ORIGINAL

Cu T Issues IN AID
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

oS

as

PRESENTED AT THE OPENING PLENARY SESSION OF THE
69TH ANNUAL MEETING OF THE
AMERICAN COLLEGE OF PHYSICIANS
New York, New York
MarcH 3, 1988
1
(GREETINGS TO HOSTS, GUESTS, FRIENDS, ETC.)

IT IS INDEED A GREAT HONOR TO BE YOUR KEYNOTE SPEAKER THIS
MORNING. I’VE BEEN A GUEST AT YOUR PODIUM BEFORE AND -- FOR ME,
AT LEAST -- THEY’VE BEEN IMPORTANT MOMENTS IN MY LIFE,

BUT THIS MORNING IS SOMETHING SPECIAL. THIS PLENARY SESSION
IS A DEPARTURE FROM YOUR ANNUAL PRACTICE AND I AM TRULY HONORED
TO BE THE ONE CHOSEN TO SPEAK,

I KNOW -- FROM LONG, PERSONAL EXPERIENCE -- HOW DIFFICULT
IT IS FOR PHYSICIANS TO CHANGE THE WAY THEY DO THINGS, WE ARE
VERY MUCH CREATURES OF HABIT, MOST OF THE TIME, THE HABITS
AREN'T SO BAD EITHER. BUT THEY ARE HABITS NEVERTHELESS,
2
SO I AM SENSITIVE TO THE FACT THAT, FOR THE COLLEGE TO

DEPART FROM ITS CUSTOMARY AGENDA THIS MORNING IS AN EVENT OF SOME
CONSEQUENCE THAT ONLY A PHYSICIAN -- AND A PHYSICIAN’S SPOUSE --
CAN TRULY APPRECIATE.

WERE ONLY A MINUTE OR SO INTO THIS EVENT AND IT IS ALREADY
MEMORABLE. SO I’M TEMPTED TO QUIT RIGHT NOW, WHILE I’M AHEAD,
BUT I WON’T DO THAT.

RATHER, [’D LIKE TO TAKE ADVANTAGE OF THIS OPPORTUNITY --
AND YOUR HOSPITALITY -- TO EXPLORE A COUPLE OF QUESTIONS WITH YOU
.++ QUESTIONS THAT I KNOW TROUBLE A GREAT MANY OF OUR COLLEAGUES
AND TROUBLE A GREAT MANY OF OUR FELLOW AMERICANS AS WELL.
3
THE QUESTIONS HAVE TO DO WITH THE AIDS EPIDEMIC ... WHOM IT

TS AFFECTING AND HOW WE ARE RESPONDING,

I’M NOT GOING TO DWELL ON THE PARTICULARS OF THE DISEASE.
THE DAILY PRESS -- AND OUR PROFESSIONAL JOURNALS -- DO A VERY
GOOD JOB OF THAT.

AND THE AMERICAN COLLEGE OF PHYSICIANS HAS ITSELF DONE AN
EXCELLENT JOB OF INFORMING THE MEDICAL PROFESSION OF THE MEDICAL,
THE SCIENTIFIC, AND THE SOCIAL ASPECTS OF THIS EPIDEMIC,
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AND I WANT TO EXTEND A SPECIAL WORD OF APPRECIATION TO THE

COLLEGE FOR ITS RECENT “POSITION PAPERS,” APPROVED AND RELEASED
LAST MONTH, WHICH RECOUNT NOT ONLY THE FACTS ABOUT AIDS, BUT

ALSO DEAL WITH THE ETHICAL AND FINANCIAL ISSUES THAT HAVE EVOLVED
OVER THE 6-YEAR HISTORY OF THIS DREADFUL DISEASE.

IN ONE RESPECT, THOSE PAPERS ECHO THE REQUEST -- MADE BY
MANY OTHER GROUPS -- THAT THE FEDERAL GOVERNMENT COME FORWARD
WITH A CLEARER AND MORE PRECISE STATEMENT OF NATIONAL POLICY
REGARDING AIDS.
5
BUT TO BE PERFECTLY HONEST ABOUT IT, I PLACE AS MUCH OR

POSSIBLY EVEN MORE FAITH IN THE POLICY POSITIONS TAKEN BY THIS
COLLEGE, BY THE AMERICAN MEDICAL ASSOCIATION, BY THE AMERICAN
NURSES ASSOCIATION, AND BY MANY OTHER GROUPS REPRESENTING HEALTH
PROFESSIONALS. AFTER ALL, YOU ARE THE PEOPLE WHO PROVIDE THE
DAY-TO-DAY, HANDS-ON CARE FOR PERSONS WITH AIDS.

IF YOU, AS CONCERNED PROFESSIONALS, SAY YOU OUGHT TO BE
DOING SOMETHING, THE CHANCES ARE VERY GOOD THAT IT WILL BE DONE
»+. CERTAINLY MUCH BETTER THAN IF I SAID YOU SHOULD DO THE SAME
THING,
6
HENCE, I AM PERSUADED -- AS A RESULT OF MANY DISCUSSIONS

WITH PHYSICIANS AND OTHERS AND THROUGH PERSONAL OBSERVATION --
THAT THE OVERWHELMING MAJORITY OF AMERICAN HEALTH PROFESSIONALS
ARE LIVING UP TO THE HIGHEST IDEALS OF THEIR CALLING,

] HAVE EVERY INDICATION THAT THEIR PATIENTS WHO BECOME
INFECTED WITH THE AIDS VIRUS DO GET APPROPRIATE HEALTH AND
MEDICAL CARE.

] ADMIT THAT I’M BIASED AND THAT I CAN’T COMPLETELY IGNORE
THE PROFESSIONAL INSTINCTS I DEVELOPED DURING NEARLY FIVE DECADES
AS A PRACTICING PHYSICIAN AND SURGEON,
/
STILL, I THINK IT’S TRUE THAT VIRTUALLY ALL PATIENTS WHO

DEVELOP AIDS ARE BEING CARED FOR ... AND I THINK THE AMERICAN
PEOPLE OUGHT TO BE AWARE OF THAT AND BE COMFORTED BY IT.

HOWEVER, YOU AND I KNOM THAT’S NOT THE WHOLE STORY. WE KNOW
THAT MANY AMERICANS -- POSSIBLY AS MANY AS 35 MILLION -- ARE
OUTSIDE THE TRADITIONAL SYSTEM OF HEALTH CARE DELIVERY IN THIS
COUNTRY.

THEY ARE NOT OUR FAMILIAR “PATIENTS.” THEY DON’T HAVE A
FAMILY PHYSICIAN WHO HAS KNOWN THEM AND CARED FOR THEM OVER THE
YEARS, AND THEY'RE NOT COVERED BY HEALTH INSURANCE, EITHER,
8
FORTUNATELY, MOST OF THESE 35 MILLION INDIVIDUALS DO NOT

ENGAGE IN HIGH-RISK BEHAVIOR AND, THEREFORE, THEY WILL NOT
CONTRACT AIDS.

IF THE OPPOSITE WERE TRUE, WE WOULD CERTAINLY KNOW ABOUT IT
BY NOW. THE UNITED STATES WOULD ALREADY BE ENGULFED IN A
DEVASTATING AIDS CATASTROPHE WITH A ROLL-CALL OF THE DEAD THAT
WOULD BE MANY TIMES THE CURRENT TOTAL OF 30,000.

THINGS ARE BAD ... MAKE NO MISTAKE OF THAT. BUT WE‘VE NOT
YET PASSED BEYOND THE BRINK OF A NATIONAL CATASTROPHE AND MY
READING OF THE STATISTICS SO FAR IS THAT WE MAY YET AVERT ONE
DOWN THE ROAD.
9
BUT NOTE THAT I SAID “MOST” OF THOSE 35 MILLION FELLOW

AMERICANS MIGHT NOT CONTRACT AIDS. NOT “ALL.”

THERE IS -- UNHAPPILY -- A SMALL MINORITY AMONG THEM WHO ARE
UNINSURED ... WHO ARE CULTURALLY AND SOCIALLY ISOLATED ... AND
WHO ARE AT RISK OF CATCHING AIDS -- OR OF ALREADY BEING INFECTED.
THEY MAY WELL COMPRISE NEARLY ALL OF THE MILLION-AND-A-HALF
AMERICANS WE ESTIMATE TO BE NOW CARRYING THE VIRUS, BUT NOT YET
SHOWING ANY SYMPTOMS,
10
IF OUR EXPERIENCE THUS FAR MEANS ANYTHING, THEN THE PEOPLE

NOW INFECTED -- PLUS THE PEOPLE WHO ARE MOST AT RISK FOR
BECOMING INFECTED -- WOULD INCLUDE...

 

* DRUG ADDICTS WHO “SHOOT” DANGEROUS SUBSTANCES INTO
THEIR VEINS MANY TIMES A DAY. 1.V, DRUG ABUSERS COMPRISE A
FOURTH OF ALL AIDS VICTIMS SO FAR. AND ALL SIGNS POINT TO
THIS GROUP AS BEING THE ONE THAT IS GROWING THE FASTEST.
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AND THEY’VE NEVER BEEN WITHIN EASY REACH OF THE HEALTH CARE

SYSTEM. EVEN THE AIDS EPIDEMIC HAS CONVINCED JUST A FEW OF
THEM TO COME FORWARD AND SHAKE THEIR HABIT. FOR OUR PART,
I’M NOT SURE WE‘VE BEEN AS INNOVATIVE -- OR EVEN AS
ENERGETIC -- AS WE OUGHT TO BE TO REACH THIS DIFFICULT BUT
HIGHLY VULNERABLE GROUP.

* THE HIGH-RISK POPULATION ALSO INCLUDES HOMOSEXUALS OR
BISEXUAL MALES WHO ARE NOT MONOGAMOUS AND WHO STILL ENGAGE
IN ROUGH AND UNPROTECTED ANAL INTERCOURSE WITH MULTIPLE
PARTNERS.
12
THIS HAS BEEN THE GROUP THAT ACCOUNTED FOR TWO-THIRDS OF ALL

AIDS CASES SO FAR. BUT WE SEE EVIDENCE THAT PUBLIC
EDUCATION PROGRAMS HAVE GREATLY REDUCED THE NUMBERS OF MEN
ENGAGING IN HIGH-RISK SEXUAL BEHAVIOR. HENCE, THERE’S EVEN
SPECULATION THAT THE EPIDEMIC MAY HAVE ALREADY PEAKED AMONG
HOMOSEXUALS AND BISEXUAL MALES. I HOPE THAT’S THE CASE ...
BUT I THINK IT’S A LITTLE EARLY TO CELEBRATE.

* THE AT-RISK POPULATION ALSO INCLUDES A NUMBER OF WOMEN
-- MAINLY BUT NOT EXCLUSIVELY PROSTITUTES. THEY ARE EITHER
DRUG ABUSERS THEMSELVES OR THEY’VE BEEN THE SEXUAL PARTNERS
OF INFECTED DRUG ADDICTS OR INFECTED BISEXUAL MALES.
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ABOUT A THOUSAND SUCH WOMEN HAVE ALREADY BEEN REPORTED AS

HAVING AIDS. WITHIN A VERY SHORT TIME, THAT NUMBER COULD
DOUBLE OR EVEN TRIPLE.

I NEEDN'T ADD THAT THESE WOMEN -- LIKE MOST OF THE OTHERS
WHO ARE AT THE HIGHEST RISK FOR CONTRACTING AIDS -- ARE
PERSONS NOT COMMONLY FOUND ON THE PATIENT ROLLS OF MOST
PRACTICING PHYSICIANS,
14
* AND THEN THERE ARE THE CHILDREN ... INFANTS REALLY,

SOME 700 HAVE ALREADY BEEN GIVEN THE GIFT OF LIFE -- AND OF
AIDS -- BY THEIR VIRUS-INFECTED MOTHERS. OF THESE INFECTED
NEONATES, QUITE A FEW HAVE BEEN ABANDONED BY THEIR MOTHERS
AND ARE THE “PATIENT-WARDS,” IF YOU WILL, OF THE NURSING

STAFFS IN THE URBAN GENERAL HOSPITALS WHERE THEY WERE BORN,

* FINALLY, A DISPROPORTIONATE NUMBER OF PERSONS WITH AIDS
ARE BLACK OR HISPANIC. THESE MINORITIES ARE SHOWING UP
AMONG THE AIDS POPULATION AT TWICE THE RATE AT WHICH THEY
APPEAR IN THE AMERICAN POPULATION GENERALLY. THEY TEND TO
BE POOR AND TO LIVE IN URBAN AREAS WHERE HEALTH CARE SYSTEMS
ARE ALREADY STRETCHED TO THE LIMIT.
15
LET ME ADD THAT THE OVERWHELMING MAJORITY OF BLACK AND

HISPANIC AMERICANS ARE NOT AT RISK FOR AIDS -- JUST AS THE
OVERWHELMING MAJORITY OF WHITES ARE NOT AT RISK EITHER,
HOWEVER, THE BLACK COMMUNITY -- ALREADY GRAPPLING WITH
SERIOUS ISSUES OF HOUSING, EMPLOYMENT, AND EDUCATION -- IS
BEGINNING TO FEEL OVERWHELMED BY THE ADDITION OF THE AIDS
ISSUE AS WELL. THEY NEED THE UNDERSTANDING AND ASSISTANCE
OF THE MAJORITY WHITE COMMUNITY IN THIS COUNTRY -- AND WE
ARE OBLIGED TO RESPOND.
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THIS, THEN, A ROUGH SKETCH OF THE POPULATION OF AMERICANS

MOST AT RISK FOR CONTRACTING AIDS ... AND OF DYING OF THE
DISEASE:

T.V¥. DRUG ABUSERS ... PROMISCUOUS HOMOSEXUALS AND BISEXUAL
MALES ... PROSTITUTES AND SEXUAL PARTNERS OF MEN WITH AIDS
vee THE CHILDREN OF MOTHERS WITH AIDS ... AND -- TOA
DISPROPORTIONATE DEGREE -- ALL THESE GROUPS AS THEY APPEAR
IN THE BLACK AND HISPANIC COMMUNITIES.

FOR THE MOST PART THESE AMERICANS STILL LINGER ON THE PERIMETER
OF -- OR ARE CLEARLY OUTSIDE -- OUR SYSTEM OF HEALTH CARE
DELIVERY. BUT, AS THE AIDS EPIDEMIC PROGRESSES, THEY DESPER-
ATELY NEED TO GET IN,
17
T HAVE VISITED WITH THESE INDIVIDUALS AND HAVE HEARD THEIR

PESSIMISTIC VIEW ABOUT THEIR ABILITY TO GAIN ACCESS TO
APPROPRIATE HEALTH CARE. I HAVE HEARD MANY OF THEM ACCUSE ALL OF
GOVERNMENT AND ALL OF SOCIETY OF BEING, AT THE VERY LEAST,
CALLOUS AND INDIFFERENT OR, AT THE VERY WORST, RACIST AND
VENGEFUL.

I DON'T AGREE. I THINK WE’RE IN A TERRIBLE BIND -- ONE
THAT PERSISTS DESPITE THE BEST EFFORTS BY PEOPLE OF GOOD WILL OF
ALL BACKGROUNDS.
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ON THE OTHER HAND, I‘VE SPOKEN TO COLLEAGUES IN MEDICINE AND

SOCIAL SERVICES WHO DISMISS THE PLIGHT OF PEOPLE WITH AIDS AS
SOMETHING THEY "BROUGHT UPON THEMSELVES,”

BUT I DON’T AGREE WITH THEM EITHER. IT’S NOT AT ALL CLEAR
TO WHAT EXTENT AN AMERICAN MAN OR WOMAN, BORN IN -- AND DYING IN
-- AN URBAN AMERICAN GHETTO, HAS THE EMOTIONAL, CULTURAL,
EDUCATIONAL, OR ECONOMIC WHEREWITHAL TO TRULY CONTROL HIS OR HER
OWN PERSONAL BEHAVIOR, .

BUT I AM LESS CONCERNED WITH THE PARTICULAR ARGUMENTS RAISED
BY EACH SIDE THAN I AM BY THE UNDERLYING FEELING AMONG BOTH
GROUPS.
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QUITE SIMPLY, IT IS FEAR ... FEAR OF THIS STILL-MYSTERIOUS

DISEASE ... FEAR OF ITS MORTALITY RATE, WHICH IS VIRTUALLY 100
PERCENT ... FEAR OF THE STIGMA OF THE DISEASE, OF WHAT OTHER
PEOPLE WILL CONCLUDE ABOUT THEIR BEHAVIOR AND THEIR JUDGMENT ...
FEAR OF THE CONSEQUENCES OF THAT STIGMA, WHICH CAN BE LOSS OF A
JOB OR HOUSING, EXPULSION FROM SCHOOL, OR DENIAL OF CERTAIN
NECESSARY HEALTH OR SOCIAL SERVICES.

] FEAR IT, ALSO. BUT FOR OTHER REASONS. I FEAR THE AFFECTS
OF THE AIDS VIRUS UPON THE SOCIAL COMPACT THAT HAS HELD AMERICAN
SOCIETY TOGETHER THROUGH PERIODS OF PROFOUND TURMOIL AS WELL AS
TRANQUILITY.
20
T FEAR ITS AFFECT UPON THE HEALTH SYSTEM IN OUR COUNTRY, A

SYSTEM THAT REFLECTS AN HISTORIC NATIONAL TEMPERAMENT OF CHARITY
AND TOLERANCE ... OF RESPONSIVENESS AND AFFIRMATION,

AND I FEAR THE AFFECT OF THE AIDS VIRUS UPON THE PEOPLE WHO
MAKE THAT SYSTEM WORK ... THE PHYSICIANS AND NURSES, THE DENTISTS
AND TECHNICIANS, THE SOCIAL WORKERS, THE ADMINISTRATORS.

OUR “CALLING,” IF YOU WILL, IS BASED UPON THE MOST VALUED
ETHIC IN HUMAN HISTORY ... AN ETHIC THAT IS INTEGRAL TO OUR

PROFESSIONAL OATH, WHICH SAYS, IN EFFECT, ...

“DO WHAT YOU CAN TO HELP ... BUT IN ANY CASE, DO NO HARM.”
21
MY PARAPHRASE OF THE OATH MAY SOUND A BIT SIMPLISTIC, I

SUPPOSE, AND MAY NOT BE ALTOGETHER REFLECTIVE OF A LIFE IN
MEDICINE, BUT I THINK IT DOES TOUCH UPON THE ESSENTIAL NATURE OF
THE HEALING ARTS, |

“DO WHAT YOU CAN TO HELP ... BUT IN ANY CASE, DO NO HARM.”

WORDS LIKE THAT SHOULD HOLD GREAT MEANING FOR ALL OF US, AS
WE CONFRONT THE CHALLENGE OF THE AIDS EPIDEMIC.

HOW CAN YOU HELP? AS YOUR "POSITION PAPERS” SAY, YOU CAN
HELP BY CARING FOR PATIENTS YOU KNOW WHO CONTRACT THE DISEASE OF
AIDS.
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YOU CAN HELP BY INFLUENCING THE HEALTH CARE SYSTEM TO REMAIN

OPEN TO PATIENTS YOU DON'T KNOW, WHO CONTRACT THE DISEASE OF
AIDS.

YOU CAN HELP BY REINFORCING -- THROUGH PATIENT AND COMMUNITY
EDUCATION PROGRAMS -- THE KIND OF LOW-RISK OR NO-RISK BEHAVIOR
THAT MOST PEOPLE ENGAGE IN ANYWAY,

CONVERSELY, YOU CAN ALSO HELP -- AGAIN, THROUGH EDUCATION
PROGRAMS -- TO GET OTHERS TO ABANDON THEIR HIGH-RISK DRUG AND
SEXUAL BEHAVIORS.

“AND ... DO NO HARM.” FIGHT THE DISEASE WITH EVERYTHING
YOU'VE GOT. BUT DON’T FIGHT THE PEOPLE WHO HAVE IT.
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IF YOU ARE STILL UNFAMILIAR WITH THE SIGNS AND SYMPTOMS OF

THE DISEASE -- OR IF YOU KNOW YOU ARE UNSKILLED IN THE KIND OF
PERSONAL COUNSELING THAT SHOULD GO ALONG WITH A DIAGNOSIS OF AIDS
~~ THEN REFER THE PATIENT TO SOMEONE OR SOME PLACE THAT PROVIDES
THOSE SERVICES.

RECOGNIZE THE FACT THAT HAVING AIDS IS STIGMATIZING IN MOST
COMMUNITIES. THEREFORE, THERE IS A REAL NEED FOR MAINTAINING
CONFIDENTIALITY IN RESPECT TO AIDS-RELATED PATIENT INFORMATION,
BUT CONFIDENTIALITY IS NOT AN ABSOLUTE PRESCRIPTION. WE KNOW
THAT, IN THE CASE OF SPOUSES, FOR EXAMPLE, CONFIDENTIALITY ITSELF
CAN BRING ABOUT GREAT PERSONAL HARM,
24
THESE KINDS OF ISSUES MUST BE WORKED THROUGH WITH GREAT CARE

AND WITH THE GUIDANCE OF THOUGHTFUL, EXPERIENCED COLLEAGUES. TO
DISMISS OR DODGE THESE ISSUES WOULD BE TO DO GREAT AND
IRREVERSIBLE HARM TO PEOPLE.

AND MANY OF THEM -- SUCH AS SPOUSES OR CHILDREN -- ARE
INDIVIDUALS WHO CANNOT TRULY BE CRITICIZED FOR BECOMING INFECTED
WITH THE AIDS VIRUS. THEY DID NOT INCUR THE DISEASE BY THEIR OWN
CHOICE,

IT SHAN’T GO THROUGH A LONG LIST OF SUGGESTIONS AS TO WHAT TO
DO IN EACH OF THESE SITUATIONS. I'M SURE THAT EACH OF YOU --
DRAWING UPON YOUR OWN EXPERIENCE AND YOUR OWN HUMANITY -- CAN
COME UP WITH A LIST THAT’S EVERY BIT AS USEFUL AS MINE.
25
THE MOST IMPORTANT ASPECT OF SUCH A LIST, HOWEVER, WOULD NOT

ONLY BE ITS RELEVANCE TO CARING FOR MOSTLY WHITE, MAINLY
HETEROSEXUAL, MONOGAMOUS, AND DRUG-FREE PATIENTS ~~ THE ONES WITH
WHOM WE ARE MOST FAMILIAR --- BUT ALSO ITS RELEVANCE TO THE CARE
OF SUBSTANTIALLY BLACK AND HISPANIC, PRIMARILY HOMOSEXUAL AND
BISEXUAL, GENERALLY PROMISCUOUS, AND DRUG-ADDICTED PATIENTS, THE
ONES ABOUT WHOM WE KNOW VERY LITTLE BUT, IN THIS “AGE OF AIDS,”
THE VERY ONES WHO NEED OUR HELP THE MOST.

I HAVE NO DOUBT BUT THAT SUCH CARE WILL BE PROVIDED. I DO
NOT BELIEVE WE WILL EVER ABANDON ANY OF THESE PATIENTS. HERE IN
THE UNITED STATES, THAT’S SIMPLY OUT OF THE QUESTION,
26
BUT WE ARE BEING TESTED, THERE’S NO QUESTION ABOUT THAT.

THE EPIDEMIC OF AIDS IS PROVIDING ONE OF THE MOST SERIOUS TESTS
OF SOCIAL AND POLITICAL WILL THAT OUR SOCIETY HAS EVER UNDERGONE.

YET, I BELIEVE WE WILL COME THROUGH SUCH A TEST WITH OUR
IDEALS AND OUR INSTITUTIONS INTACT,

AND THE REASON I CAN DARE TO PREDICT SUCH AN OUTCOME IS THAT
I BELIEVE THE PROFESSIONAL MEN AND WOMEN OF THIS COUNTRY WILL, IN
THE LONG RUN, ROLL UP THEIR SLEEVES AND DO WHAT HAS TO BE DONE,
DESPITE AN ENVIRONMENT OF OVERWHELMING TRAGEDY, BOTH PERSONAL AND
NATIONAL.
2/7
THE NEXT FEW YEARS -- A DECADE OR TWO -- WILL NOT BE EASY.

BUT WE'LL MAKE IT ... AND WE’LL MAKE IT TOGETHER,

THANK YOU,
HEH #