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ADDRESS

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

PRESENTED TO THE PRESIDENT’S COMMSSION ON AIDS
WASHINGTON, D.C,
SEPTEMBER 9, 1987
DR, MAYBERRY AND MEMBERS OF THE COMMISSION...

MY COLLEAGUES HAVE THUS FAR TOUCHED UPON A RANGE OF
EPIDEMIOLOGICAL AND BIOMEDICAL ISSUES REGARDING THE PANDEMIC OF
AIDS, AND I SEE NO REASON TO GO OVER THAT MATERIAL AGAIN,

INSTEAD, I WOULD LIKE TO SPEND THE NEXT FEW MOMENTS SHARING
WITH YOU A NUMBER OF CONCERNS THAT HAVE BEEN BROUGHT TO MY
ATTENTION, AS I HAVE TRAVELED ABOUT THIS COUNTRY AND ALSO OVERSEAS.

FIRST, LET ME EMPHASIZE AGAIN 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 PURELY SCIENTIFIC ISSUES
PALE IN COMPARISON TO THE HIGHLY SENSITIVE ISSUES OF LAW, ETHICS,
ECONOMICS, MORALITY. AND SOCIAL COHESION THAT ARE BEGINNING TO
SURFACE,

I BELIEVE WE ARE 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,
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 CONTINUE TO PROVIDE
QUALITY, COMPASSIONATE CARE TO PERSONS DYING OF 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? 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, 1’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.

WHAT SHALL WE DO TO 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: WHO
SHOULD BEAR THAT COST?

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, AS WELL AS 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 AMERICAN PEOPLE. AS
THE CONSTITUTION INSTRUCTS,

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

ON THE OTHER HAND, AIDS IS PROVING TO BE VERY EXPENSIVE. THEN,
AFTER CONSUMING TENS OF THOUSANDS OF DOLLARS WORTH OF MEDICAL CARE
AND SOCIAL SERVICES... THE AIDS PATIENT DIES.
AS THE AIDS CASE-LOAD CLIMBS AND THE COSTS RISE. ALSO, WILL THE
AMERICAN PEOPLE CONTINUE TO SUPPORT SUCH CARE? OR WILL THEY ASK FOR
RELIEF AND SUPPORT ONLY SECOND-CLASS CARE FOR AIDS PATIENTS?

HOW SHOULD WE RESPOND TO THAT POSIBILITY? IT IS A VERY
TROUBLING QUESTION FOR DOMESTIC PUBLIC POLICY.

OTHERS HAVE ALREADY MENTIONED THE ISSUE OF INDIVIDUAL PRIVACY
versus THE NEED TO PROTECT THE COMMUNITY FROM DANGER, NEITHER SIDE
OF THE QUESTION REQUIRES AN ABSOLUTE RESPONSE. BUT HOW MUCH LEEWAY
DO WE HAVE, AS A FREE BUT REPSONSIBLE PEOPLE? HOW MUCH RISK CAN THE
COMMUNITY TOLERATE IN ORDER TO PRESERVE THE RIGHTS OF INDIVIDUALS.

 
THIS IS THE HEART OF THE DEBATE OVER CONFIDENTIALITY IN
RECORDS. IT HAS BEEN A LONG-STANDING PRACTICE IN PUBLIC HEALTH TO
GET AS MUCH SENSITIVE, HEALTH-RELATED INFORMATION AS POSSIBLE FROM
THE INDIVIDUAL, IN EXCHANGE FOR A GUARANTEE OF CONFIDENTI- ALITY,
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 PREVENTION,

WE IN PUBLIC HEALTH 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 AGAIN. WE MUST BE CAREFUL OF TAKING AN ABSOLUTE 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
GENERALLY REGARDING 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 TO THE CHILD
VICTIM DURING THE SEXUAL ATTACK.
WE NEED TO KNOW THAT BECAUSE A CHILD WITH THE AIDS VIRUS SHOULD
NOT RECEIVE THE ROUTINE SERIES OF VACCINATIONS THAT NEARLY EVERY
CHILD IN AMERICA NOW GETS, FOR THE CHILD WITH AIDS, VACCINATION
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. BUT
SHOULD THE SCHOOL BE TOLD? SHOULD THE CHILD’S RELIGIOUS
CONGREGATION BE TOLD? HOW MUCH OF THE PUBLIC HAS A “NEED 10 KNOW”
WHETHER OR NOT THE CHILD IS SEROPOSITIVE?

I HAVE MAINTAINED 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 HUOSING... HAVE BEEN
SENT HOME FROM SCHOOL...AND SO ON.
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THESE REACTIONS HAVE BEEN IRRATIONAL, UNFAIR, AND DISCRIM-
INATORY. WHAT SHOULD WE DO ABOUT IT? HOW CAN WE DEAL WITH THESE
INCLINATIONS TOWARD DISCRIMINATION?

SOME PEOPLE HAVE ARGUED 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 THE GREAT MARCH OF PUBLIC POLICY OVER THE PAST CENTURY IN
THIS COUNTRY HAS BEEN TO REDUCE OR ELIMINATE ALTOGETHER CRITERIA FOR
ELIGIBILITY TO RECEIVE ESSENTIAL PUBLIC SERVICES.

IS AIDS THE EXCEPTION? AND WHY?
ll

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.

THIS COUNTRY 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 -- BY ITSELF -- REVERSE THIS TREND OF
HISTORY? WE HOPE AND PRAY THAT IT WILL NOT.
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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,

HOW CAN THIS COMMISSION CONTRIBUTE TO THAT LEADERSHIP? HOW CAN
YOU...AND 1...AND EVERY AMERICAN INSURE THAT OUR COUNTRY WILL NOT
RETURN IN FEAR AND HATRED TO THE WAYS OF A SHAMEFUL PAST.

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,

CAN WE REMAIN COLOR-BLIND IN THIS WAR AGAINST AIDS? HOW CAN WE
MAKE SURE WE DO?
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THESE AND OTHER ISSUES LIE BEFORE YOU. AS I INDICATED EARLIER,
THEY ARE EVERY BIT AS COMPLEX AS THE PURELY SCIENTIFIC ISSUES ARE,
AND THEY NEED EVERY BIT AS MUCH OF YOUR BEST THINKING AND
LEADERSHIP,

IN MY ROLE AS DIRECTOR OF THE OFFICE OF INTERNATIONAL HEALTH, |
HAVE HAD MANY OCCASIONS TO SPEAK WITH THE HEALTH MINISTERS OF OTHER
NATIONS 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 HAS REACHED 14,600, WE HAVE EVERY REASON 10
BELIEVE THAT SUCH A FIGURE REPRESENTS VERY LOW UNDER-REPORTING OF
THE DISEASE.
14

HOWEVER, THE WORLD HEALTH ORGANIZATION NOTES THAT THE NUMBERS
ARE 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,

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. THE DISEASE OF AIDS ITSELF
APPARENTLY CAME TO THESE SHORES FROM AFRICA BY WAY OF THE
CARIBBEAN. AND CLEARLY PART OF OUR SUCCESS IN CONTAINING THE
DISEASE HERE WILL DEPEND ON HOW WELL IT IS CONTAINED ELSEWHERE.
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IT WILL BE TERRIBLY SELF-DEFEATING, IF THE UNITED STATES DOES
NOT PAY ITS FULL ASSESSMENT TO THE UNITED NATIONS AND THUS ENABLE
THE WORLD HEALTH ORGANIZATION TO BE AN EFFECTIVE WORLD LEADER IN THE
FIGHT AGAINST AIDS.

HERE, AGAIN, WE MUST MAKE THE CHOICE THAT IS ETHICALLY
CORRECT. WE MUST STAND WITH OUR NEIGHBORS ON THIS TINY PLANET.
AIDS IS A TRAGEDY FOR EACH PERSON WHO IS INFECTED, BUT IT IS ALSO A
TRAGEDY FOR HUMANITY ITSELF.

THESE ARE A FEW OF THE THOUGHTS AND CONCERNS THAT HAVE RISEN IN
OUR DISCUSSIONS OVER THE PAST 6 YEARS, BUT MOST INSISTENTLY OVER THE
PAST YEAR OR SO,
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] HOPE YOU WILL INVESTIGATE THESE ISSUES AS WELL AND COME
FORWARD WITH GUIDANCE AND GOOD COUNSEL WHEN YOUR DELIBERATIONS ARE
OVER.

BEST WISHES...AND THANK YOU,

He dt HH