ORIGINAL | eer atc nt tenets egatertameme = r / < ADDRESS By C, Everett Koop, MD. ScD SURGEON GENERAL OF THE U, S, PuBLic HEALTH SERVICE AND DepuTY ASSISTANT SECRETARY OF HEALTH U. S. DEPARTMENT OF HEALTH AND HUMAN SERVICES PRESENTED TO THE THRASHER RESEARCH FUND SALT LAKE City. UTAH May 26, 1987 (GREETINGS TO HOSTS, GUESTS, FRIENDS, ETC.) I’M INDEED HONORED TO PRESENT THIS ANNUAL LECTURE. MY PREDECESSORS AT THIS PODIUM HAVE ALL BEEN DISTINGUISHED PERSONS INTERESTED, AS YOU ARE. IN THE HEALTH OF CHILDREN, IT 1S ALSO AN HONOR TO BE AMONG PEOPLE WHO, AS BISHOP PACE HAS WRITTEN, ARE “WILLING TO INVEST IN THE WORLD’S CHILDREN, TO AFFIRM THE PRECIOUSNESS OF HUMAN LIFE AND THE HOPE OF THE FUTURE,” IT REMINDS ME OF A LINE FROM THE GREAT INDIAN POET, TAGORE. HE WROTE THAT “EVERY CHILD COMES WITH THE MESSAGE THAT GOD IS NOT YET DISCOURAGED OF MAN,” I CAN TELL YOU THAT THE WORLD SORELY NEEDS SUCH AFFIRMATION. WE STRUGGLE TO BECOME -- BUT NOT YET ARE -- THE “CITY ON A HILL.” THAT STRUGGLE WAS AGAIN EVIDENT TO ME AT THE RECENT WORLD HEALTH ASSEMBLY IN GENEVA, WHERE I HEADED THE AMERICAN DELEGATION. WHEN YOU LOOK BEHIND ALL THE POMP AND POSTURING THAT GOES ON AT SUCH EVENTS, YOU SEE A PROFOUND DESIRE ON THE PART OF ALL COUNTRIES TO IMPROVE THE LIVES OF THEIR CITIZENS AND, ESPECIALLY, THE LIVES AND HOPES OF THEIR CHILDREN, I KNOW HOW IMPORTANT IS THE CONTRIBUTION OF THE THRASHER FUND TO THE INTERNATIONAL PROGRAM IN CHILDREN’S HEALTH. ALL I CAN SAY IS “GOD BLESS YOU AND KEEP UP YOUR COMMITMENT TO THIS VITAL ACTIVITY.” IT DOES MAKE A DIFFERENCE IN THE LIVES OF CHILDREN EVERYWHERE... AND I WOULD VENTURE TO SAY THAT IT MAKES A DIFFERENCE IN YOUR LIVES, TOO. IT GIVES YOU SOME PROOF THAT, DESPITE THE NOISE LEVEL OF MODERN LIVING, YOU CAN STILL HEAR THAT MESSAGE THAT CHILDREN BRING INTO THE WORLD WITH THEM... THE MESSAGE, AS TAGORE SAYS, THAT “GOD IS NOT YET DISCOURAGED OF MAN.” WHICH, TO TELL YOU THE TRUTH, MAY BE SOMEWHAT SURPRISING, SINCE THERE IS A LOT TO BE DISCOURAGED ABOUT. AND TONIGHT 1 WANT TO SPEND JUST A FEW MOMENTS TALKING ABOUT A SUBJECT THAT IS OCCUPYING SO MUCH OF MY PROFESSIONAL LIFE...A SUBJECT THAT IS EVEN MORE TAXING UPON THE LIFE OF MY FRIEND AND COLLEAGUE, DR. JIM MASON...A SUBJECT THAT HAS DEPRESSED THE SPIRIT OF OUR COUNTRY...AND THAT IS AIDS. THERE WAS A TIME -- JUST A FEW YEARS AGO, IN FACT -- WHEN OUR CONCERNS ABOUT AIDS WERE CENTERED ALMOST EXCLUSIVELY IN THE POPULA- TIONS MOST AT RISK, PRIMARILY HOMOSEXUAL AND BISEXUAL MEN. IN SAN FRANCISCO, LOS ANGELES, AND NEW YORK CITY. AND WHILE THESE CITIES STILL HAVE THE HIGHEST NUMBERS OF AIDS CASES, THEY'RE NO LONGER ALONE. AT THE LATEST COUNT, 19 CITIES HAVE EACH REPORTED MORE THAN 300 CASES OF AIDS SINCE 1981, WHEN THE FIRST CASES WERE REPORTED. THE LONGER LIST NOW INCLUDES HOUSTON, MIAMI, AND WASHINGTON, D.C.. WHICH HAVE EACH HAD MORE THAN A THOUSAND CASES OF AIDS SINCE 1981. ONE OR MORE CASES HAVE BEEN REPORTED IN ALL 50 STATES, GUAM, THE TRUST TERRITORIES, AND THE VIRGIN ISLANDS. UTAH HAS HAD 60 CASES SO FAR...AND 25 OF THEM WERE REPORTED WITHIN JUST THE PAST 12 MONTHS, THE UNRELENTING SPREAD OF THIS DISEASE OVER FOR THE PAST 6 YEARS HAS CARRIED IT FURTHER AND DEEPER INTO OUR SOCIETY AND WE SIMPLY AREN'T YET ABLE TO SLOW IT DOWN, MUCH LESS STOP IT ALTOGETHER. THE CUMULATIVE TOTAL OF REPORTED CASES OF AIDS IS NOW APPROACHING 36,000. OF THAT NUMBER, HOWEVER, NEARLY 21,000 HAVE ALREADY DIED. AIDS 1S AN UGLY, RELENTLESS, AND LETHAL DISEASE. WE HAVE EVERY REASON TO FEAR ITS SPREAD. NOW, I AGREE THAT THE AIDS VIRUS IS PASSED ALONG BY PEOPLE WHO DO THINGS THAT THEY OUGHT NOT TO DO. I DON’T CONDONE INTRAVENOUS DRUG ABUSE AND I FLATLY OPPOSE THE KIND OF SEXUAL PROMISCUITY THAT ENDANGERS A PERSON'S PHYSICAL, MENTAL, EMOTIONAL, AND SPIRITUAL HEALTH. BUT RIGHT NOW WE MUST STOP THE CHAIN OF TRANSMISSION OF THE AIDS VIRUS, AND WE MUST DO THAT IN A WAY THAT IS NOT ONLY EFFECTIVE. BUT IS ALSO CONSISTENT WITH AMERICAN LAW AND TRADITION, IT 1S ESSENTIAL, THEREFORE, THAT THE AMERICAN PEOPLE HAVE A CLEAR UNDERSTANDING OF THE THREAT POSED TO THEM BY THIS DISEASE AND ARE, THEMSELVES, READY TO FIGHT BACK WITH THE BEST AND ONLY WEAPON THAT'S AVAILABLE: THEIR INTELLIGENT BEHAVIOR. AND FOR THAT, OF COURSE. WE NEED GOOD SCIENCE AND GOOD PUBLIC EDUCATION, AS THE AIDS EPIDEMIC SPREADS, IT IMPOSES SEVERE SOCIAL AND ECONOMIC BURDENS UPON MORE AND MORE OF OUR COMMUNITIES, CLEARLY, IT’S GOING TO TAKE THE COMBINED RESOURCES OF ALL LEVELS OF GOVERNMENT AND. THE PRIVATE SECTOR TO MEET THE COST CHALLENGES PRESENTED BY THIS DISEASE... CHALLENGES SUCH AS... THE INCREASING COSTS OF IN-PATIENT CARE FOR AN EXPANDING PATIENT POPULATION... THE NATURE AND COST OF EDUCATIONAL EFFORTS TO REDUCE HIGH-RISK BEHAVIOR... THE COST OF MAINTAINING AN EFFECTIVE RESEARCH EFFORT FOR IMPROVED PREVENTION, TREATMENT AND CURE... AND THE COSTS OF SOCIAL SUPPORT FOR JUVENILE AIDS VICTIMS AND THEIR FAMILIES, THE COSTS ARE HIGH...AND THEY’RE GETTING HIGHER. AND ONE AREA IN WHICH WE MUST EXPECT A STEADY ESCALATION OF COSTS IS THE AREA OF PEDIATRIC AIDS, AN AREA OF PARTICULAR INTEREST TO THE THRASHER FUND, OF COURSE, AS OF LAST WEEK, A TOTAL OF 501 CASES OF AIDS HAVE BEEN REPORTED AMONG CHILDREN UNDER 13 YEARS OF AGE SINCE THE COUNT BEGAN, BACK IN JUNE OF 1981, FIVE HUNDRED CASES DOESN’T SOUND LIKE MUCH. BUT IT IS DOUBLE THE NUMBER OF CASES REPORTED AS OF A YEAR AGO. SIXTY PERCENT OF THOSE CHILDREN HAVE ALREADY DIED. UNFORTUNATELY, WE EXPECT THE NUMBER OF INFECTED CHILDREN TO CONTINUE TO INCREASE DRAMATICALLY. BY 1991, OUR PUBLIC HEALTH SERVICE STATISTICIANS ESTIMATE THAT 3,000 CHILDREN WILL HAVE SUFFERED FROM THIS DISEASE. AND VIRTUALLY ALL WILL DIE. AS FRIGHTENING AS THIS MAY SOUND, WE ARE ALSO AWARE THAT EVEN THIS LARGE A NUMBER MAY BE AN UNDER-ESTIMATION, TODAY, FOR EXAMPLE, AS MANY AS 2,000 CHILDREN ARE REPORTED TO HAVE SYMPTOMS OF AN AIDS INFECTION, BUT THEY DON’T YET FIT THE SPECIFIC DIAGNOSTIC CRITERIA, A CONGENITALLY ACQUIRED AIDS INFECTION, FOR EXAMPLE, MAY AFFECT AN INFANT'S CENTRAL NERVOUS SYSTEM, LEADING TO ALTERATIONS IN GROWTH AND DEVELOPMENT. THESE ARE SIGNS AND SYMPTOMS THAT HAVE NOT BEEN IDENTIFIED WITH AIDS THUS FAR, 10 RECOGNIZING THIS, OUR CENTERS FOR DISEASE CONTROL HAVE DEVELOPED A MORE DETAILED AND EXHAUSTIVE CLASSIFICATION SYSTEM FOR THE ASYMPTOMATIC CHILD versus THE SYMPTOMATIC CHILD... THE IMMUNOLOGICALLY COMPROMISED CHILD...AND THE CHILDREN WITH NEUROLOGICAL DISEASE, LUNG DISEASE, SECONDARY CANCER, CARDIOPATHY, AND NEPHROPATHY. WE ARE LEARNING THAT THIS DISEASE HAS MANY PRESENTATIONS IN CHILDREN. AS OUR KNOWLEDGE OF THESE EXPANDS, WE WILL ALSO BE EXPAND- ING OUR PUBLIC HEALTH SURVEILLANCE. IN THIS WAY WE HOPE TO GENERATE A MORE ACCURATE PICTURE OF JUST WHAT IS HAPPENING TO CHILDREN WITH AIDS, HOW DO CHILDREN CONTRACT THIS DEADLY INFECTION ANYWAY? ll BEFORE 1985, A NUMBER OF CHILDREN DID ACQUIRE AIDS FROM CONTAMINATED BLOOD,..86, AT THE LAST COUNT, OF WHOM 61 HAVE ALREADY DIED. SOME WERE HEMOPHILIACS,.,SOME RECEIVED CONTAMINATED TRANSFUSED BLOOD FOR OTHER MEDICAL REASONS, THE SURVIVING CHILDREN AND THEIR FAMILIES NEED OUR CONTINUED ATTENTION, THESE CHILDREN, SOME OF WHOM MAY ALSO HAVE OTHER SEVERE CHRONIC ILLNESSES, ARE CARRYING THE ENORMOUS BURDEN OF THEIR OWN IMPENDING DEATH. THE DEVELOPMENT OF BLOOD-SCREENING PROCEDURES AND METHODS OF HEAT-TREATING BLOOD FACTOR PRODUCTS HAS VIRTUALLY ELIMINATED THE RISK OF NEW AIDS CASES -- PEDIATRIC OR OTHERWISE -- OCCURRING BECAUSE OF CONTAMINATED BLOOD AND BLOOD PRODUCTS, 12 BUT CONTAMINATED TRANSFUSED BLOOD IS NO LONGER THE KEY REASON BEHIND PEDIATRIC AIDS. THE FACT OF THE MATTER IS THAT TWO-THIRDS OF PEDIATRIC AIDS CASES ARE THE RESULT OF THE TRANSMISSION OF THE VIRUS FROM AN INFECTED MOTHER TO HER CHILD. THIS CAN OCCUR EITHER IN UTERO OR AT THE TIME OF DELIVERY, WHEN THE MOTHER’S AIDS-INFECTED BLOOD MAY - CONTAMINATE HER CHILD AS THE BABY PASSES THROUGH THE BIRTH CANAL, OUR CURRENT INFORMATION SUGGESTS THAT OF EVERY 100 BABIES BORN 10 MOTHERS INFECTED WITH AIDS, AS MANY AS 50 MAY BE BORN WITH AIDS, ALSO, BUT EVEN HERE WE MUST PROVIDE SOME QUALIFICATIONS, 13 IT’S POSSIBLE, FOR EXAMPLE, FOR A CHILD TO BE BORN AND TEST SERO- POSITIVE: THAT 1S, TO HAVE AIDS ANTIBODIES IN ITS BLOODSTREAM... BUT NOT HAVE THE AIDS VIRUS ITSELF. THEN, AFTER A PERIOD OF TIME, THE INFANT -- SENSING THAT IT IS SAFELY OUT OF DANGER -- BEGINS TO SHED THESE ANTIBODIES AND, IF TESTED AGAIN, WOULD BE SERONEGATIVE. WHEN WE SPEAK OF PEDIATRIC AIDS, THEREFORE, WE HAVE TO UNDER- STAND THAT WE’RE TALKING ABOUT SOME CHILDREN WHO ACTUALLY HAVE THE VIRUS IN THEIR BLOODSTREAMS AND ARE AT RISK OF DEATH...AND ABOUT OTHER CHILDREN WHO HAVE THE ANITBODIES ONLY AND ARE AT NO RISK, EITHER TO THEMSELVES OR TO OTHERS, OF COURSE. OF THE CHILDREN WHO TEST SEROPOSITIVE, WE DON’T KNOW WHICH ONES ARE WHICH, HENCE, WE MUST TREAT THEM ALL AS IF THEY WERE CARRYING BOTH THE ANTIBODIES AND THE AIDS VIRUS, 14 CHILDREN BECOME INFECTED AT BIRTH AND THROUGH OTHER EVENTS AS WELL -- SEXUAL ABUSE, DRUG ABUSE, AND SEXUAL INTERCOURSE, FOR EXAMPLE. IN MOST OF THESE CASES, THE ACT IS A CRIMINAL ACT AGAINST THE CHILD UNDER THE CHILD ABUSE STATUTES IN ALL STATES AND TERRITORIES, IF THE PERPETRATOR ALSO HAS AIDS AND PASSES IT ON TO THE CHILD VICTIM WHO, UNTIL THEN, HAS NOT HAD IT. THEN I’M TOLD THAT THAT COULD BE AN ADDITIONAL CRIMINAL COMPLICATION, THOSE ARE OTHER SERIOUS POSSIBILITIES OF INFECTION AND WE OUGHT TO KEEP THEM IN MIND. HOWEVER, IT SEEMS CLEAR ENOUGH AT THIS POINT THAT WE SHOULD PLACE OUR MAJOR FOCUS IN PEDIATRIC AIDS ON THE TRANSMISSION OF THE VIRUS FROM AN INFECTED PREGNANT WOMAN TO HER NEWBORN CHILD, I5 MOST OF THESE WOMEN ARE THE SEX PARTNERS OF DRUG ABUSERS OR BI- SEXUAL MEN OR ARE THEMSELVES INTRAVENOUS DRUG ABUSERS, HOWEVER, AS THE VIRUS CONTINUES ITS SPREAD AMONG THE GENERAL HETEROSEXUAL POPULA- TION, THE DANGER TO WOMEN WILL MOST CERTAINLY ESCALATE, WHETHER OR NOT THEY THEMSELVES ABUSE DRUGS, THEREFORE, THE INCIDENCE OF AIDS AMONG THE NEWBORN WILL MOST LIKELY RISE AS WELL. AND THAT’S WHAT WE’RE PREDICTING WILL HAPPEN, DO WE KNOW ANYTHING ELSE ABOUT THIS PROBLEM? YES, I’M AFRAID WE DQ, WHILE IT IS TRUE THAT AIDS CAN AFFLICT CHILDREN FROM ALL SECTORS OF SOCIETY. THE FACT OF THE MATTER IS THAT THE DISEASE IS CROPPING UP AT A DISPROPORTIONATE RATE AMONG THOSE FAMILIES WITH THE LEAST CAPACITY AND RESOURCES TO COPE. lo THEY ARE POOR AND THEY ARE MINORITIES...AND THEY ARE MOSTLY BLACK, IN THE POPULATION GENERALLY, 1 OF EVERY 8 AMERICANS IS BLACK... BUT AMONG AMERICANS WITH AIDS, 1 OF EVERY 4 1S BLACK: 24 PERCENT OF THE TOTAL CASES REPORTED SO FAR, ONE OF EVERY 12 AMERICANS IS HISPANIC...BUT 1 OF EVERY 7 AMERICANS WITH AIDS IS HISPANIC, ALSO, MORE THAN HALF THE NUMBER OF INFANTS WITH AIDS ARE BLACK AND ANOTHER 24 PERCENT ARE HISPANIC, AGAIN, THESE ARE HIGHLY DISPROPORTIONATE FIGURES,..AND THEY MAY VERY WELL REPRESENT AN UNDER- COUNT. 17 THIS IS ADDITIONAL CATASTROPHIC NEWS FOR THE BLACK COMMUNITY. WHICH ALREADY IS UNDER GREAT ECONOMIC AND SOCIAL STRESS. AND IT’S ALSO MORE EVIDENCE OF THE APPARENT INABILITY OF AMERICAN SOCIETY IN GENERAL TO MAKE MUCH HEADWAY IN HELPING YOUNG BLACK WOMEN CONTROL THEIR OWN SEXUALITY AND THEIR OWN DESTINIES, AIDS IS DEMONSTRATING A PREFERENCE FOR A POPULATION ALREADY BURDENED WITH HIGH-RISK PREGNANCIES: THAT IS. BLACK WOMEN UNDER THE AGE OF 19...WHO ARE POOR...WHO ARE NOT READY FOR THE WORLD OF WORK... .WHO MAY NOT EVEN HAVE A HIGH SCHOOL DIPLOMA,..AND WHO DO NOT HAVE READY ACCESS -- FOR WHATEVER REASONS -- TO GOOD PRENATAL AND PERINATAL HEALTH CARE, 18 THESE ARE THE YOUNG WOMEN WHO ALSO GIVE BIRTH TO A DISPROPOR- TIONATELY LARGE NUMBER OF LOW-BIRTH-WEIGHT BABIES...BABIES BORN WITH A DRUG HABIT...BABIES WITH FETAL ALCOHOL SYNDROME...AND NOW. BABIES WITH AIDS, LIFE FOR THESE BABIES IS A STRUGGLE FROM “DAY ONE”...AND MANY OF THEM NEVER MAKE IT TO “DAY TWO.” SO FAR I’VE TALKED ABOUT THE WAYS IN WHICH CHILDREN GET AIDS AND WHO THOSE CHILDREN ARE MOST LIKELY TO BE, NOW LET ME TURN TO THE NEXT QUESTION: WHAT HAPPENS TO THE CHILDREN WHO ARE BORN WITH AIDS? WHAT ARE WE DOING FOR THEM? 19 IN ORDER TO GET SOME ANSWERS TO THOSE QUESTIONS, I CONVENED A SURGEON GENERAL'S WORKSHOP ON PEDIATRIC AIDS IN LATE MARCH, I CAN TELL YOU THAT THIS COUNTRY HAS MANY, MANY DEDICATED PEOPLE WORKING IN OUR CHILDREN’S HOSPITALS AND PEDIATRIC CENTERS. BUT, AS DEDICATEED AS THEY AND AS HARD AS THEY WORK, THEY ARE NEVERTHELESS SERIOUSLY HANDICAPPED BY THE SCARCITY OF SERVICES AVAILABLE TO NEWBORN AIDS VICTIMS AND THEIR FAMILIES. THERE ARE VIRTUALLY NO PROGRAMS WHICH PROVIDE COORDINATED, COMMUNITY-BASED CARE FOR PEDIATRIC H.1.V.-INFECTED PATIENTS. AND 1T’S ABOUT THE SAME SITUATION WITH FOSTER CARE. BECAUSE OF THE STIGMA OF AIDS. THERE ARE FEWER FOSTER HOMES OPEN TO INFANTS AND CHILDREN WITH AIDS. I'D SAY THAT THE STIGMA OF AIDS HAS BECOME AN INVISIBLE BUT VIRTUALLY INPENETRABLE BARRIER BETWEEN THESE CHILDREN AND A WHOLE VARIETY OF SOCIAL AND PUBLIC HEALTH SERVICES THAT THEY DESPERATELY NEED. 1’VE HEARD FROM MANY HEALTH WORKERS WHO ARE IN AREAS WITH CONCENTRATIONS OF HIGH-RISK POPULATIONS. THEY TELL ME THAT THEIR PEDIATRIC UNITS ARE ALREADY OVERWHELMED BY THE SOCIAL AND MEDICAL DEMANDS OF BOTH ILL AND WELL CHILDREN WITH AIDS INFECTIONS. 2] THEY COME FROM PUERTO RICO, WHERE 21 SUCH CHILDREN HAVE BEEN BORN WITH AIDS, THEY’RE FROM FLORIDA, WHICH HAS HAD 60 SUCH CHILDREN...NEW JERSEY. WHICH HAS HAD 68,...AND NEW YORK, WHICH HAS HAD 184 INFANTS BORN WITH AIDS. THE PLAIN FACT OF THE MATTER IS THAT THE COUNTRY DOES NOT HAVE ENOUGH HOSPITAL PERSONNEL TO PROVIDE AND COORDINATE THE MULTI- DISCIPLINARY INPATIENT, OUTPATIENT, AND COMMUNITY CARE THESE CHILDREN NEED,..MUCH LESS THE PLAIN HUGGING AND PLAYING THAT THESE CHILDREN, LIKE ALL CHILDREN EVERYWHERE, NEED AND OUGHT TO RECEIVE. SOME PEDIATRIC HOUSE STAFF ADMIT THAT THEIR NEONATAL EXPERIENCE UP TO NOW HAS NOT PREPARED THEM AT ALL FOR TAKING CARE OF NEONATES WITH AIDS. NOR ARE THEY PREPARED TO DEAL WITH YOUNG MOTHERS WITH AIDS AND A DRUG ADDICTION. MOST OF THESE CHILDREN ARE NOT ONLY ABANDONED BY THEIR MOTHERS BUT. AS IT APPEARS, BY SOCIETY, ALSO, OUR PROFESSIONAL ETHICS AND OUR NATIONAL PUBLIC HEALTH POLICY REQUIRE OF US THAT WE GIVE SUCH AFFLICTED CHILDREN AS NORMAL AND AS DIGNIFIED A LIFE EXPERIENCE AS POSSIBLE...FOR AS LONG AS POSSIBLE. 25 THEY MUST BE NURTURED, HELPED TO GROW AND DEVELOP, ALLOWED 10 INTERACT WITH PEERS, AND ATTEND SCHOOL. WE MUST ENCOURAGE THEM TO ENJOY AND PARTICIPATE IN ALL ACTIVITIES OF CHILDHOOD, DESPITE THE REAL POSSIBILITY THAT MOST OF THEM WILL DIE OF AN AIDS-RELATED DISEASE. UNDER ALL CIRCUMSTANCES WE MUST REMAIN COMMITTED TO PROVIDING THJEM WITH HUMANE AND DIGNIFIED CARE. AND WE MUST BE WILLING TO BEAR THE RESPONSIBILITIES AND ALL THE COSTS DURING THE SHORT. TROUBLED LIVES OF MOST OF THESE CHILDREN, THE NUMBER OF BABIES BORN WITH PEDIATRIC AIDS IS NOT LARGE ALL BY ITSELF: AS I MENTIONED A MOMENT OR SO AGO, THE CUMULATIVE TOTAL REACHED 501 AS OF LAST WEEK. 24 BUT IF WE LOOK ONLY AT THE NUMBERS, WE’LL MISS THE TRUE MEANING OF WHAT’S GOING ON. AND HERE I’M AGAIN EMPHASIZING THE PROFOUND DYSFUNCTION THAT IS TAKING PLACE IN THE FAMILY LIFE OF A SIGNIFICANT NUMBER OF OUR FELLOW AMERICANS, FROM THIS PERSPECTIVE, THEN. YOU MIGHT EVEN SAY THAT PEDIATRIC AIDS IS NOT -- BY ITSELF -- THE ISSUE. RATHER, IT IS MORE -- AND DEADLIER -- EVIDENCE OF LARGER THE ISSUES FACING OUR SOCIETY AS A WHOLE... ISSUES OF BARRIERS TO HEALTH CARE... OF THE INEQUALITY OF OPPORTUNITY... OF RACIAL, ETHNIC, AND CULTURAL SEPARATION... ISSUES OF ISOLATION... AND OF THE CLASH BETWEEN PERSONAL AND COMMUNITY VALUES, CHILDREN WITH AIDS ARE INNOCENT VICTIMS OF A DISEASE. YES. BUT THEY ARE ALSO A LIVING INDEX OF OTHER TROUBLES WITHIN OUR SOCIETY... TROUBLES WHICH WE MUST CONTINUE TO ADDRESS, IF WE WISH TO IMPROVE THE DELVIERY OF MATERNAL AND CHILD HEALTH CARE IN THIS COUNTRY. THIS, THEN, HAS BEEN A BRIEF OVERVIEW OF ONE ASPECT OF THE AIDS TRAGEDY THAT IS PARTICULARLY DISTURBING TO THOSE OF US CONCERNED WITH THE HEALTH AND WELFARE OF CHILDREN. IT IS AN ASPECT FROUGHT WITH STIGMA AND DISCRIMINATION... WITH CONFUSION AND FRUSTRATION...AND WITH MUCH PAIN AND CERTAIN DEATH, 26 IT 1S VERY DIFFICULT TO ENTER A HOSPITAL NURSERY AND SEE THESE TINY VICTIMS OF THEIR PARENTS’ DANGEROUS BEHAVIOR, SUCH CHILDREN -- IN THEIR INNOCENCE -- BRING A MESSAGE THAT IS, IN FACT, QUITE "DISCOURAGING OF MAN.” BUT | DON’T BELIEVE THAT’S THEIR FINAL MESSAGE. THEIR TRAGIC LIVES AND PAINFUL DEATHS ARE A REBUKE TO US, THAT'S TRUE. BUT THEY ARE ALSO A WARNING TO CHANGE. I THINK PEOPLE WILL CHANGE THEIR BEHAVIOR...1 THINK THE GUILT OF THIS DISEASE -- ESPECIALLY AS IT AFFECTS CHILDREN -- IS MORE THAN MOST PEOPLE CAN ENDURE. AND THEY WILL CHANGE, WE MUST BE THERE TO HELP THEM CHANGE AND, IN SO DOING. RE-AFFIRM OUR COMMITMENT TO CHILDREN,..TO LIFE.,..AND TO THE FUTURE. THANK YOU, HHH # #