ORIGINAL

t |

ADDRESS
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

a

PRESENTED TO THE HARVARD AIDS INSTITUTE
Boston, MASSACHUSETTS
DECEMBER 1, 1988
1
(GREETINGS TO HOSTS, GUESTS, FRIENDS, ETC.)

I APPRECIATE THIS OPPORTUNITY TO SPEAK AT THIS SPECIAL JOINT
MEETING. YOU HAVE QUITE A FULL SCHEDULE AHEAD OF YOU, PACKED
WITH PRESENTATIONS BY A TRULY IMPRESSIVE ARRAY OF EXPERTS ON A
BROAD RANGE OF AIDS-RELATED ISSUES.

I THINK THE PLANNERS OF THIS MEETING HAVE DONE AN
OUTSTANDING JOB IN BRINGING TOGETHER SUCH A FACULTY. IT
CERTAINLY REFLECTS A MORE THAN CASUAL INVOLVEMENT BY THE SEVERAL
CO-SPONSORING AND COOPERATING ORGANIZATIONS WHO’VE MADE THIS ALL
POSSIBLE:

THE AMERICAN FOUNDATION FOR AIDS RESEARCH ... THE AMERICAN
SOCIETY OF LAW AND MEDICINE .., THE HARVARD SCHOOL OF PUBLIC
HEALTH AND THE AIDS INSTITUTE ... THE AMERICAN PUBLIC

HEALTH ASSOCIATION ... THE AMERICAN HOSPITAL ASSOCIATION ...
AND MANY, MANY OTHERS.
2
T WISH I COULD STAY TO LISTEN TO ALL THE PRESENTATIONS, BUT

I CAN'T, HOWEVER, I KNOW THERE WILL BE A VOLUME OF PROCEEDINGS,
AND I LOOK FORWARD TO ITS PUBLICATION, EVEN THOUGH SUCH BOOKS
USUALLY DO NOT CAPTURE THE GIVE-AND-TAKE THAT GOES ON IN A PUBLIC
MEETING. SO I ENVY THOSE OF YOU WHO ARE ABLE TO STAY AND ABSORB
WHAT WILL BE SAID OVER BOTH DAYS.

A PROGRAM WITH SUCH AN EMBARRASSMENT OF RICHES MAKES MY
POSITION HERE A BIT AWKWARD, SINCE I DO NOT ADVERTISE MYSELF AS
BEING ESPECIALLY KNOWLEDGEABLE IN PUBLIC HEALTH FINANCING ... OR
IN VIROLOGY ... OR IN MODALITIES OF PATIENT CARE FOR PEOPLE WITH
AIDS,

SO I WILL BE PRUDENT AND LEAVE THOSE KINDS OF [SSUES TO THE
OUTSTANDING SPEAKERS AND PANELISTS COMING ALONG OVER THE
REMAINDER OF TODAY AND TOMORROW.

STILL, THE ASSIGNED TITLE OF MY REMARKS THIS MORNING IS
SUFFICIENTLY AWESOME TO INTIMIDATE MOST OF YOU AS WELL AS IT DOES
ME: “SETTING PRIORITIES AND DEVELOPING POLICIES FOR THE NEXT
DECADE.”
3
ONE MIGHT THINK THAT THE SUBSTANCE BEHIND SUCH A TITLE WOULD

MORE LIKELY BE DEDUCED OVER THE COURSE OF THIS MEETING AND THEN
ANNOUNCED AT ITS CLOSE, RATHER THAN HAVE IT ALL PRESENTED AT THE
VERY BEGINNING,

AND THAT WOULD CERTAINLY BE TRUE, IF I CHOSE TO DEAL WITH
THESE MATTERS IN A NARROW SENSE. BUT I WON’T AND IT HOPE MY
REMARKS ENCOURAGE EACH OF YOU ALSO TO PURSUE MY MORE GENERAL
APPROACH TO THE MATTER,

THERE WAS, AT ONE TIME, A SUGGESTION THAT THE SURGEON
GENERAL BE A KIND OF “CZAR” FOR THE TOTAL GOVERNMENT EFFORT
AGAINST AIDS. FORTUNATELY, IT WAS AN IDEA THAT SUDDENLY APPEARED
AND JUST AS QUICKLY -- AND MERCIFULLY -- DISAPPEARED.

HENCE, I ADDRESS YOU THIS MORNING AS YOUR SURGEON GENERAL,
AND I‘LL SPEAK FROM THE SPECIAL PERSPECTIVE OF THAT OFFICE ... A
PERSPECTIVE, I WOULD ADD, THAT MAY BE PARTICULARLY IMPORTANT AT
THIS TIME IN THE BRIEF BUT CATASTROPHIC HISTORY OF THE AIDS
EPIDEMIC.
4
I DO HAVE SOME IDEAS ABOUT POLICIES AND PRIORITIES FOR

AIDS, BUT ONLY IN THE CONTEXT OF OUR OVERALL NATIONAL PUBLIC
HEALTH EFFORT. AND THAT’S WHAT I WANT TO SHARE WITH YOU DURING
OUR FEW MINUTES TOGETHER THIS MORNING:

IN OTHER WORDS, I WANT TO FOCUS ON THE POSITION OF THE AIDS
EPIDEMIC, RELATIVE TO THE MANY OTHER PUBLIC HEALTH MATTERS
ON OUR NATIONAL AGENDA.

THIS IS NOT AN EASY THING TO DO BECAUSE THE HEALTH AND
WELL-BEING OF SO MANY MILLIONS OF PEOPLE ARE AT STAKE, RIGHT
ACROSS THE BOARD,

ALSO -- TO MY MIND, AT LEAST -- WHILE THE AMERICAN PEOPLE
ARE QUITE AWARE OF AIDS, THEY HAVE NOT YET GIVEN A CLEAR SIGNAL
TO INDICATE WHAT THEY REALLY WANT TO DO ABOUT IT.

 
5
AND SO, FOR BETTER OR FOR WORSE, THOSE OF US IN PUBLIC

HEALTH WHO ARE CONCERNED ABOUT THE PLANNING AND THE ORGANIZING

AND THE FUNDING TO SERVE A VARTETY OF NEEDY AND WORTHY PEOPLE,

TEND TO FALL BACK UPON OUR OWN PREDISPOSITIONS FOR THE ULTIMATE
GUIDANCE,

IN OTHER WORDS, THE QUESTION BECOMES THIS: “HOW DO I FEEL
ABOUT THE AIDS EPIDEMIC AND WHAT DO L THINK OUGHT TO BE DONE
ABOUT IT?” [ THINK THIS IS ESPECIALLY THE CASE AT THE STATE AND
LOCAL LEVELS, WHERE THERE IS STILL MUCH AMBIVALENCE AND WHERE THE
LAW AND STANDARDS OF PRACTICE AND PATIENT EXPECTATIONS ARE ALL

STILL EVOLVING,

THAT’S NOT THE MOST STABLE SITUATION FOR “SETTING
PRIORITIES” AFTER “DEVELOPING POLICIES” FOR THE HANDLING OF THIS
EPIDEMIC. NEVERTHELESS, I THINK IT’S A CLOSE APPROXIMATION OF
WHAT IS GOING ON AND [ THINK WE’D DO WELL TO RECOGNIZE IT AT THE
VERY BEGINNING,
6
IF THAT IS THE CASE -- THAT THERE IS STILL NO CLEAR SIGNAL

FROM THE PUBLIC ABOUT THE AIDS EPIDEMIC -- DOES THAT MEAN WE ARE
OPERATING IN A KIND OF SOCIAL AND MEDICAL LIMBO, OUTSIDE THE
PERIMETER OF PUBLIC HEALTH?

NO, WE AREN’T, OR AT LEAST, WE SHOULDN’T BE. AND THAT’S MY
POINT THIS MORNING,

STRICTLY SPEAKING, THE GOAL OF THE PUBLIC HEALTH SERVICE IS
TO HELP -- IN CONCERT WITH THE PRIVATE SECTOR -- TO PROTECT AND
IMPROVE THE HEALTH OF THE NATION,

THE PUBLIC HEALTH SERVICE DOES THIS -- WITH THE PRIVATE
SECTOR -- BY DEVELOPING POLICIES, SETTING PRIORITIES, AND GUIDING
IMPLEMENTATION, IN ORDER TO ASSURE THE DELIVERY OF REASONABLE
CARE AT REASONABLE COST TO PREVENT ILLNESS AND DISEASE.

THE PUBLIC HEALTH COMMUNITY SEES THE ROLE OF THE PUBLIC
HEALTH SERVICE IN THAT WAY, ALTHOUGH AT HAVE TIMES THEY MAY HAVE
A MUCH BROADER VIEW.

 
7
NOW, LET’S LOOK AT THAT QUESTION OF PRIORITIES.

I BELIEVE THAT -- BY ANY STANDARD YOU WISH TO USE -- OUR
FIRST NATIONAL PRIORITY IN PUBLIC HEALTH IS TO PROTECT AND
IMPROVE THE HEALTH STATUS OF ALL PREGNANT WOMEN, NURSING MOTHERS,
AND INFANTS THROUGH THEIR FIRST YEAR OF LIFE.

AS PUBLIC HEALTH PROFESSIONALS, OF COURSE, MANY OF US ARE
"PREDISPOSED” TO THIS PRIORITY, BUT OVER THE YEARS THE AMERICAN
PEOPLE HAVE ALSO SPOKEN CLEARLY ON THE MATTER AS WELL. THERE
HAVE BEEN MANY EMERGENCIES ... NEW VIRULENT DISEASES ... NEW
ENVIRONMENTAL CHALLENGES ... AND, AT THE TIME, THEY CREATED
WIDESPREAD FEAR AND DISTRESS.

BUT THROUGHOUT THE DECADES, OUR FIRST PRIORITY HAS BEEN TO
IMPROVE THE HEALTH OF MOTHERS AND CHILDREN,

AND, TO BE QUITE PLAIN ABOUT IT, WE OUGHT TO BE CONCERNED
ABOUT CHILD-BEARING AND DELIVERY, A PHENOMENON THAT OCCURS CLOSE
TO 4 MILLION TIMES IN OUR SOCIETY EACH YEAR.
8
ASIDE FROM THE IMMEDIATE MORBIDITY OR MORTALITY AT THE TIME

OF CHILDBIRTH, WE MUST ALSO BE CONCERNED ABOUT THE LONG-TERM
PROBLEMS OF HUNDREDS OF THOUSANDS OF OUR PEOPLE WHO LIVE THEIR
LIVES UNDER GREAT AND IRREVERSIBLE STRESS, BOTH PHYSICAL AND
MENTAL.

SO IT IS AN ALTOGETHER APPROPRIATE NATIONAL COMMITMENT TO
PLACE AT THE TOP OF OUR LIST OF PRIORITIES.

IT IS ALSO THE KIND OF COMMITMENT THAT WE MUST MAKE, IN
ORDER TO EFFECTIVELY DEAL WITH MANY OTHER ISSUES IN PUBLIC
HEALTH,

FOR EXAMPLE, IF WE HONOR OUR DEBTS TO MATERNAL AND CHILD
HEALTH, I WOULD SAY WE ARE THEREFORE PREPARED TO CARE FOR THE
PREGNANT WOMAN WITH AIDS -- AND FOR HER CHILD, WHO HAS A GOOD
CHANCE OF BEING INFECTED, ALSO.

AND SO FAR, I THINK WE‘RE DOING THAT. BUT CAN WE MAKE SURE
WE WILL DO SO IN THE FUTURE?
9
I BELIEVE WE CAN BEST TRY TO MAINTAIN OR IMPROVE OUR LEVEL

OF EFFORT IN REGARD TO MATERNAL AND PEDIATRIC AIDS BY MAINTAINING
OR IMPROVING OUR OVERALL NATIONAL COMMITMENT TO MATERNAL AND
CHILD HEALTH.

I SEE THEM AS INSEPARABLE ISSUES.

AND, THEREFORE, I BELIEVE WE WILL CARE FOR EVERY BABY WITH
AIDS -- WHATEVER THE REQUIREMENTS ARE IN HUMAN AND FISCAL TERMS.

YOU MAY RECALL THAT, AT TIMES, SOME PEOPLE HAVE RAISED
ARGUMENTS AGAINST PROVIDING SUCH CARE. THEY ARGUED AGAINST
PROVIDING CARE FOR “BABY DOE.” BUT THEIR ARGUMENTS WERE
DEFEATED.

AS A RESULT OF THAT KIND OF EVOLUTION IN PUBLIC HEALTH
POLICY, WE -- AS A CIVILIZED, POST-INDUSTRIAL SOCIETY -- WILL
CARE FOR MOTHERS AND BABIES WITH AIDS. WE DO SO NOT BECAUSE
THEY HAVE AIDS OR ANY OTHER DISEASE, BUT BECAUSE THEY ARE MOTHERS
AND CHILDREN.
10
THEREFORE, A FIRST NATIONAL PUBLIC HEALTH PRIORITY, WITH

STRONG IMPLICATIONS FOR OUR FIGHT AGAINST AIDS, IS OUR COMMITMENT
TO MATERNAL AND CHILD HEALTH,

A SECOND NATIONAL HEALTH PRIORITY, FOR WHICH THERE IS
UNIVERSAL AGREEMENT IN OUR COUNTRY, IS TO PROVIDE FOR OUR ELDERLY
CITIZENS WHATEVER HEALTH AND MEDICAL CARE THEY REQUIRE.

THERE IS MUCH DEBATE SURROUNDING THIS PRIORITY. BUT PLEASE
NOTE THAT, AT LEAST FOR THE MOMENT, THE AMERICAN PEOPLE AREN'T
DEBATING WHETHER THEY SHOULD OR SHOULD NOT PROVIDE SUCH CARE.
THE CURRENT DEBATE REVOLVES ALMOST EXCLUSIVELY AROUND HOW TO PAY
FOR SUCH CARE WITHOUT IN ANY WAY COMPROMISING OUR COMMITMENT TO
PROVIDE IT.

THAT DOESN'T MAKE THE DEBATE ANY SIMPLER.
11
IN ADDITION, AS WITH OUR COMMITMENT TO MOTHERS AND CHILDREN,

WE IN PUBLIC HEALTH ARE COMMITTED TO CARING FOR OUR ELDERLY
WITHOUT QUALIFICATION ... THAT IS, WE ARE COMMITTED TO PROVIDE
APPROPRIATE CARE, WHETHER THE ELDERLY PERSON HAS ONE, TWO, OR
MORE CHRONIC CONDITIONS ... WHETHER HE OR SHE IS IN SOME WAY
DISABLED OR NOT ... AND WHETHER OR NOT THE ELDERLY PERSON IS A
MEMBER OF A MINORITY GROUP OR A MAJORITY GROUP. IT DOESN'T
MATTER.

 

PART OF THIS COMMITMENT TO THE AGED OBVIOUSLY REQUIRES THAT
WE TRY TO CARE FOR THE OLDER PERSON WHO IS TERMINALLY ILL. AND
SO WE‘VE ERECTED A FAIRLY ELABORATE SYSTEM OF “HALFWAY” CARE AND
SKILLED NURSING CARE AND HOSPICE CARE.

IN OTHER WORDS, WE AMERICANS HAVE REACHED A CONSENSUS THAT
IT IS RIGHT AND PROPER FOR OUR SOCIETY TO MAKE SURE THAT
EVERYTHING NECESSARY BE DONE FOR ANYONE GOING THROUGH THE FINAL
STAGES OF LIFE.

SUCH A CONSENSUS, WE SEEM TO BE SAYING, IS FURTHER EVIDENCE
OF OUR COMPASSION AND GENEROSITY AS AN ADVANCED CIVILIZATION.
12
IT'S NOT AN IDEA THAT WE EMBRACE LIGHTLY, I SHOULD ADD.

SOME 2 TO 3 MILLION OF OUR PEOPLE DIE EACH YEAR FROM A VARIETY OF
CAUSES, NOT JUST FROM THOSE DISEASES THAT COME WITH ADVANCED AGE.
THE GREAT MAJORITY OF THOSE PEOPLE DIE WITHOUT REQUIRING ANY
SPECIAL CARE.

BUT -- RELATIVELY SPEAKING -- A FEW PEOPLE DO. AND SO WE'VE
ORGANIZED A GOOD PART OF OUR HEALTH AND MEDICAL CARE SYSTEM TO
PROVIDE SUCH SPECIAL CARE.

| BELIEVE THAT THE AMERICAN PEOPLE HAVE AGREED ON AN
OVERALL NATIONAL COMMITMENT TO EASE THE BURDEN OF TERMINAL
ILLNESS FOR THE INDIVIDUAL AND FOR HIS OR HER FAMILY.

THEREFORE, AND CONSISTENT WITH THIS OVER-ARCHING COMMITMENT
TO THE AGED, EVEN WHEY THEY ARE TERMINALLY ILL, I ALSO BELIEVE
THAT THE AMERICAN PEOPLE WILL CONTINUE TO PROVIDE THE NECESSARY
AND APPROPRIATE CARE FOR TERMINALLY ILL PERSONS WITH AIDS.
13
TO ACHIEVE THESE TWO PUBLIC HEALTH PRIORITIES -- CARE FOR

MOTHERS AND CHILDREN AND CARE FOR OUR AGED AND THE TERMINALLY --
WE NEED CERTAIN SUPPORT ACTIVITIES. AND KEY AMONG THEM IS
RESEARCH,

 

] BELIEVE THE PEOPLE OF THIS COUNTRY ARE GENUINELY COMMITTED
TO A STRONG AND INNOVATIVE BIOMEDICAL RESEARCH PROGRAM,

WE’VE HAD SUCH A PROGRAM FOR MOST OF THIS CENTURY. IT HAS
YIELDED EXTRAORDINARY BENEFITS FOR THE HEALTH OF AMERICANS AND,
INDEED, FOR ALL MANKIND.

AND ITS VERY STRENGTH AND BREADTH HAVE MADE IT AN EXCELLENT
BASE UPON WHICH TO MOUNT A RESEARCH PROGRAM TARGETED SPECIFICALLY
TO AIDS. 1 BELIEVE OUR AIDS RESEARCH PROGRAM HAS BEEN QUITE
SUCCESSFUL SO FAR, EVEN THOUGH MUCH MYSTERY STILL SURROUNDS THE
VIRUS,

T ALSO BELTEVE THAT WE‘LL CONTINUE TO MAKE GOOD PROGRESS IN
AIDS RESEARCH, IF WE MAINTAIN AN OPTIMUM BIOMEDICAL RESEARCH
ENTERPRISE ACROSS THE BOARD.
14
SO FAR THIS MORNING I’VE DISCUSSED WHAT I BELIEVE ARE OUR

TWO TOP NATIONAL HEALTH PRIORITIES: MATERNAL AND CHILD HEALTH
AND HEALTH CARE FOR THE AGED. 1’VE ALSO MENTIONED THE KEY
SUPPORTING ROLE OF BIOMEDICAL RESEARCH. AND I’LL STOP THERE,

1 DON’T BELIEVE I NEED TO GO THROUGH THE WHOLE GAMUT OF
HEALTH AND MEDICAL ISSUES TO MAKE MY CENTRAL POINT, WHICH IS
THIS:

* WE CAN BEST STRENGTHEN ALL OUR AIDS RESEARCH AND PATIENT
CARE EFFORTS, IF WE RECOGNIZE THE RELATIONSHIP OF THOSE
EFFORTS TO WHAT WE ARE ALREADY COMMITTED TO IN HEALTH AND
MEDICAL CARE.

* IN OTHER WORDS, WE MUST NOT ISOLATE OUR EFFORTS IN AIDS FROM
THE MAINSTREAM OF PUBLIC HEALTH AND MEDICINE, DESPITE THE
MANY TEMPTATIONS TO DO SO.

WE’VE ALREADY HAD SEVERAL OPPORTUNITIES TO DEAL WITH AIDS AS
A SEPARATE AND SPECIAL PUBLIC HEALTH MATTER. AND SOME OF THOSE
OUTCOMES HAVE NOT BEEN POSITIVE.
15
YES, IT LS A SEXUALLY TRANSMITTED DISEASE, BUT -- SOME

PEOPLE HAVE SAID -- IT’S REALLY NOTHING MORE THAN THAT AND,
THEREFORE, WE DON’T NEED ANY SPECIAL SAFEGUARDS FOR
CONFIDENTIALITY BEYOND WHAT WE ALREADY HAVE FOR S.T.D.’s.

OR WE‘VE SAID, YES, IT LS POSSIBLE THAT A DRUG MAY HELP
STABILIZE OR EVEN REVERSE AN ASPECT OF THIS DISEASE. BUT -- SOME
PEOPLE HAVE SAID -- DRUGS TO FIGHT AIDS ARE REALLY DIFFERENT AND
THEY OUGHT NOT TO BE BOUND BY THE GENERALLY ACCEPTED RULES OF
DRUG SAFETY AND EFFICACY.

YES, AIDS CAN BE A HANDICAPPING CONDITION TO A LESSER OR
GREATER DEGREE, BUT -- SOME PEOPLE HAVE SAID -- AIDS IS REALLY
QUITE DIFFERENT AND HAVING AIDS OUGHT TO BE REASON ENOUGH TO BE
BARRED FROM EMPLOYMENT, SCHOOLING, HOUSING, AND OTHER NORMAL
SOCIAL ENVIRONMENTS.
16
AND, YES, WE SHOULD MAKE SURE THAT NO HEALTH PROFESSIONAL

"NOES HARM” TO A PERSON WITH AIDS THROUGH TESTING OR THROUGH POOR
RECORD-KEEPING, BUT -- SOME PEOPLE HAVE SAID -- HAVING AIDS IS
DIFFERENT AND, THEREFORE, A PERSON WITH AIDS SHOULD BE FREE NOT
TO KNOW IF HE OR SHE HAS THE VIRUS AND LIKEWISE FREE TO POSSIBLY
“DO HARM” TO SOMEONE ELSE THROUGH A SEXUAL ENCOUNTER,

AS THESE FEW EXAMPLES MAY SHOW -- AND THEY’RE ONLY A FEW OF
MANY wan

* IT’S IMPORTANT THAT WE APPLY TO AIDS THE SAME ETHICAL
STANDARDS WE APPLY TO PUBLIC HEALTH AND SOCIAL RELATIONSHIPS
IN GENERAL «+.

* IT’S IMPORTANT THAT WE NOT PLEAD THAT AIDS SOMEHOW BELONGS
OUTSIDE THE ACCEPTED UNIVERSE OF MAJOR NATIONAL PUBLIC
HEALTH CONCERNS ...

* AND IT’S IMPORTANT THAT WE DEAL WITH THIS EPIDEMIC WITHIN A
STRENGTHENED FRAMEWORK OF OVERALL PUBLIC HEALTH POLICY-MAKING
AND PRIORITY-SETTING,
17
SO I WOULD ASK THAT, ON THIS “WORLD AIDS DAY” COMMEMORATION,

WE DEDICATE OURSELVES NOT ONLY TO THE ERADICATION OF THIS
CALAMITOUS DISEASE OF AIDS, BUT THAT WE ALSO RE-DEDICATE
OURSELVES TO THE TOTAL PUBLIC HEALTH COMMITMENT THAT HAS BEEN
MADE BY THIS SOCIETY.

THANK YOU,
HHH # #