Luncheon for Top Aides to Republican Senators Talking Points: 1. Strategies for control of spread of AIDS for those already infected or at risk. 2. Resources for care and treatment. 3. Potential economic impact. 4. The U.S. role in the global response to AIDS You need only talk for 20 minutes and answer a few questions. The? 196 3 DIFFERENT AND IMPORTANT TO SAY TO YOU AT THIS PLENARY LN-ANE=EASE, I'M NOT GOING TO DWELL ON A GREAT MANY PARTICULARS CONCERNING THE DISEASE OF AIDS. THE DAILY PRESS -- AND OUR PROFESSIONAL JOURNALS -- DO A VERY GOOD JOB OF THAT. BUT, AT THE VERY LEAST, I WILL UNDERSCORE THREE OF THE MOST IMPORTANT FACTS ABOUT THE DISEASE OF AIDS ... BASIC FACTS THAT INFLUENCE JUST ABOUT EVERYTHING WE SAY OR DO ABOUT THE VIRUS AND ABOUT THE PEOPLE INFECTED WITH IT. 4 FACT NUMBER ONE, THE DISEASE IS SPREADING. | THE WORLD HEALTH ORGANIZATION CALLS AIDS A “PANDEMIC” -- AN EPIDEMIC THAT IS EXPANDING AND ROLLING ACROSS ALL THE WORLD’S BOUNDARIES, GEOGRAPHIC OR DEMOGRAPHIC. HERE IN THE UNITED STATES, AS I’M SURE YOU KNOW, MORE THAN © 53,000 PERSONS HAVE BEEN REPORTED AS HAVING AIDS, SINCE THE COUNT BEGAN IN JUNE OF 1981, 5 TO DATE, NO STATE HAS HAD FEWER THAN 5 CASES OF AIDS ... AND 20 AMERICAN CITIES HAVE EACH REPORTED MORE THAN 400 CASES OF AIDS OVER THE PAST 7 YEARS, IN OTHER WORDS, IT IS FOOLISH TO THINK YOU CAN JUST SIT TIGHT AND WAIT FOR AIDS TO PASS YOU BY OR GO AWAY. THAT’S NOT GOING TO HAPPEN, FOR MANY OR EVEN MOST OF US IN THIS ROOM TONIGHT, AIDS WILL NOT DISAPPEAR IN OUR LIFETIMES. THE SECOND FACT IS THAT AIDS IS VIRTUALLY FATAL. 6 OF THE 53,000 PERSONS WHO’VE REPORTEDLY HAD AIDS, SOME 30,000 -- MORE THAN HALF -- HAVE ALREADY DIED. AND OUR EXPERIENCE TELLS US THAT THE REST PROBABLY WILL. IN FACT, 93 PERCENT OF THOSE WITH AIDS BACK IN 1981 HAVE ALREADY DIED. AND IF YOU KNOW YOUR EPIDEMIOLOGY, YOU KNOW THAT A 93 PERCENT FATALITY RATE IS AS GOOD AS 100 PERCENT. / BUT JUST AS AN ASIDE, LET ME SAY THAT I HAVE ABSOLUTELY NO DOUBT THAT OUR COLLEAGUES IN RESEARCH WILL COME UP WITH A VACCINE TO PREVENT THE SPREAD OF AIDS ONCE AND FOR ALL. REALISTICALLY THAT DAY IS STILL QUITE FAR OFF ... MAYBE A DOZEN YEARS OR MORE DOWN THE ROAD. IN THE MEANTIME, THEREFORE, WE MUST LIVE WITH A DISEASE THAT HAS ONE OF THE HIGHEST MORTALITY RATES OF ANY DISEASE WE’VE KNOWN -- PAST OR PRESENT, 8 FACT ONE: IT’S SPREADING, FACT TWO: IT’S FATAL. BUT FACT THREE IS MORE DIFFICULT TO STATE QUITE AS BALDLY AS IVE STATED THOSE OTHER TWO. AT ANY RATE, FACT THREE IS THIS: THE AIDS VIRUS IS TRANSMITTED THROUGH SPECIFIC ACTS OF BEHAVIOR THAT THE GREAT MAJORITY OF PEOPLE DON‘T ENGAGE IN AND DON’T APPROVE OF, 9 ANAL INTERCOURSE IS ONE OF THESE BEHAVIORS. NEEDLE-SHARING AMONG DRUG ADDICTS IS ANOTHER. THESE TWO BEHAVIORS ACCOUNT FOR ABOUT 90 PERCENT OF THE TOTAL AIDS CASELOAD. AS I NOTED EARLIER, THESE THREE FACTS INFLUENCE VIRTUALLY EVERYTHING WE SAY OR DO ABOUT THE AIDS EPIDEMIC. SOMETIMES THAT’S GOOD. AND SOMETIMES IT’S NOT SO GOOD. FOR EXAMPLE, THESE THREE PECULIARITIES OF THE AIDS EPIDEMIC HAVE INFLUENCED THE MANNER IN WHICH SOME HEALTH PROFESSIONALS ARE RESPONDING TO THE AIDS CRISIS ... OR, MORE PARTICULARLY, ARE NOT RESPONDING TO THE AIDS CRISIS. 10 I THINK, FIRST, IT NEEDS TO BE SAID THAT THAT THE OVERWHELMING MAJORITY OF OUR COLLEAGUES HAVE PROVIDED -- AND WILL CONTINUE TO PROVIDE -- QUALITY, COMPASSIONATE CARE TO PERSONS DYING OF AIDS. — AND I WANT TO ADD A SPECIAL WORD OF PRAISE FOR THE PHYSICIANS, NURSES, TEACHERS, SOCIAL WORKERS, AND OTHERS IN AREAS WITH THE HIGHEST CONCENTRATIONS OF AIDS CASES ... SPECIFICALLY, THE CITIES OF NEW YORK, SAN FRANCISCO, LOS ANGELES, NEWARK, AND MIAMI, 11 OVER 40 PERCENT OF THE NATION’S AIDS CASELOAD HAS APPEARED IN JUST THOSE FIRST THREE CITIES ALONE: THAT IS, NEW YORK, SAN FRANCISCO, AND LOS ANGELES. AND THE RESPONSE BY THE GREAT MAJORITY OF HEALTH PROFESSIONALS IN THOSE CITIES HAS BEEN OUTSTANDING, HOWEVER, EVEN THERE -- AND IN MANY OTHER CITIES ACROSS THE COUNTRY -- WE ARE SEEING A MOUNTING NUMBER OF INSTANCES IN WHICH HEALTH PROFESSIONALS REFUSE NOT ONLY TO TREAT PERSONS WITH AIDS, BUT ALSO TURN AWAY PATIENTS ALLEGED TO BE FROM POPULATION GROUPS IDENTIFIED WITH THOSE TWO HIGH-RISK BEHAVIORS: THAT IS, HOMOSEXUALS AND BISEXUAL MALES AND INTRAVENOUS DRUG ABUSERS. 12 FOR GOVERNMENT, FOR THE PROFESSIONS INVOLVED, AND FOR AMERICANS GENERALLY, THIS KIND OF BEHAVIOR BY AN IRRATIONAL MINORITY MUST BE A CAUSE FOR DEEP CONCERN. OF COURSE, THE REASON MOST OFTEN GIVEN IS THAT AIDS IS CONTAGIOUS AND FATAL AND “I DON’T WANT TO GET IT.” BUT THE PLAIN FACT IS THAT THE RISK OF CONTRACTING AIDS FROM AN INFECTED PATIENT IS EXTREMELY SMALL. OF THE NEARLY 7 MILLION AMERICANS IN THE HEALTH PROFESSIONS, WE KNOW OF FEWER THAN A DOZEN WHO HAVE BECOME INFECTED WITH THE VIRUS WHILE DOING THEIR JOBS, 13 AND IN 8 OR 9 OF THOSE 8 CASES, NOTHING WOULD HAVE HAPPENED, IF THE PERSON HAD FOLLOWED THE COMMON-SENSE WORKPLACE GUIDELINES PUBLISHED BY THE CENTERS FOR DISEASE CONTROL TWO YEARS AGO, THE DECISION BY SOME HEALTH PROFESSIONALS TO DENY CARE TO HOMOSEXUALS, I.V. DRUG ABUSERS, OR OTHERS SUSPECTED OF CARRYING THE AIDS VIRUS IS, THEREFORE, IRRATIONAL AND UNWORTHY OF ANYONE IN THE HEALTH OR SOCIAL SERVICE PROFESSIONS. IT IS A DECISION BASED MORE ON FEAR OR DISLIKE OF THE CARRIER OF THE VIRUS, AND LESS ON THE VIRUS ITSELF. 14 WE DEFINE AND CATEGORIZE DISEASE CONDITIONS IN ORDER TO TREAT THEM, BUT WE NEVER DEFINE WHO IS -- AND IS NOT -- ACCEPTABLE AS A PATIENT OR CLIENT, IN ORDER TO DENY TREATMENT TO SUCH A PERSON, WE NEVER DO THAT. AND I WOULD HOPE WE WOULDN’T START NOW, AS I READ AND LISTEN TO THE STATEMENTS OF THOSE ‘INDIVIDUALS AND ORGANIZATIONS WHO WISH TO WITHHOLD CARE, I’M STRUCK BY THEIR CURIOUS APPEALS TO SCIENCE AND TO THE LAW, 15 THEY SAY, IN EFFECT, “LOOK, WE STILL DON’T KNOW EVERYTHING ABOUT THIS DISEASE. THEREFORE, WHY SHOULD I TAKE A RISK?” OR THEY SAY, “LOOK, THE COURTS HAVEN’T YET TAKEN A LOOK AT THIS QUESTION. THEREFORE, WHY SHOULD I TAKE THE RISK?" MY ANSWER -- AND I DEEPLY HOPE IT IS YOUR ANSWER AS WELL -- COMES DOWN TO THIS: 16 "NO, WE DON’T KNOW EVERYTHING ABOUT THE DISEASE OF AIDS ... AND NO, THE COURTS HAVE NOT LOOKED AT ALL THE ISSUES. BUT THAT'S NOT WHAT HEALTH CARE IS REALLY ALL ABOUT ANYWAY. IT’S ABOUT CARING FOR PEOPLE WHO NEED OUR EXPERTISE TO LIVE .++ AND IT’S ABOUT OUR PROVIDING THAT CARE AS BEST WE CAN, WHENEVER IT’S NEEDED.” THE THINGS WE ARE TRAINED TO DO ARE THINGS THAT GIVE PEOPLE HOURS, DAYS, OR EVEN YEARS MORE OF LIFE. 17 OUR “CALLING,” IF YOU WILL, IS A CALLING BASED UPON THE MOST VALUED ETHIC IN HUMAN HISTORY ... AN ETHIC THAT HAPPENS TO BE INTEGRAL TO OUR PROFESSIONAL OATH, WHICH SAYS... “DO WHAT YOU CAN TO HELP ... BUT IN ANY CASE DO NO HARM.” THAT OATH HAS BEEN SUBSCRIBED TO FOR GENERATIONS WITHOUT NUMBER. YET, I TRULY CANNOT RECALL ANY TIME IN THE PAST QUITE LIKE THIS ONE, WHEN THE MEDICAL PROFESSION HAS ANGUISHED SO MUCH OVER THE BURDENS OF ITS OWN HIPPOCRATIC OATH. AND WE'VE HAD MANY OPPORTUNITIES IN PRIOR TIMES. 18 HERE IN THE UNITED STATES, IN THE 19TH CENTURY, YELLOW FEVER SWEPT THROUGH OUR MAJOR CITIES, ESPECIALLY IN THE SOUTH, LEAVING THOUSANDS OF DEAD IN ITS WAKE ... 4,000 DEAD IN NEW ORLEANS ... 5,000 IN MEMPHIS, TENNESSEE ... AND SO ON, PHYSICIANS AND NURSES SHOWED EXCEPTIONAL HEROISM DURING THOSE YEARS OF PLAGUE, IT IS SAID, FOR EXAMPLE, THAT A THIRD OF THE PHYSICIANS OF SAVANNAH, GEORGIA, WERE AMONG THE HUNDREDS OF CITIZENS WHO DIED WHEN YELLOW FEVER STRUCK THAT CITY IN 1854, O . 19 NO SANE PERSON -- IN OR OUT OF THE HEALTH PROFESSIONS -- WANTS TO DIE FROM A VIRULENT DISEASE, BUT THE HEROISM OF THOSE SOUTHERN HEALTH WORKERS SHOULD BE AN INSPIRATION TO US ALL. THEY DID NOT WAIT FOR SCIENCE OR THE LAW TO TELL THEM THE “RIGHT” TIME TO TAKE THE “RIGHT” COURSE OF ACTION. THEY TOOK THEIR CUES FROM THEIR HEARTS AND FROM THEIR CONSCIENCES, AND WE REVERE THEIR MEMORIES BECAUSE OF THAT. 20 THESE KINDS OF EXPERIENCES ARE IMPORTANT TO RECALL BECAUSE WE MUST ALWAYS REINFORCE, THROUGH HISTORY AS WELL AS THROUGH PERSONAL EXAMPLE, THE NOTION THAT THE HEALTH PROFESSIONS HAVE THE ETHICAL DUTY TO TREAT. AND I DO NOT WANT TO SEE THE DISEASE OF AIDS -- WHICH CAN DEVASTATE AN INFECTED HUMAN BEING -- WREAK SIMILAR HAVOC UPON THE CARING AND HELPING PROFESSIONS IN OUR SOCIETY. 21 YES, AIDS IS A DANGEROUS DISEASE. YES, IT CAN BE FATAL. AND, YES, YOU MAY NOT APPROVE OF THE KINDS OF BEHAVIOR BY WHICH THE DISEASE IS TRANSMITTED, BUT IF YOU CHOSE A LIFE OF MEDICINE OR DENTISTRY OR NURSING, YOU CHOSE TO SERVE YOUR FELLOW HUMAN BEINGS IN THEIR TIME OF NEED -- AND YOU WERE NOT GIVEN, IN RETURN, ANY PRIVILEGE TO JUDGE THEM, TREATMENT MAY BE DIFFICULT ... AND IT MAY -- REMOTELY -- BE DANGEROUS. BUT TREATMENT MAY NOT BE DENIED. 22 THE DISEASE OF AIDS, THEN, IS TESTING THE DEGREE TO WHICH HEALTH WORKERS -- PHYSICIANS, NURSES, TECHNICIANS, AND OTHERS -- UNDERSTAND AND ARE TRULY DEDICATED TO THE ETHICAL FOUNDATION OF HEALTH CARE ITSELF, AND 1 WOULD REMIND YOU THAT SUCH A TEST IS COMING QUITE EARLY IN MANY PROFESSIONAL CAREERS. WE ARE ALREADY NOTICING, FOR EXAMPLE, THAT PUBLIC HOSPITALS WITH MOUNTING CASE-LOADS OF AIDS PATIENTS ARE BEING SHUNNED BY YOUNG HEALTH PROFESSIONALS AS PLACES TO COMPLETE THEIR FORMAL TRAINING. THAT’S A VERY BAD SIGN, 23 I NOTE THAT THE STATE OF NEW YORK IS SENDING A VERY STRONG MESSAGE TO YOUNG PHYSICIANS WHO REFUSE TO TRAIN IN SUCH INSTITUTIONS. THAT MESSAGE IS ... IF YOU SEE NO ROOM ON YOUR PRACTICE FOR PERSONS WITH AIDS, THEN THE STATE SEES NO ROOM FOR YOU AS A LICENSED PRACTITIONER. THIS ISSUE IS FURTHER COMPLICATED BECAUSE AIDS-RELATED ILLNESSES ARE OFTEN PROTRACTED ... AND THEY ARE TERMINAL. THE PERIOD BETWEEN DIAGNOSIS AND THE DEATH OF THE INDIVIDUAL MAY LAST 18 MONTHS OR MORE, O 24 NOW, WITH THE DEVELOPMENT OF NEW LIFE-EXTENDING DRUGS, SUCH AS A.Z.T., THE COURSE OF SUCH DISEASES MAY RUN EVEN LONGER. THESE AIDS-RELATED ILLNESSES ARE ALSO EXTREMELY DEBILITATING AND REQUIRE CARE THAT IS VERY LABOR-INTENSIVE. HENCE, WE’RE GOING TO COUNT ON THE UNQUALIFIED COMMITMENT OF ALL HEALTH PROFESSIONALS TO GET US THROUGH THE NEXT DECADE OR TWO, AS THE AIDS EPIDEMIC EXPANDS. I DON'T HAVE TO TELL YOU THAT ALL OUR PROJECTIONS AS TO THE FULL BURDEN OF CARE FOR PERSONS WITH AIDS FOR THE REMAINDER OF THIS CENTURY TAKE FOR GRANTED -- AS I BELIEVE THEY SHOULD -- THE PRESENCE AND THE INVOLVEMENT OF THE ENTIRE HEALTH COMMUNITY. 25 WE HAVE NO BUSINESS PLANNING FOR ANYTHING LESS THAN THAT ... AND HEALTH PROFESSIONALS HAVE NO BUSINESS PROVIDING ANYTHING LESS THAN THAT. AS A PHYSICIAN, I AM PROUD TO BE PART OF A TRADITION OF CARE THAT WILL NOT ABANDON THE SICK AND THE DISABLED ... WHOEVER THEY ARE. I CERTAINLY AM NOT ALONE. WHAT’S MORE, I’M SURE I AM PART OF THE GREAT MAJORITY OF MY PROFESSION. NEVERTHELESS, I REGARD AS EXTREMELY SERIOUS THE REPORTS OF A FEW PHYSICIANS AND OTHERS WHO ARE WITHHOLDING CARE FROM PERSONS WITH AIDS ... OR -- WORSE -- PERSONS SUSPECTED OF CARRYING THE VIRUS. SUCH CONDUCT THREATENS THE VERY FABRIC.OF HEALTH CARE HERE AND EVERYWHERE ELSE IN THE WORLD. 26 THE HEALTH PROFESSIONS ARE INDEED SHOULDERING THE LARGEST SHARE OF THE RESPONSIBILITY FOR RESPONDING TO THIS DISEASE. BUT WE ARE FAR FROM ALONE. IN FACT, OTHER PROFESSIONS -- LAW, BUSINESS MANAGEMENT, AND SO ON -- ARE BEING DRAWN IN AS WELL, AND ULTIMATELY IT WILL BE THE GENERAL PUBLIC ITSELF WHICH WILL NEED TO SORT THROUGH MANY OF THE ISSUES AND COME TO TERMS WITH THE LOGICAL AND ETHICAL CONCLUSIONS. AND AT THE TOP OF THE LIST, I’M AFRAID, IS THE ISSUE OF COST: THAT IS, WHAT IS THE COST OF AIDS-RELATED PATIENT CARE 11. AND WHO SHOULD PAY? 2/ ORDINARILY THIS IS NOT AN ISSUE IN AMERICAN SOCIETY. OVER THE PAST CENTURY WE HAVE EVOLVED A GENERAL NATIONAL POLICY OF DOING WHAT HAS TO BE DONE, RELATIVE TO THE HEALTH OF OUR PEOPLE, AND OF PAYING FOR IT OUT OF GENERAL TAX REVENUES ... FEDERAL, STATE, AND/OR LOCAL. IN THIS WAY 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. | 28 THESE PROGRAMS ALL SHARE A CERTAIN COMMON ELEMENT: THEY ARE DESIGNED TO RAISE -- OR TO RETURN -- MEN, WOMEN, AND CHILDREN TO A STATE OF GOOD HEALTH. | THAT'S PROBABLY THE MAIN REASON THAT AMERICANS STRONGLY SUPPORT SUCH PUBLIC HEALTH PROGRAMS. THE GOAL OF EACH ONE IS A POSITIVE OUTCOME, BUT THAT MAY ALSO BE THE MAIN REASON THAT BROAD, NATIONAL SUPPORT FOR AIDS WILL BE MORE DIFFICULT TO ACHIEVE. IMPOSSIBLE? NO. DIFFICULT? YES. 29 AIDS IS DIFFERENT FROM THE OTHER PUBLIC HEALTH PROGRAMS I MENTIONED BECAUSE, AFTER CONSUMING TENS OF THOUSANDS OF DOLLARS WORTH OF MEDICAL CARE AND SOCIAL SERVICES ... THE AIDS PATIENT DIES, | IN OTHER WORDS, THE COMMITMENT OF THE AMERICAN PEOPLE MUST BE TO HELP PAY PART -- AND SOMETIMES ALL -- OF THE COSTS OF CARE FOR WHAT IS ESSENTIALLY A TERMINAL ILLNESS. WHAT KINDS OF AIDS-RELATED COSTS ARE WE TALKING ABOUT? 30 A NUMBER OF COST SURVEYS HAVE BEEN DONE, AND WE HAVE, AS A RESULT, SOME SPECIFIC EXAMPLES OF COSTS OR RANGES OF COSTS, NOTHING IS PRECISE, YET ... BUT EVERYTHING IS CERTAINLY INSTRUCTIVE, FOR EXAMPLE, A RECENT SURVEY INDICATES THAT, IN 1985, IT COST ABOUT $635 A DAY TO PROVIDE INPATIENT CARE TO A PERSON WITH AIDS IN A PUBLIC HOSPITAL. HOWEVER, THE HOSPITAL GOT BACK -- MAINLY FROM MEDICAID -- ONLY $482, FOR A NET DEFICIT OF $153, 31 THAT’S FOR ONE DAY ... FOR ONE PATIENT. MULTIPLY THAT NUMBER BY THOUSANDS -- OR EVEN TENS OF THOUSANDS -- AND IT IS CLEAR THAT THE AMERICAN PEOPLE MUST COME FORWARD WITH A GREAT DEAL OF MONEY, AS THE AIDS EPIDEMIC EXPANDS, CURRENT ESTIMATES PUT THE COST OF PATIENT CARE AT ABOUT A BILLION DOLLARS. THAT INCLUDES ALL DIRECT AND PERSONAL MEDICAL COSTS. 32 THERE ARE, IN ADDITION, ABOUT ANOTHER HALF-BILLION TO A BILLION DOLLARS IN NONPERSONAL COSTS, MAINLY FOR GOVERNMENT SERVICES SUCH AS DRUG AND VACCINE RESEARCH, PUBLIC EDUCATION, SCREENING AND TESTING, AND SO ON. IN A COUPLE OF YEARS, THESE COMBINED COSTS ARE EXPECTED TO CLIMB TO SEVERAL BILLION DOLLARS ... DOLLARS THAT, FOR THE MOST PART, THE AMERICAN TAXPAYER MUST PROVIDE. THERE ARE ADDITIONAL SOCIAL COSTS, SUCH AS LOST HUMAN CAPITAL, AND THESE ARE OFTEN TRANSLATED AS LOST WAGES AND PRODUCTIVITY. 33 HOWEVER, SINCE WE KNOW SO VERY LITTLE ABOUT I.V. DRUG ABUSERS, FOR EXAMPLE, I HESITATE ADDING AN AUTOMATIC, FORMULA- GENERATED FIGURE OF MANY BILLIONS OF DOLLARS OF LOST PRODUCTIVITY PER YEAR BECAUSE OF 1.V. DRUG ABUSERS WHO’VE BEEN INFECTED BY THE AIDS VIRUS. BUT EVEN IF YOU PUT TO ONE SIDE THESE INDIRECT SOCIAL COSTS, WE WILL STILL FACE, IN THE YEAR 1991, A NATIONAL BILL OF $3-TO-$5 BILLION FOR THE COST OF AIDS-RELATED CARE -- BOTH INPATIENT AND OUT-PATIENT, HOSPITAL AND HOSPICE. 34 THESE COSTS WILL BE INCURRED BY AN ESTIMATED 145,000 PERSONS WITH AIDS WHO WILL BE IN VARIOUS STAGES OF A TERMINAL ILLNESS. THIS IS AN OVERWHELMING FIGURE AND I DOUBT THAT THE AMERICAN PEOPLE HAVE COME TO TERMS WITH IT YET. ~ BUT THIS IS NOT JUST AN ISSUE FOR THE GENERAL PUBLIC, IT’S AN ISSUE FOR ALL OUR PROFESSIONS AS WELL. 35 CLEARLY, THE HEALTH PROFESSIONS MUST DO A GREAT DEAL MORE TO DEVELOP ALTERNATIVE, LESS COSTLY, BUT HIGHLY EFFECTIVE WAYS TO ‘CARE FOR AIDS PATIENTS. WE NEED TO DO THIS IN LIGHT OF THE SPECIFIC AIDS-RELATED DISEASES AND CONDITIONS WE KNOW ABOUT AND _ JHE DIFFERENT STAGES THROUGH THEY PROGRESS. THIS WILL BE A NEW APPROACH TO MEDICAL CARE FOR SOME OF US. MUCH OF THE TIME WE HAVE A GENIUS FOR INCREASING THE COST OF CARE FOR ALMOST EVERYTHING, THE CHALLENGE TODAY, HOWEVER, IS TO REVERSE THAT INCLINATION AND GIVE THE COUNTRY -- AND THE WORLD -- A WAY OF CARING FOR AIDS PATIENTS WITHOUT AN ESCALATION OF COSTS AND THE CONSEQUENT BANKRUPTING OF THE NATIONAL TREASURY. 36 SO IT WOULD SEEM THAT SOCIETY IS GOING TO NEED A STRONG AND UNQUALIFIED COMMITMENT FROM ITS HEALTH PROFESSIONALS TO CARE FOR THE RISING CASE-LOAD OF PERSONS WITH AIDS ... REGARDLESS OF WHO THEY ARE AND HOW THEY BECAME INFECTED, WE WILL ALSO NEED THEIR COMMITMENT TO CARE FOR SUCH PATIENTS, WHO WILL BE, FOR THE MOST PART, IN VARIOUS STAGES OF TERMINAL ILLNESS. AND WE WILL NEED THEIR COMMITMENT TO PROVIDE QUALITY CARE FOR SUCH PATIENTS ... REGARDLESS OF THE METHOD -- OR LEVEL -- OF REIMBURSEMENT, 37 I HAVE NO DOUBT BUT THAT SUCH CARE WILL BE PROVIDED. WE WILL NOT ABANDON THESE PATIENTS. HERE IN THE UNITED STATES, THAT'S SIMPLY OUT OF THE QUESTION, BUT I ALSO HAVE NO DOUBT THAT, FOR US, THIS EPIDEMIC OF AIDS -~ THE WAY IT RUNS ITS COURSE OVER THE NEXT FEW YEARS -- WILL PROVIDE ONE OF THE MOST SERIOUS TESTS OF SOCIAL AND POLITICAL WILL THAT OUR SOCIETY HAS EVER UNDERGONE, T FIRMLY BELIEVE WE WILL COME THROUGH SUCH A TEST WITH OUR IDEALS AND OUR INSTITUTIONS FULLY INTACT.