BY C, EVERETT KOOP, M.D,. SC.D, SURGEON GENERAL OF THE U. S$, PUBLIC HEALTH SERVICE PRESENTED TO THE 4TH PRESBYTERIAN CHURCH CHICAGO, ILLINOIS NOVEMBER 1, 1987 [3/6 (GREETINGS TO HOSTS, GUESTS, FRIENDS, ETC.) | APPRECIATE THIS OPPORTUNITY TO SPEAK WITH YOU ABOUT A RELATIVELY NEW AND VERY SERIOUS PUBLIC HEALTH MATTER WHICH AFFECTS OUR COUNTRY meee -- AND INDEED THE REST OF THE WORLD. I'M TALKING ABOUT AIDS.. LET ME TAKE JUST A MOMENT TO BRING YOU UP TO DATE ON THIS ISSUE. AND THEN | WANT TO EXPLORE SOME OF THE KEY QUESTIONS THAT AIDS POSES TO OUR SOCIETIVE TODAY...AND TOMORROW. FIRST...A LITTLE HISTORY ‘qacmaainaaiaaiiiiiili, ALMOST SIX YEARS AGO, IN JUNE 1981, THE PUBLIC HEALTH SERVICE PUBLISHED THE FIRST REPORTS OF FIVE CASES OF PNEUMOCYSTIS CARINII PNEUMONIA IN LOS ANGELES. NOW, FIVE CASES AREN'T MUCH...BUT THIS LETHAL DISEASE IS SO RARE THAT A HANDFUL OF CASES IN A SINGLE YEAR 1S LIKE AN EPIDEMIC:< PREVIOUSLY HEAILAAY INDIVIDUALS WITHOUT A Le CLINICAL YyJRPPARENT UNDERLYING {IMMUNODEFICIENCY soon, THERE WERE SIMILAR REPORTS TRICKLING IN FROM OTHER CITIES AS WELL. THEN, A MONTH LATER, 17 wal REPORRSTHAT 26 YOUNG MEN HAD BEEN Site@aniity DIAGNOSED AS HAVING KAPOSI’'S SARCOMA, "AN UNCOMMONLY REPORTED MALIGNANCY” USUALLY FOUND -- IF AT ALL -- AMONG ELDERLY MEN. 5 IN LOS ANGELES WITH PNEUMOCYSTIS, WERE YOUNG HOMOSEXUALS. aebideahhins iT ETT STS THEY © THERE wEenre 10 NEW REPORTS OF PNEUMOCYSTIS...AND ALL OF THEM INVOLVED YOUNG HOMOSEXUALS, ALSO. PUBLIC HEALTH INVESTIGATORS THEN REPORTED THAT PEOPLE WERE NOT ONLY SICK WITH THESE VERY DANGEROUS DISEASES...THEY WERE DYING OF THEM. FOR SOME MYSTERIOUS REASON, THEIR BODIES WERE NOT FIGHTING BACK. APPARENTLY THESE VICTIMS HAD ACQUIRED SOME KIND OF "BUG" -- A VIRUS, MOST LIKELY -- THAT ATTACKED AND DESTROYED THEIR NATURAL IMMUNE SYSTEMS. MEDICINE HAD NEVER COME UPON A SYNDROME QUITE LIKE IT BEFORE. WE GAVE IT A LONG TITLE: THE "ACQUIRED IMMUNE DEFICIENCY SYNDROME.” BUT WE SOON SETTLED JUST FOR THE INITIALS...A.L.D.S. ..OR “AIDS.” AND IT’S BEEN AIDS EVER SINCE. YOU'VE READ THE STORIES AND HAVE SEEN IT ON TELEVISION, I'M SURE, SO 1 WON'T GO THROUGH THE WHOLE HISTORY ALL OVER AGAIN. INSTEAD, LL JUST TOUCH ON A FEW KEY POINTS: FIRST OF ALL, WE'RE TALKING ABOUT A DISEASE THAT IS SPREADING AND IS FATAL. iT NOW TAKES 12/77 E More THAN. get A YEAR IN THE U.S. FOR THE NUMBER OF VICTIMS TO DOUBLE. FOR EXAMPLE, AT THE END OF 1985, WE HAD A CUMULATIVE TOTAL OF ABOUT 19,000 REPORTED CASES. TODAY THE TOTAL NUMBER OF AIDS Yyioe VICTIMS IS CLOSE TO aime. mMo cE THAN AYS6O QGianmmeer OF THEM HAVE ALREADY DIED OF THE DISEASE...AND THE REST PROBABLY WILL. THIS YEAR WE EXPECT TO ADD ANOTHER 23,000. AND BY THE END OF 1990 THE CUMULATIVE TOTAL WILL BE OVER A QUARTER OF A MILLION. SECOND POINT: EVEN THOUGH SCIENTISTS HAVE HAD A LOOK AT THE AIDS VIRUS, WE STILL DON’T KNOW PRECISELY WHAT IT IS. IN 1984 THE SEARCH WAS NARROWED DOWN TO SOMETHING CALLED A "HUMAN RETROVIRUS.” THE SCIENTISTS AT THE NATIONAL CANCER INSTITUTE WERE EVEN ABLE TO PIN-POINT A SPECIFIC ONE. THEY CALLED IT THE “HUMAN T-CELL LYMPHOTROPIC VIRUS TYPE 111,” OR SIMPLY "HTLV-II." THE SAME VIRUS SHOWED UP IN THE WORK OF THE PASTEUR INSTITUTE, WHERE IT BECAME KNOWN AS THE “LYMPHADENOPATHY-ASSOCIATED VIRUS,” OR "LAV." SCIENTISTS NOW AGREE TO CALL IT BY THE SINGLE COMMON NAME OF “HUMAN IMMUNODEFICIENCY VIRUS,” OR "H.I.V." THE ABILITY TO RECOGNIZE THE VIRUS WAS A VERY IMPORTANT DEVELOPMENT. ONCE YOU KNOW WHERE THE AIDS VIRUS IS, YOU CAN THEN RECOGNIZE THE PRESENCE OF ANTIBODIES SPECIFIC TO IT. OF COURSE, THOSE ANTIBODIES AREN'T VERY EFFECTIVE, BUT THEY'RE PRESENT NEVERTHELESS. AS OF 1985 WE'VE HAD A TEST THAT CAN DETECT THE PRESENCE OF THESE ANTIBODIES IN A PERSON'S BLOODSTREAM. BEFORE THE TEST WAS DEVELOPED, THE AIDS ANTIBODIES WERE TURNING UP IN ABOUT 4 OR 5 UNITS OF BLOOD PER 10,000 UNITS. NOW, SINCE SEPHED BLOOD SCREENING WAS BEGUN, THAT FIGURE HAS GQ Bevel yy awd 10 At Quang UNITS PER 1 MILLION UNITS OF TRANSFUSED BLOOD. AND, AS YOU KNOW, I'M SURE, THAT’S AS CLOSE TO PERFECT AS YOU CAN GET IN THIS KIND OF SERVICE. ON THE BASIS OF SUCH TESTING, PLUS OTHER EPIDEMIOLOGICAL DATA, WE THINK THERE ARE BETWEEN A MILLION AND A MILLION-AND-A-HALF AMERICANS WALKING AROUND WITH THE AIDS. VIRUS IN THEIR SYSTEMS. ALTHOUGH, HONESTLY, IT COULD BE 400,000 TO 4 MILLION. THEY HAVE THE VIRUS...BUT THEY AREN'T YET SICK WITH AN AIDS-RELATED DISEASE, SUCH AS op AVY otHER arpeeTunin ( sme SARCOMA OR @& Tin nee PNEUMOCYSTIS CARINII! PNEUMONIA OR KAPOSI’S enon” ONE MAJOR COMPLICATION FOR MAKING ESTIMATES FOR THE FUTURE IS THE LENGTH OF THE INCUBATION PERIOD. IT CHANGES. APPARENTLY IT CAN BE ANYWHERE FROM A YEAR OR SO IN SOME PEOPLE TO 10 | YEARS IN OTHERS. SO WE STILL CAN'T PREDICT WHICH PERSON CARRYING THE AIDS VIRUS WILL OR WILL NOT GET AN AIDS-RELATED DISEASE. - 10 - BUT IT’S NOT A 50-50 RISK. THE ODDS ARE WORSE THAN THAT. THE POSSIBILITY OF BEING OVERCOME BY AN INFECTIOUS DISEASE OF SOME KIND IS VERY, VERY HIGH. IN FACT, SOME RESEARCHERS NOW FEEL THAT ANYONE WITH THE AIDS VIRUS WILL EVENTUALLY CONTRACT AN AIDS-RELATED DISEASE IF HE LIVES LONG ENOUGH...AND WILL DIE FROM IT. THERE'S OTHER RESEARCH GOING ON AS WELL, IN THE AREA OF DRUG THERAPY AND VACCINE DEVELOPMENT. IN FACT, RESEARCH NOW COMMANDS | 2/9 ipeseae, MILLION IN U.S. FEDERAL FUNDS THIS YEAR, PLUS MANY MILLIONS MORE IN STATE AND PRIVATE SECTOR FUNDS. wire Yet ty ES fet tele Fu wniy 6 wie BE Yl3 MILEY vvT7 oF A M7 KC Feg tance 005 ExXFEAD SK IFAM oF 7 2 Biceewow. - 11 - ONE NEW EXPERIMENTAL DRUG -- AZIDOTHYMIDINE, OR A.Z.T. -- HAS GONE THROUGH A SO-CALLED "FAST-TRACK" APPROVAL PROCESS AND IS- NOW BEING USED TO PROLONG THE LIVES OF AIDS VICTIMS DYING OF PNEUMOCYSTIS CARINII PNEUMONIA. BUT I'M AFRAID THAT'S ALL A.Z.T. DOES...IT PROLONGS SOME LIVES, IT DOES NOT: SAVE THEM. FOR SAVING LIVES, WE NEED A VACCINE. AND EVERYBODY WANTS TO KNOW WHEN AN EFFECTIVE VACCINE MIGHT BE AVAILABLE. | HAVE TO TELL THEM THAT ! DON’T SEE ONE IN THE NEAR FUTURE. -12- DEVELOPMENT IS ONE THING THAT CANNOT BE RUSHED WITHOUT CREATING MORE PROBLEMS THAN WE ALREADY HAVE. WE NEED TO REMEMBER, FOR EXAMPLE, THAT IT TOOK 17 YEARS TO DEVELOP THE HEPATITIS B VACCINE...AND THAT WAS A COMPARATIVELY EASY VIRUS TO UNDERSTAND. NOW FOR MY THIRD POINT: WE DON'T KNOW VERY MUCH ABOUT AIDS...BUT WE BO KNOW --WITH COMPLETE CERTAINTY -- THAT THE AIDS VIRUS TENDS TO CONCENTRATE IN BODY FLUIDS - 13 - WHICH ALSO CARRY LARGE CONCENTRATIONS OF INFECTED LYMPHOCYTES. IN MOST BODY FLUIDS -- SUCH AS TEARS, SALIVA, AND PERSPIRATION, FOR EXAMPLE -- THE VIRUS PARTICLE COUNT IS VERY LOW OR ABSENT ALTOGETHER. ON THE OTHER HAND, LARGE NUMBERS OF VIRUS PARTICLES ARE FOUND IN BLOOD AND SEMEN. THIS IS ONE OF THE MOST IMPORTANT PIECES OF INFORMATION WE HAVE SO FAR. IT EXPLAINS, FOR EXAMPLE, WHY THE INITIAL ALARM ABOUT AIDS WAS SOUNDED AMONG HOMOSEXUALS AND BISEXUAL MEN. -14- FEC TAC PWIEACOUALE eh S0boMy OQMIPSIEIINEAS. AMONG THESE MEN NOT ONLY PRODUCE SEMEN BUT MAY ALSO CAUSE SOME BLEEDING. AND, AGAIN, BLOOD AND SEMEN ARE THE ONLY TWO BODY FLUIDS THAT CARRY -- AND TRANSMIT - HIGH ENOUGH CONCENTRATIONS OF THE LIVE AIDS VIRUS. THE BIOPHYSICAL PECULIARITIES OF THE AIDS VIRUS ALSO EXPLAIN WHY 25 PERCENT OF ALL AIDS CASES ARE INTRAVENOUS DRUG ABUSERS WHO USE © CONTAMINATED NEEDLES AND OTHER PARAPHERNALIA THEY'VE BORROWED FROM OTHER ADDICTS WHO HAVE AIDS. THIS GROUP INCLUDES DRUG ABUSERS WHO ARE HOMOSEXUALS, ALSO. - 15 - WHEN WE FIRST BEGAN TO CONFRONT THE AIDS EPIDEMIC, THE PEOPLE AT HIGHEST RISK WERE EITHER ‘HOMOSEXUALS AND BISEXUAL MEN AND LV. DRUG ABUSERS, MALE AND FEMALE. I'M AFRAID THEY STILL ARE: 9 OF EVERY 10 CASES INVOLVE THESE KINDS OF INDIVIDUALS. BUT NOWADAYS WE'RE RECEIVING MORE AND MORE REPORTS OF THE AIDS VIRUS OCCURRING AMONG HETEROSEXUAL MEN AND WOMEN WHO ARE NOT L.V. DRUG ABUSERS. IN FACT, THEIR HETEROSEXUAL ACTIVITY SEEMS TO BE THEIR ONLY RISK FACTOR. hinder , 4 PERCENT OF ALL REPORTED ALE AIDS CASES IN THE U.S. amg OF SUCH HETEROSEXUAL MEN AND WOMEN...A PERCENTAGE, BY THE WAY. THAT'S . CLIMBING. Stowe - 16 - ANOTHER CONCERN IS THE RISE IN AIDS AMONG BLACKS AND HISPANICS. BLACKS ACCOUNT FOR 12 PERCENT OF THE U.S. POPULATION, BUT THEY ACCOUNT FOR 25 PERCENT OF ALL AIDS CASES. SIMILARLY, | HISPANICS ACCOUNT FOR 6 PERCENT OF THE US. POPULATION, BUT THEY ACCOUNT FOR 14 PERCENT OF ALL AIDS CASES. ¢S % oe gue Awarers Sone ¢ Ard ARE Berek. 0& pb td PANE SO THE DEMOGRAPHY OF THIS DISEASE IS BECOMING AS COMPLEX AS THE DISEASE ITSELF. AND THAT LEADS ME TO MY FOURTH POINT: OUR SINGLE DEFENSE AGAINST THIS DISEASE FROM THE VERY BEGINNING HAS BEEN INFORMATION AND EDUCATION. AND IT STILL IS. - 17 - OVER THE PAST 5 YEARS, WE'VE BEAMED INFORMATION ALMOST EXCLUSIVELY TO HOMOSEXUALS AND BISEXUAL MEN AND, WHEREVER POSSIBLE, TO DRUG ABUSERS. AMONG HOMOSEXUALS, THIS CAMPAIGN SEEMS TO HAVE BEEN EFFECTIVE...THEIR SEXUAL BEHAVIOR HAS APPARENTLY CHANGED. Peri Grisr Eaaenie TN 3. Pease er et eee ee eee eee ari Pe a cee crete eee ee IN THE INCIDENCE OF OTHER SEXUALLY TRANSMITTED DISEASES AMONG HOMOSEXUAL MEN, SUCH AS GONORRHEA, HEPATITIS B., AND SYPHILIS. Bu7 STRANGE To eEeIRe cw 7HE mid37 OF MS FovVEcATreWAC PREERAM, an NEVEAO. TS ExvAres FA EF va NMunbeEr are Case> eesmb er aeonetnrten mre Rerw PERLE oF Sf Fbittess pW6 7 AWD Chit Fea 4 wv Yeurm é - 18 - 1% [rio s Ewzveneo PFHE PPE TEMG FE URL aem7% FRom THE AHomestxunes BY whf gisFruae mena weno Fee sSeERUNS oF tv Deve Abyst& Com oF GarR7vERS THAT WAS THE BASIS FOR THE SURGEON GENERAL'S REPORT ON AIDS, WHICH | RELEASED LAST OCTOBER. LET ME TAKE JUST A MINUTE HERE TO EXPLAIN HOW THAT REPORT CAME ABOUT. EARLY IN FEBRUARY 1986, PRESIDENT REAGAN INSTRUCTED ME TO PULL TOGETHER EVERYTHING WE KNEW ABOUT AIDS AND PUT IT INTO A PLAIN-ENGLISH REPORT TO THE AMERICAN PEOPLE. -19 - THE PRESIDENT WAS CONCERNED THAT THERE WAS STILL TOO MUCH CONFUSION AMONG THE AMERICAN PEOPLE ABOUT THE NATURE OF THIS THREAT TO PUBLIC HEALTH. HE ASKED ME TO DO WHAT } COULD TO SET THE RECORD STRAIGHT. FOR THE NEXT 8 MONTHS | MET WITH CONCERNED INDIVIDUALS AND GROUPS FROM ACROSS THE SPECTRUM OF SOCIETY...HEALTH, EDUCATION, THE CHURCHES, CIVIL RIGHTS GROU PS. THEY WERE ALL EXTRAORDINARILY CANDID AND HELPFUL. - 20 - AFTER 8 MONTHS OF LISTENING AND WRITING, I DELIVERED BY REPORT TO THE CABINET AND TO THE PRESIDENT. IT WAS ACCEPTED...AND | RELEASED IT TO THE AMERICAN PEOPLE ON OCTOBER 22, 1986. [F foo ae wor Have Pe CaP} B06 BYY— APS | WANT TO ASSURE YOU THAT AT NO TIME HAVE | HAD ANY MISGIVINGS ABOUT ANYTHING | WROTE. THERE IS MUCH SCIENTIFIC AND PUBLIC HEALTH INFORMATION IN THAT REPORT, BUT ON THE BEHAVIORAL SIDE, THERE WERE JUST THREE MESSAGES THAT ARE VITALLY IMPORTANT: THE FIRST MESSAGE 1S SIMPLE ENOUGH. IT SAYS THAT THE BEST DEFENSE AGAINST AIDS IS TOTAL ABSTINENCE FROM SEXUAL RELATIONS. - 21 - ‘| THINK THAT'S PRECISELY THE RIGHT MESSAGE TO GIVE TO OUR CHILDREN -- AIDS OR NO AIDS. BUT ADULTS ARE AT RISK, ALSO, AND A RECOMMENDATION OF TOTAL ABSTINENCE FOR THE ENTIRE POPULATION iS, TO SAY THE LEAST, UNREALISTIC. HENCE, MY SECOND MESSAGE IS THIS: FIND SOMEONE WHO IS WORTHY OF YOUR RESPECT AND YOUR LOVE...GIVE THAT PERSON BOTH...AND STAY FAITHFUL TO HIM OR HER. IN OTHER WORDS, SHORT OF TOTAL ABSTINENCE, THE BEST DEFENSE AGAINST AIDS 1S TO MAINTAIN _A FAITHFUL. MONOGAMOUS RELATIONSHIP IN WHICH YOU HAVE ONLY ONE CONTINUING SEXUAL PARTNER...AND THAT PERSON IS AS FAITHFUL AS YOU ARE. MOTe A eT FaetmaFue mManeiArnces NAVE May Mopeé PossTrb € FHewS Fo EMMAHCE one 3 LvFe , Gr tw CAE mM ELE P hive Tow of A $.7, 0." Evin A Lerane ewe arsee Mos MY THIRD MESSAGE IS FOR PEOPLE WHO AREN'T ABSTINENT BUT DON'T YET HAVE A FAITHFUL MONOGAMOUS RELATIONSHIP...FOR WHATEVER REASON. : A ve How CHW YoU ic Hous UNLESS YOU KNOW WITH ABSOLUTE CERTAINTY, THAT NEITHER YOU NOR YOUR PARTNER IS CARRYING THE AIDS VIRUS, YOU MUST USE CAUTION. FROM THE VIEWPOINT OF EPIDEMIOLOGY, WHEN YOU HAVE SEX WITH SOMEONE, YOU'RE ALSO HAVING SEX WITH EVERYONE ELSE WITH WHOM THAT PERSON HAS HAD SEX. - 23 - AND, WHEN YOU CONSIDER THE LONG INCUBATION PERIOD FOR THE AIDS VIRUS, WE'RE TALKING ABOUT THAT PERSON'S HISTORY OF SEXUAL RELATIONS GOING BACK 5 YEARS OR PERHAPS LONGER. ~ JE Vo" (9 7 EGE Fo Z+ose 2 Ceo0s peete 7a Héll ACES ned IF YOU DO DECIDE TO HAVE SEX WITH SOMEONE AND YOU ARE NOT ABSOLUTELY CERTAIN ABOUT HIS OR HER SEXUAL HISTORY, THEN -- IF YOU'RE A MAN -- USE A CONDOM FROM START TO FINISH. IF YOU'RE A WOMEN, MAKE SURE YOUR MALE PARTNER USES A CONDOM...AGAIN, FROM START TO FINISH. A CONDOM WON'T PROVIDE 100 PERCENT PROTECTION -- FEW THINGS IN LIFE DO -- BUT sO CF FAR IT SEEMS TO BE THE BEST PROTECTION fe SPERM ICID E~ 10 WORE AVAILABLE. ter tected Ww Roos Fuaged Fe 237 Mow ¢ Ave BEem CRITICS 2 EO, PoR MER FRiéwot CHS TCATE 2, Mis REL Rres&v7 ¢ Wfecr Feo BY AWD coechtovet For sArrave FAth f3t7 Aaeod Cowdem!. / stave WVECER fe Eg Maeno Covbems wlTHoo7s vou vus7 rt Eet-Fed Gowwe ortRu WE Le 7etwy7 Abin iw Fwcé - MowA cory — rind “7 Peo Freind cence = cowmoems. / wAs Vow AP Pew PEA FSF. 6. oF > pak now OF ME Cr EFAS Bu? of prec THE PEo pceF, S pws MANDATED FO beerveh CAE MESIA CE of Heaewn ve FuErg Gavel ~ evEw 7 a oT nwPPvE oF PER Benak to LET ME MHreE TAC BEC Avidk Ola yrs Viflws CLTAR € wrne r pwpee Toy x 7 7 su om ARC Rios rb A che O ~ 24 - X EDUCATION FOR THE YOU D O HOW TO BEST PROTECT INDIVIDUALS WHO ARE HIV POSITIVE, OR HAVE AIDS, FROM UNWARRANTED DISCLOSURE AND DISCRIMINATION, WHILE PROTECTING THE PUBLIC FROM INFECTION. | 2S »— How Ve comtmarnw AW eer oeAd ° 6TVE mA ,_ eonwed gvTIAclty. ? NEED Fy (CN cow rtf ceworimerty vs Pre Mame 7S WNC CURRENT CONTROVERSY quai |S BETWEEN THOSE WHO FAVOR MANDATORY TESTING AND THOSE WHO DO NOT. THE MOTIVATION OF THE FORMER GROUP IS MIXED, MOST OF THE PUBLIC HEALTH PEOPLE ADHERE TO THE LATTER STANCE. THE TWO AREAS OF MOST HEATED CONTROVERSY ARE PREMARITAL TESTING AND THE TESTING OF HOSPITAL ADMISSIONS. HIGH RISK PEOPLE ARE USUALLY NOT GETTING MARRIED IN THE UNITED STATES. THE OLD LAWS PERTAINING TO MARRIAGE LICENSES AND TESTING FOR SYPHILIS ARE NOT APPLICABLE BECAUSE FOR SYPHILIS THERE WAS A CURE; THERE IS NO SUCH THING AVAILABLE FOR AIDS. SEVENTY-FIVE PERCENT OF THOSE GETTING MARRIED HAVE ALREADY BEEN LIVING TOGETHER. THE COSTS OF SUCH TESTING IS EXORBITANT IN REFERENCE TO THE NUMBER OF CASES FOUND, AFTER WHICH THERE 1S NO PROGRAM AVAILABLE EXCEPT EDUCATION. IT IS ESTIMATED THAT IN T went Suen nArtaw STATE OF NEW HAMPSHIRE, jena Sa eT PASSED FAAT 7 : WOULD COST $100,000 TO FIND A SINGLE HIV HE wis INFECTED PERSON IN PREMARITAL SCREENING. vs aa faa pats Da son MANDATORY FA HION IS OPPOSED4 “MOST PUBLIC HEALTH AUTHORITIES PN “OMPROMISE PLAN IS UNDER gle DISCUSSIODeMHERE ONLY SURGICAL ADMISSIONS WOULD cor ppaeworereer STEDTIN'O MBER TO REUU CET > onrp owe SIMDE— 1h cr wors 38 pach 1 fro te tyc, 00d, ow Vou E TITLE OF MY REMARKS TODAY WOULD INDICATE, ] EVIEWING FOR YOU -- ALBEIT IN A BRIEF HOICES THAT LIE AHEAD OF US, AND NOW, WANT TO SPEND A FEW MO MANNER -- SOME OF THE OTHER DIFET RELTQIVE 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 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, J 12 FOR EXAMPLE, WE ARE ALREADY WITNESSING THE ASSAULT BY THIS DISEASE UPON THE ETHICAL FOUNDATION OF HEALTH CARE ITSELF. | a - 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 -- S ER -- I'M PROUD TO BE PART OF A TRADITION OF CARE THAT WILL NOT ABANDON THE SICK AND THE DISABLED «« HHOE Y . J 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? V'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 Titos€ wit why € ST. -- INSTRUCTION, BY THE WAY, IS 200 YEARS OLD. GOOD FOR EE...AND GOOD FOR US. V6 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 1S 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. WHA? MAST OF oul C1M2EWs CAEL AIDS 1S LINKED TO, QUESTIONABLE BEHAVIOR. THE WAY DRUG ADDICTION, LIVER FAILURE, AND LUNG CANCER ARE CAUSALLY LINKED TO POOR INDIVIDUAL JUDGMENTS. J 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. Vi8 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.” pe ehan Row © futeat +F YF. Wo Hever FExuvne Ex peo 500% - 38 - NOT GIVING TPMBEST CARE T QEOSITIVITY AND IT IS OUR ONLY HOPE AS A NATION -- INDEED AS A CIVILIZATION -- IS THAT WE ALL DO OUR PART TO STOP THE SPREAD OF AIDS...THAT WE WILL PROTECT AND SAVE THE LIVES OF PEOPLE AT RISK. THAT'S A TALL ORDER -- AND THERE ARE MANY SAYING IT CAN’T BE DONE. BUT, THEY'RE WRONG. - 39 - 1 THINK WE WILL EVENTUALLY AGREE ON THE TASKS THAT REALLY MATTER -- AND GET THEM DONE. MY PERSONAL HOPE IS THAT FLL STILL BE AVAILABLE TO HELP! THANK YOU.