBIOUS AND EVEN UNWILLING
PUBLIC.

WE CERTAINLY NEED A CONTINUING, CAREFUL, AND SANE DIALOGUE
ON THIS SUBJECT.
10
BUT I DON’T BELIEVE THE GROWING PUBLIC SKEPTICISM REGARDING

TECHNOLOGY IS LIMITED TO ONE’S FINAL MOMENTS ON EARTH. I BELIEVE
THE PUBLIC IS ALSO BEGINNING TO QUESTION THE ADEQUACY OF
TECHNOLOGY FOR SOLVING THE MAJOR CONTEMPORARY HEALTH PROBLEMS OF
OUR PEOPLE.

TO SOME EXTENT, WE IN PUBLIC HEALTH HAVE BEEN RESPONSIBLE
FOR THIS DEVELOPMENT. FOR THE PAST SEVERAL YEARS WE’VE BEEN
STRESSING THE FACT THAT EACH PERSON, DAY-BY-DAY, MAKES THE REALLY
IMPORTANT DECISIONS REGARDING HIS OR HER OWN HEALTH, I’M
THINKING OF DECISIONS RELATED TO ...
11
* A BALANCED DIET AND A REGIMEN OF PHYSICAL EXERCISE ...

* THE AVOIDANCE OF DANGEROUS DRUGS ...
* — QUITTING CIGARETTES OR NOT STARTING TO SMOKE ..,
* AND ACTING IN A SAFE MANNER BOTH AT HOME AND AT WORK,

~ AS MORE AND MORE PEOPLE MAKE -- AND BENEFIT FROM --THESE
KINDS OF PERSONAL LOW-TECH OR NO-TECH DECISIONS, I THINK WE’LL
ALSO SEE A DROP IN THE NUMBER OF PEOPLE WHO RETAIN A COMPLETE AND
UNCRITICAL FAITH IN HIGH-TECH MEDICINE THAT WAS THE CASE, SAY, IN
THE 1950s AND 60s,
12
FOR EXAMPLE, AS YOU MAY KNOW, INCONTINENCE IS THE ONE OF THE

MORE COMMON AND MORE SOCIALLY UNDERSTANDABLE REASONS FOR SENDING
OLDER PEOPLE TO NURSING HOMES.

BUT WITH SOME TRAINING FOR BEHAVIOR MODIFICATION, SOME
MEDICATION, AND THE HELP OF A DEVICE OR TWO, A GREAT MANY
ELDERLY INCONTINENT PATIENTS CAN ESCAPE INSTITUTIONALIZATION AND
ALL THE HIGH COST AND LOW SELF-ESTEEM IT BRINGS IN ITS WAKE,
13
THIS IS JUST ONE SMALL EXAMPLE OF MEDICAL PROGRESS BEING

ACHIEVED WITH A “LOW-TECH” SOLUTION. AND I BELIEVE WE’RE GOING
SEE AN INCREASINGLY IMPORTANT ROLE FOR MANY, MANY MORE SUCH “LOW-
TECH” APPLICATIONS TO HEALTH CARE AND HEALTH ADMINISTRATION,

SO THE FIRST QUESTION THAT WE MAY HAVE TO WRESTLE WITH IN A
SERIOUS MANNER OVER THE NEXT CENTURY IS THIS: WHAT ROLE DO WE
WANT TECHNOLOGY TO PLAY IN MODERN HEALTH CARE?

A SECOND ISSUE IS THE CHANGING RELATIONSHIP BETWEEN THE
PUBLIC AND H_ CARE SYSTEM ITSELF.
14
MANY FACTORS ARE BRINGING ABOUT THIS CHANGE. ONE IS THE

INCREASED MOBILITY OF THE AMERICAN PEOPLE. WE MOVE AROUND SO
MUCH THAT IT’S BECOMING HIGHLY UNLIKELY THAT THE AVERAGE PATIENT
WILL BE KNOWN AND SERVED BY THE SAME PHYSICIAN AND SAME HOSPITAL
STAFF THROUGHOUT HIS OR HER LIFETIME.

THAT WAS THE NORM IN OUR SOCIETY FOR ALMOST THREE
CENTURIES. BUT NOT ANY MORE.

ANOTHER FACTOR CHANGING THE RELATIONSHIP BETWEEN THE PUBLIC
AND MEDICINE, IN ADDITION TO OUR SOCIAL MOBILITY, IS THE RISE IN
PRE-PAID PRACTICES OF ONE KIND OR ANOTHER. THESE PLANS, WHILE
MORE COST-EFFICIENT, ALSO TEND TO ATOMIZE AND SUB-DIVIDE PATIENT
CARE,
15
I’M NOT SAYING THAT THE RESULTS ARE EITHER GOOD OR BAD, |

DON’T THINK WE CAN MAKE THOSE KINDS OF GENERALIZATIONS AS YET,
I’M ONLY SAYING THAT THE RESULTS ARE DIFFERENT AND THAT
DIFFERENCE MAY BE QUITE SIGNIFICANT IN SHAPING THE LONG-TERM
RELATIONSHIP BETWEEN HEALTH CARE AND THE PUBLIC.

A THIRD FACTOR CHANGING THE RELATIONSHIP BETWEEN THE PUBLIC
AND THEIR SYSTEM OF HEALTH CARE IS THE WELL-ADVERTISED AND WELL-
DISCUSSED SHIFT IN THE DEMOGRAPHY OF OUR COUNTRY, BEST
ILLUSTRATED BY THE CURRENT POPULATION BULGE OF “BABY BOOMERS” AND
THE SO-CALLED “GRAYING OF AMERICA,”
16
THERE'S A CERTAIN IRONY HERE, BECAUSE EVEN AS WE EXTOL THE

VIRTUES OF THE “CONTINUITY OF CARE,” WE ARE ALSO RESIGNED TO THE
FACT THAT THE INDIVIDUAL, IN THE COURSE OF HIS OR HER LIFETIME,
WILL BE PASSED FROM PEDIATRICS TO FAMILY MEDICINE AND FINALLY TO
GERIATRIC MEDICINE.

BUT WE CAN'T SAY WITH ANY REAL CERTAINTY THAT SUCH A THREE-
LEVEL PATHWAY OF CARE WILL, IN FACT, CONSTITUTE CONTINUOUS CARE.

I’M AFRAID THAT MANY OF THE ASSUMPTIONS UPON WHICH WE BASE
MUCH OF OUR HEALTH PLANNING -- AND FINANCING, I MIGHT ADD -- MAY
STILL REFLECT A PATIENT-TO-SYSTEM RELATIONSHIP THAT, FOR MANY
INDIVIDUALS AND MANY INSTITUTIONS, NO LONGER EXISTS. IT JUST
ISN’T THERE ANY MORE AND I DOUBT THAT IT WILL EVER RE-APPEAR,
17
BUT THIS IS REALLY MORE THAN JUST A MATTER OF NEW SPECIAL-

TIES APPEARING, SUCH AS FAMILY MEDICINE AND GERIATRICS. LET ME
ILLUSTRATE MY POINT WITH A LITTLE ANECDOTE.

LAST YEAR I CONVENED A “SURGEON GENERAL‘S WORKSHOP ON SELF-
HELP.” MY PURPOSE WAS TO GAIN A BETTER SENSE OF WHAT WAS GOING
ON IN THIS NEW AREA AND WHAT THE GOVERNMENT’S ROLE MIGHT BE -- OR
IF IT HAD ANY ROLE TO PLAY AT ALL.

I DISCOVERED THAT AN ESTIMATED 15 MILLION AMERICANS ARE NOW
INVOLVED IN THE SELF-HELP MOVEMENT, AND THAT’S VERY LIKELY A
GROSS UNDERCOUNT,
18
I DISCOVERED THAT THEY REPRESENT ALL SOCIAL, RACIAL,

ETHNIC, GEOGRAPHIC, AND ECONOMIC GROUPS ... AND THAT THEY ARE
FIERCELY INDEPENDENT.

AND I ALSO DISCOVERED THAT THEY ARE PROVIDING LEADERSHIP IN
THREE HEALTH AREAS IN WHICH TRADITIONAL MEDICINE AND PUBLIC
HEALTH ARE STILL SEARCHING FOR MEANINGFUL ROLES: HEALTH
PROMOTION, DISEASE PREVENTION, AND THE COUNSELING FUNCTION,
CALLED “COGNITIVE MEDICINE” BY SOME PHYSICIANS.
19
THE SELF-HELP MOVEMENT EMBRACES ALCOHOLICS ANONYMOUS AND

MANY, MANY GROUPS TO HELP SMOEKRS QUIT THEIR HABIT. AND THERE
ARE PARENTS WITHOUT PARTNERS AND THE GRAY PANTHERS ... LA LECHE
LEAGUE AND OVEREATERS ANONYMOUS ... BROTHER TO BROTHER AND MY
SISTER‘S PLACE ... THE AMERICAN SCHIZOPHRENIA ASSOCIATION AND THE
EPILEPSY FOUNDATION ...AND SO ON,

THE DISEASES AND DISORDERS DEALT WITH BY THESE SELF-HELP
GROUPS ARE AMONG THE MOST SERIOUS PUBLIC HEALTH PROBLEMS WE FACE
TODAY: SUBSTANCE ABUSE, INCLUDING CIGARETTES ... THE EPIDEMICS OF
SYPHILIS, HERPES, GONORRHEA, AND AIDS ... AND THE THREE
PERSISTENT MAJOR KILLERS OF OUR PEOPLE: HEART DISEASE, CANCER,
AND STROKE,
20
I’M AMAZED AT THE EXTRAORDINARY DEGREE TO WHICH AVERAGE

AMERICANS ENGAGED IN THESE “DO-IT-YOURSELF” HEALTH PROGRAMS ARE
TRULY HELPED BY THEM. THESE ARE NOT “BUBBLE-GUM” PALLIATIVES,
THESE PROGRAMS DO WORK.

AS A TRAINED SURGEON WHO PRACTICED FOR NEARLY A HALF-CENTURY
IN A UNIVERSITY SPECIALTY HOSPITAL, I’M NATURALLY UNCOMFORTABLE
ADMITTING THIS, NEVERTHELESS, THERE IT IS.

I SUSPECT THAT NEITHER TRADITIONAL FEE-FOR-SERVICE MEDICINE
NOR TAX-SUPPORTED PUBLIC HEALTH PROGRAMS HAVE YET MADE A
COMPELLING ENOUGH RESPONSE TO THE INTENSELY PERSONAL ASPECT OF
THESE OVERWHELMING PUBLIC HEALTH PROBLEMS, SUCH AS HEART DISEASE,
CANCER, AIDS, MENTAL ILLNESS, AND SO ON,
21
MY ONLY CONCERN -- AND IT’S A MAJOR CONCERN -- IS THAT SOME

PEOPLE WHO NEED THE HELP OF TRADITIONAL, MEDICALLY TRAINED
EXPERTS AREN’T GOING TO GET IT OR THEY’LL BE ABLE TO AVOID IT
++ AND CONSEQUENTLY THEIR HEALTH -- AND POSSIBLY THEIR LIVES --
MAY BE IN DEEP PERIL.

FRANKLY, I'D LIKE TO SEE MORE PHYSICIANS, NURSES, AND ALLIED
HEALTH PROFESSIONALS BECOME INVOLVED IN WHAT IS NOW CALLED “SELF-
HELP” OR “MUTUAL AID” HEALTH CARE. MY INSTINCTS TELL ME IT
WOULD BE VERY USEFUL IF THEY DID.

BUT MY INSTINCTS -- AND MY EXPERIENCE -- REMIND ME OF THE
DIFFICULTIES. SELF-HELP CAME ON THE SCENE BECAUSE OF A NEED THAT
THE PUBLIC PERCEIVED WAS NOT BEING MET BY TRADITIONAL MEDICAL
PRACTICE. I THINK WE HAVE TO BUILD A GOOD STOUT BRIDGE ACROSS
THAT VERY IMPORTANT GAP.

WILL IT BE EASY? OF COURSE NOT.

SHOULD WE TRY ANYWAY? ABSOLUTELY.
22

BUT WHETHER TRADITIONAL MEDICINE AND PUBLIC HEALTH DO OR DO
NOT GET INVOLVED, I BELIEVE THIS MOVEMENT WILL CONTINUE TO GROW
INTO THE NEXT CENTURY AND BECOME NOT MERELY AN “ALTERNATIVE”
SYSTEM OF HEALTH CARE BUT, IN FACT, OUR OTHER NATIONAL SYSTEM OF
HEALTH MAINTENANCE, HEALTH PROMOTION, AND DISEASE AND DISABILITY
PREVENTION.

AND THAT LEADS ME TO THE THIRD AND FINAL ISSUE I WANT TO
TOUCH ON THIS AFTERNOON. IT’S THE RELATED ISSUE OF HEALTH,
COMMUNITY VALUES, AND PUBLIC SUPPORT.
25
I MENTION IT BECAUSE, IN THE COURSE OF MY INVOLVEMENT WITH

THE AIDS EPIDEMIC, I‘VE SEEN THE OUTLINES OF THIS ISSUE ALREADY
FORMING. ALSO, IT’S A KIND OF COROLLARY OF THE ISSUES I‘VE
DISCUSSED SO FAR,

LET ME BEGIN BY SAYING THAT THE AMERICAN PEOPLE ARE GENEROUS
TO A FAULT. THROUGH TAXES AND THROUGH PERSONAL, OUT-OF-POCKET
DONATIONS THEY WANT TO HELP EVERYONE IN OUR SOCIETY ACHIEVE GOOD
HEALTH AND THE GOOD LIFE THAT COMES WITH GOOD HEALTH,
24
BUT THE AMERICAN PEOPLE CAN ALSO BE IMPATIENT. FOR

EXAMPLE, MOST AMERICANS DISAPPROVE OF SMOKING AND WOULD LIKE TO
SEE ALL SMOKERS STOP. AND, THROUGH THE SELF-HELP MOVEMENT, MANY
SMOKERS ARE INDEED QUITTING THE HABIT. BUT IT’S HAPPENING VERY
SLOWLY,

HENCE, THE NON-SMOKING PUBLIC IS DEMANDING -- AND GETTING --
NEW AND STRONGER STATE AND LOCAL LAWS TO CURB CIGARETTE SMOKING
IN THE WORKPLACE AND IN ALL PUBLIC GOVERNMENTAL AND COMMERCIAL
BUILDINGS,

AND THE STATE OF MINNESOTA IS A MARVELOUS EXAMPLE OF HOW
THIS CAN BE DONE.
25
NEW LAWS, HIGHER PREMIUMS, AND SEGREGATION AT THE WORKSITE

ARE THE RESULTS OF DEEP PUBLIC DISPLEASURE WITH SMOKERS. BUT
SUCH DISPLEASURE IS BEING EXERCISED AGAINST OTHERS AS WELL:

DRUNK DRIVERS, DRUG ADDICTS, PROMISCUOUS AND PREGNANT TEEN-
AGERS, AND OTHERS WHO DEVIATE -- OR WHO ARE PERCEIVED AS
DEVIATING -- FROM THE COMMUNITY’S STANDARD OF NORMATIVE BEHAVIOR.

NEVERTHELESS, I STILL BELIEVE THAT THE AMERICAN PEOPLE ARE
STILL VERY GENEROUS AND VERY FORGIVING. THEY DO HONESTLY BELIEVE
IN -- AND WILL CONTINUE TO SUPPORT -- PUBLIC HEALTH PROGRAMS THAT
PROMISE REDEMPTION,
26
BUT OUR CITIZENS ARE NOT PUSH-OVERS. AND IT’S POSSIBLE THAT

THE AMERICAN PEOPLE -- ALREADY TAKING A CONTENTIOUS APPROACH
TOWARD BACKSLIDERS -- MAY DEMONSTRATE THEIR IMPATIENCE AND
DISPLEASURE ON A GRANDER SCALE, ADDING A STRONG FOOTNOTE OF
DISAPPROVAL TO THE EXISTING BODY OF AMERICAN PUBLIC HEALTH LAW,

I DON’T LIKE THAT PROSPECT AT ALL. YET, IT DOES STAND TO
REASON THAT SOCIETY WANTS SOME PENALTY TO ACCRUE TO CITIZENS WHO
WILFULLY BEHAVE IN A HIGH-RISK MANNER: DRUNKS, CHILD MOLESTERS,
WIFE BEATERS, DRUG ADDICTS, CIGARETTE SMOKERS, SEXUALLY
PROMISCUOUS PEOPLE OF ALL AGES, DANGEROUS DRIVERS, AND OTHERS.
27
UNFORTUNATELY, IN THE MINDS OF MANY CITIZENS, THE MOST

WILLFUL MISCREANTS IN OUR SOCIETY TODAY ARE PERSONS WITH AIDS ...
PEOPLE WHO MOST LIKELY CONTRACTED THAT LINGERING BUT FATAL
DISEASE THROUGH WHAT THE COMMUNITY REGARDS AS UNSAVORY ACTS:
DOING THINGS THAT MOST PEOPLE DO NOT DO AND DO NOT APPROVE OF
OTHERS DOING EITHER,

I BELIEVE THIS REACTION BY A RELATIVELY HEALTHY AND HEALTH-
CONSCIOUS MAJORITY TOWARD A HIGH-RISK MINORITY IS AN ISSUE FOR
AMERICANS IN THE COMING YEARS. I THINK WE HAVE TO RECOGNIZE THIS
POSSIBILITY AND TRY TO CHANNEL IT INTO MORE POSITIVE, MORE
TOLERANT RESPONSES ... RESPONSES MORE IN KEEPING WITH OUR
NATIONAL HISTORY AND VALUES.
28
LET ME CLOSE, THEN, BY SAYING THAT I ANTICIPATE CERTAIN

MAJOR CHANGES IN AMERICAN HEALTH CARE OVER THE NEXT SEVERAL
DECADES. SOME OF THESE CHANGES WILL BE EASIER TO EXPERIENCE THAN
OTHERS.

BUT, ON BALANCE, I BELIEVE THEY WILL CONTRIBUTE 10 A
STRONGER, MORE RESPONSIVE, MORE CONTEMPORARY SYSTEM OF HEALTH
CARE FOR THE NEXT AND SUCCEEDING GENERATIONS OF AMERICANS,

THANK YOU.
HHRHH EHH