ORIGINAL i 55 | “Welt AIDS AND AMERICAN VALUES BY C. Everett Koop, MD, ScD SURGEON GENERAL OF THE U. S, PuBLic HEALTH SERVICE U. S, DEPARTMENT OF HEALTH AND HUMAN SERVICES D PRESENTED TO THE WoRLD AFFAIRS COUNCIL Los ANGELES, CALIFORNIA SEPTEMBER 21, 198/ (GREETINGS TO HOSTS, GUESTS, FRIENDS, ETC.) THANK YOU FOR YOUR INVITATION... YOUR KIND WORDS...AND YOUR CONTINUED SUPPPORT FOR AMERICA’S LEADERSHIP ROLE IN INTERNATIONAL HEALTH. WITH SO MUCH ATTENTION FOCUSED ON THE WORLD PANDEMIC OF AIDS THESE DAYS -- AND IT CERTAINLY DESERVES OUR ATTENTION -- WE NEVERTHELESS TEND TO LOSE SIGHT OF THE MANY OTHER MAJOR HEALTH PROBLEMS IN THE WORLD...PROBLEMS WHICH, AT THE PRESENT TIME AT LEAST 1. CLAIM MANY MORE LIVES AND EXHAUST MANY MORE OF THE FISCAL AND HUMAN RESOURCES OF MOST COUNTRIES THAN AIDS DOES, AND I MEAN TO TALK ABOUT AIDS AT THIS LUNCHEON. AS I PROMSIED TO DO, ALTHOUGH IT WILL NOT BE THE USUAL BOILER-PLATE TALK ON AIDS. IN FACT, I MUST WARN YOU THAT I MIGHT RAISE MORE QUESTIONS THAN I ANSWER, BUT IT WOULD A MISTAKE TO DO EVEN THAT. IN MY OPINION, WITHOUT SETTING IT WITHIN THE CONTEXT OF OTHER ISSUES IN WORLD HEALTH... ESPECIALLY THE HEALTH OF CHILDREN, FOR EXAMPLE, THE 6 MAJOR COMMUNICABLE DISEASES OF CHILDHOOD TAKE THE LIVES OF AN ESTIMATED 5 MILLION CHILDREN EVERY YEAR. ABOUT AN EQUAL NUMBER OF CHILDREN MANAGE TO SURVIVE. BUT CARRY THE SCARS OF DISEASE FOR THE REST OF THEIR LIVES, THERE IS A VACCINE FOR EACH OF THESE DISEASES, THESE VACCINES HAVE BEEN GENERALLY AVAILABLE HERE. AND, AS A RESULT, MOST OF THESE DISEASES ARE VIRTUALLY DISAPPEARING FROM OUR SOCIETY: POLIO 11 TETANUS... DIPHTHERIA... WHOOPING COUGH, BUT THESE VERY SAME VACCINES HAVE YET TO PENETRATE ALL THE VILLAGES AND CROSS-ROADS OF THE DEVELOPING WORLD. IN FACT, THE DELIVERY OF IMMUNIZATION SERVICES THROUGHOUT THE DEVELOPING WORLD IS ONE OF THE GREAT TECHNOLOGICAL CHALLENGES FACING CONTEMPORARY MEDICINE, HOWEVER, I’M PLEASED TO REPORT THAT THE UNITED STATES HAS BEEN CONTRIBUTING SUBSTANTIALLY TO THE “EXPANDED PROGRAM ON IMMUNIZA- TION.” WHICH IS SPONSORED BY THE THE WORLD HEALTH ORGANIZATION. BOTH THE U.S. PUBLIC HEALTH SERVICE AND THE AGENCY FOR INTERNATIONAL DEVELOPMENT REPRESENT OUR COUNTRY IN THAT IMPORTANT WORLDWIDE EFFORT. WE'VE ALSO JOINED WITH W.H.O, IN IDENTIFYING THE MAJOR PARASTIC DISEASES AS AMONG OUR BIG TARGETS OF INTERNATIONAL SCIENCE AND MEDICINE: MALARIA, FOR EXAMPLE, WHICH, IN SOME AREAS OF AFRICA STRIKES AND DEBILITATES EVERY CHILD OVER THE AGE OF 1, FORTUNATELY, A NEW ANTI-MALARTAL VACCINE IS NOW BEING TESTED AND COULD BE GENERALLY AVAILABLE IN JUST A FEW SHORT YEARS. SCHISTOSOMIASIS, OR “SNAIL FEVER,” IS A GLOBAL DISEASE THAT AFFECTS AN ESTIMATED 180 MILLION PEOPLE...A STAGGERING BURDEN OF ILLNESS FOR THE HUMAN RACE. IRONICALLY ENOUGH, IT SEEMS TO SPREAD MOST RAPIDLY IN THOSE COUNTRIES THAT HAVE DEVELOPED NEW METHODS OF AGRICULTURAL IRRIGATION, AND TRYPANOSOMIASIS, OR “SLEEPING SICKNESS.” WAS ONE OF THOSE DISEASES ALWAYS MENTIONED IN THOSE STEAMY JUNGLE NOVELS OF THE LAST CENTURY. FOR A WHILE THE SIUTATION SEEMED TO BE IMPROVING, BUT PRESENT-DAY CONTROL MEASURES SEEM TO BE INADEQUATE. AND "SLEEPING SICKNESS” IS ON THE RISE. UNLIKE MASLARIA AND “SNAIL FEVER.” “SLEEPING SICKNESS” IS USUALLY FATAL, UNLESS THE PATIENT IS TREATED AT THE EARLIEST SIGNS OF THE DISEASE. AND “IN THE BUSH” THAT GENERALLY DOES NOT HAPPEN. SO WE CAN TAKE PRIDE IN SOME OF OUR ACHIEVEMENTS OVERSEAS... IN THE IMMUNIZATION PROGRAM AND ESPECIALLY IN THE EXPANSION OF ORAL RE- HYDRATION THERAPY IN THE THIRD WORLD. BUT THERE 1S CLEARLY A GREAT DEAL OF NECESSARY WORK STILL TO BE DONE. AND I FULLY EXPECT OUR COUNTRY WILL BE ON HAND TO HELP DO IT, 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 A 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.” 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 TS 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.O, 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. T 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, 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 THIS 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. IN THE FIGHT AGAINST AIDS, WE MUST STAND TOGETHER WITH ALL OUR NEIGHBORS ON THIS TINY PLANET. AIDS 1S CERTAINLY A PERSONAL TRAGEDY FOR EVERYONE WHO IS INFECTED. BUT IT’S ALSO A TRAGEDY FOR HUMANITY ITSELF. 10 I 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. BUT I’M CONCERNED ABOUT OUR ABILITY TO MAKE THOSE TOUGH BUT CORRECT CHOICES IN MATTERS OF INTERNATIONAL HEALTH, DESPITE THE RECORD OF COOPERATION I’VE ALREADY NOTED. FOR EXAMPLE, IN THE 6 YEARS SINCE THE AIDS EPIDEMIC BEGAN, MORE THAN 24,000 AMERICANS HAVE DIED OF AIDS. BUT JUST LAST MONTH -- AND EVERY MONTH -- SOME 29,000 PEOPLE DIE BECAUSE THEY SMOKED CIGARETTES. THE EPIDEMIOLOGY BEHIND THOSE STATISTICS IS QUITE GOOD. NEVER- THELESS, WE IN THE UNITED STATES PERMIT, CONDONE, AND ACTIVELY PROMOTE THE INCREASED CONSUMPTION OF AMERICAN BRAND-NAME CIGARETTES THROUGHOUT THE THIRD WORLD, I] AND NOW, AS THE TITLE OF MY REMARKS TODAY WOULD INDICATE, I WANT TO SPEND A FEW MOMENTS REVIEWING FOR YOU -- ALBEIT IN A BRIEF MANNER -- SOME OF THE OTHER DIFFICULT CHOICES THAT LIE AHEAD OF US, RELTAIVE TO THE PANDEMIC OF AIDS, FIRST, LET ME REMIND YOU THAT THE THREE ASPECTS OF AIDS THAT COLOR EVERYTHING DONE AND SAID ABOUT THE DISEASE ARE, ONE, THAT IT IS STILL A MYSTERY,..TWO, THAT IT IS FATAL,..AND THREE, THAT PEOPLE GET AIDS BY DOING THINGS THAT THE MAJORITY OF PEOPLE DON’T DO AND DON'T LIKE. WE NEED TO KEEP THESE THREE ASPECTS OF THE DISEASE IN MIND, BECAUSE THEY. IN COMBINATION, TRULY OBSCURE THE MANY SCIENTIFIC ISSUES SURROUNDING AIDS AND, INSTEAD, SWING OUR ATTENTION TO THE MORE SENSITIVE AND VOLATILE ISSUES OF LAW. ETHICS, ECONOMICS, MORALITY, AND SOCIAL COHESION THAT SURROUND AIDS, 12 FOR EXAMPLE, WE ARE ALREADY WITNESSING THE ASSAULT BY THIS DISEASE UPON THE ETHICAL FOUNDATION OF HEALTH CARE ITSELF, DESPITE THE SENSIBLE AND RATHER ELEMENTARY GUIDELINES ISSUED TO THE HEALTH PROFESSIONS BY OUR CENTERS FOR DISEASE CONTROL, WE STILL HEAR -- EVERY DAY -- OF PHYSICIANS, DENTISTS, NURSES, AND OTHER HEALTH PERSONNEL WHO REFUSE TO TREAT PERSONS WITH AIDS...OR EVEN TO TREAT PERSONS WHOM THEY SUSPECT OF HAVING AIDS, LET ME QUICKLY ADD THAT THIS IS NOT CHARACTERISTIC OF HEALTH PROFESSIONALS BY ANY MEANS. ON THE CONTRARY, THE OVERWHELMING MAJORITY OF MY COLLEAGUES HAVE PROVIDED -- AND WILL CERTAINLY CONTINUE TO PROVIDE -- QUALITY, COMPASSIONATE CARE TO PERSONS DYING OF AIDS, 13 BUT THE GOOD CONDUCT OF THE MAJORITY SHOULD NOT IN ANY WAY SHIELD THE UN-PROFESSIONAL CONDUCT OF A FEARFUL AND IRRATIONAL MINORITY, WELL, WHAT SHOULD WE DO ABOUT THAT? I THINK THAT’S AN IMPORTANT QUESTION, BECAUSE HEALTH CARE IN THIS COUNTRY HAS ALWAYS BEEN PREDICATED ON THE ASSUMPTION THAT -- SOMEHOW -- EVERYONE WHO NEEDS HEALTH CARE WILL RECEIVE HEALTH CARE. AND NO ONE WILL BE TURNED AWAY. AS A PHYSICIAN -- AND AS 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. 14 HENCE, I REGARD AS EXTREMELY SERIOUS THE REPORTS OF A FEW PHYSICIANS AND OTHERS WHO ARE WITHHOLDING CARE FROM PERSONS WITH AIDS. THEIR CONDUCT THREATENS THE VERY FABRIC OF HEALTH CARE IN THIS COUNTRY. ONE DAY SOON. WE WILL HAVE TO CONFRONT THAT ISSUE AND COME UP WITH SOME GOOD ANSWERS. OTHERWISE THE VIRUS OF AIDS WILL FURTHER WEAKEN THE ETHICS OF MEDICAL PRACTICE IN THE UNITED STATES. AND THAT WOULD BE ANOTHER AND JUST AS DEADLY A KIND OF EPIDEMIC FOR OUR SOCIETY. A RELATED ISSUE CONCERNS THE COST OF CARE FOR AIDS PATIENTS: WHO SHOULD PAY THOSE THAT COSTS? 15 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. THE AMERICAN TAXPAYER SUPPORTS MATERNAL AND CHILD HEALTH PROGRAMS, FOR EXAMPLE, AND DIABETES CONTROL AND HYPERTENSION SCREENING PROGRAMS. TAXPAYERS ALSO SUPPORT PROGRAMS FOR ALCOHOLICS, DRUG ADDICTS, AND SYPHILITICS., ALL SUCH PROGRAMS ARE PART OF OUR GOVERNMENT’S TOTAL COMMIT- MENT TO PROVIDE FOR “THE GENERAL WELFARE OF THE UNITED STATES.” AS THE CONSTITUTION INSTRUCTS IN ARTICLE 1, SECTION 8. THAT INSTRUCTION, BY THE WAY, IS 200 YEARS OLD. GOOD FOR THOSE WHO WROTE IT,..AND GOOD FOR US. 16 THOSE PROGRAMS THAT MORE OR LESS CLEAN UP AFTER PEOPLE WHO BEHAVE POORLY ARE NOT REALLY EXPENSIVE PROGRAMS. IN ADDITION. THEY ARE GEARED TO BRING -- OR TO BRING BACK -- MEN, WOMEN, AND CHILDREN TO A STATE OF GOOD HEALTH. BUT AIDS IS ESPECIALLY DIFFICULT. IT ALSO IS A DISEASE THAT A PERSON CONTRACTS USUALLY AS A RESULT OF HIGH-RISK BEHAVIOR, LET‘S FOR THE MOMENT DISREGARD THE FEW REMAINING CASES INVOLVING TRANS- FUSED BLOOD OR BLOOD PRODUCTS OR THE SMALL NUMBER OF BABIES BORN WITH AIDS, AIDS IS LINKED TO WHAT MOST OF OUR CITIZENS CALL “QUESTIONABLE BEHAVIOR,” THE WAY DRUG ADDICTION, LIVER FAILURE, AND LUNG CANCER ARE ALSO CAUSALLY LINKED TO POOR INDIVIDUAL JUDGMENTS. 17 BUT THE TREATMENT OF AIDS PATIENTS IS PROVING TO BE VERY EXPENSIVE. IT 1S BOTH TECHNOLOGY- AND LABOR-INTENSIVE AND CAN BE AS MUCH AS $50,000 PER YEAR -- AND MORE -- FOR SOME PATIENTS, BUT, AFTER CONSUMING TENS OF THOUSANDS OF DOLLARS WORTH OF MEDICAL CARE AND SOCIAL SERVICES,..THE AIDS PATIENT DIES. THE AIDS CASE-LOAD IS CLIMBING. BETWEEN AUGUST OF 1986 AND THIS PAST AUGUST, THERE WERE SOME 14,000 NEW CASES OF AIDS REPORTED. BY THIS TIME NEXT YEAR. WE EXPECT THERE WILL BE AN ADDITIONAL 15-16,000 NEW CASES, 18 WILL THE AMERICAN PEOPLE CONTINUE TO SUPPORT HIGH-COST PATIENT CARE FOR PEOPLE WITH AIDS? OR WILL THEY ASK FOR RELIEF AND SUPPORT A KIND OF “SECOND-CLASS CARE” FOR AIDS PATIENTS? HOW SHOULD WE RESPOND TO SUCH A DEVELOPMENT? IT’S A VERY TROUBLING POSSIBILITY BECAUSE IT WOULD DRIVE THE FIRST SMALL WEDGE INTO THE FOUNDATIONS OF HEALTH CARE POLICY IN THIS COUNTRY. WE'VE NEVER ACCEPTED THAT BEFORE, WOULD WE ACCEPT IT NOW? THEN THERE IS THE ISSUE OF “INDIVIDUAL PRIVACY versus THE NEED TO PROTECT THE COMMUNITY FROM DANGER.” 1g I 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. 20 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 MYSTERIOUS, 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? LET ME OFFER AN EXAMPLE INVOLVING THE WORK OF MY OWN OFFICE. 21 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 REGARD- ING THE CARE AND TREATMENT OF CHILD VICTIMS OF SEXUAL ABUSE. 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 TO THE CHILD VICTIM DURING THE SEXUAL ATTACK. 22 WE NEED TO KNOW THAT BECAUSE A CHILD WHO HAS A SYMPTOMATIC AIDS-RELATED INFECTION SHOULD NOT RECEIVE ANY LIVE-VIRUS OR LIVE- BACTERIAL VACCINES, THE PUBLIC HEALTH SERVICE RECOMMENDS THAT SUCH CHILDREN BE GIVEN INACITVATED POLIO VACCINE, FOR EXAMPLE. AND SHOULD BE EXCUSED FROM BEING IMMUNIZED FOR MEASLES, RUBELLA, AND/OR MUMPS, WE DON’T HAVE ALL THE FACTS YET, IN THIS PARTICULAR AREA. BUT IT 1S CLEARLY A POSSIBILITY THAT, FOR THE CHILD WITH AIDS. VACCINA- TION ITSELF COULD BE LIFE-THREATENING, NATURALLY, THE PARENTS SHOULD BE TOLD IF THEIR CHILD IS SERO- POSITIVE. AND THE FAMILY PHYSICIAN, ALSO, IF THERE IS ONE. 23 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 IS SEROPOSITIVE? 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 LOST THEIR INSURANCE...HAVE BEEN EVICTED FROM HOUSING,..HAVE BEEN SENT HOME FROM SCHOOL...AND SO ON, THESE REACTIONS HAVE BEEN IRRATIONAL, UNFAIR. AND DISCRIMINA- TORY. WHAT SHOULD WE DO ABOUT IT? HOW SHOULD WE DEAL WITH THESE INCLINATIONS TOWARD DISCRIMINATION? 24 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, 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? 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, 25 HOW TRAGIC FOR THEM. AND HOW TRAGIC FOR AMERICA, THE UNITED STATES IS ONLY NOW EMERGING FROM TWO DECADES OF TUR- MOIL, 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, RELIGION, AGE, OR SEX -- THE BIRTHRIGHT OF FREEDOM THAT IS THEIRS. WILL THE DISEASE OF AIDS -- ALL BY ITSELF -- REVERSE THIS TREND IN OUR NATION'S HISTORY? WE HOPE AND PRAY THAT IT WILL NOT. 26 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. 2/ 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 IS 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 10 BE. 28 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 COM- PASSION AND JUSTICE...NOT SCIENCE ALONE...CAN TRIUMPH OVER DISEASE. ONCE AGAIN... THANK YOU, Ht # # #