ORIGINAL ~S \ ASH FOURTH ANNUAL AsH LECTURE BY C, Everett Koop. M.D., Sc.D, SURGEON GENERAL OF THE U.S. Puspiic HEALTH SERVICE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES C5 PRESENTED AT THE ARMED Forces MEDICAL MUSEUM WASHINGTON, D.C. JUNE 1, 1988 1 (GREETINGS TO HOSTS, GUESTS, FRIENDS, ETC.) IT’S A DISTINCT HONOR TO BE CHOSEN AS THE PERSON TO DELIVER THIS YEAR’S ASH LECTURE. AND OF COURSE IT’S A GREAT PERSONAL PLEASURE TO BE AMONG SO MANY COLLEAGUES IN MILITARY MEDICINE. A HALF-DOZEN YEARS AGO, AFTER I’D BEEN IN THIS POSITION FOR A LITTLE WHILE, I PROMISED MYSELF THAT I WOULD DO WHATEVER I COULD -- DURING MY WATCH AS SURGEON GENERAL -- TO HELP BRING TOGETHER, IN A CLOSER, WORKING RELATIONSHIP, THE U.S.PUBLIC HEALTH SERVICE AND ITS SISTER UNIFORMED SERVICES. 2 AND I THINK THAT HAS HAPPENED, FOR WHICH I AM VERY PROUD AND ALSO FOR WHICH I OWE A SINCERE DEBT OF GRATITUDE TO MY COLLEAGUES WHO DIRECT THE MEDICAL AND HEALTH SERVICES OF THE VARIOUS BRANCHES OF THE ARMED FORCES. IT SEEMED TO ME, AS I CONTEMPLATED MY REMARKS FOR THIS EVENING, THAT THIS WOULD BE A FINE OPPORTUNITY TO ACKNOWLEDGE THIS P.H.S. ACHIEVEMENT AS WELL AS THE EXCELLENT COOPERATION AND ASSISTANCE WE RECEIVED FROM THE ARMED FORCES AS WE MOVED FORWARD TOWARDS OUR GOAL. 3 BUT IT’S NOT MY INTENTION TO DWELL ANY FURTHER ON SUCH MATTERS BECAUSE I WANT TO PROCEED WITH THE TOPIC THAT IS ON EVERYONE’S MIND -- AND PARTICULARLY ON THE MINDS OF EVERY HEALTH PROFESSIONAL IN THIS COUNTRY, WHETHER IN UNIFORM OR NOT. OF COURSE, I’M TALKING ABOUT AIDS, [’M NOT GOING TO REVIEW THE PARTICULARS OF THE DISEASE. THE NEW EDUCATIONAL DISPLAY HERE AT THE MUSEUM DOES THAT VERY WELL. [ COMMEND THE DIRECTOR AND THE STAFF FOR CHOOSING AIDS AS THE TOPIC FOR THE NEW EXHIBITION AND FOR MAKING THIS IMPORTANT CONTRIBUTION TO FURTHER UNDERSTANDING OF THIS KILLER EPIDEMIC. 4 THEREFORE, IF ANYONE HERE THIS EVENING IS STILL A BIT UNCLEAR ABOUT THIS DISEASE, I RECOMMEND YOU JOIN THE REST OF US AND STUDY THE NEW EXHIBIT HERE AT THE ARMED FORCES MEDICAL MUSEUM, I MUST SAY THAT, THROUGHOUT THE 7-YEAR HISTORY OF THIS EPIDEMIC, WE HAVE HAD VERY STRONG AND WELL-CONCEIVED EFFORTS T0 KEEP THE GENERAL PUBLIC, AS WELL AS AND THE MEDICAL AND HEALTH PROFESSIONS, INFORMED OF ALL DEVELOPMENTS IN THE UNFOLDING OF THIS TRAGIC CHAPTER IN HUMAN HISTORY. _ THE POPULAR DAILY PRESS -- AND OUR OWN PROFESSIONAL JOURNALS ~~ HAVE BEEN PARTICULARLY GOOD AND THEY DESERVE OUR RECOGNITION AND THANKS, 5 THEREFORE, INSTEAD OF GOING BACK OVER THE DETAILS OF THIS DISEASE AND ITS HISTORY, I WOULD LIKE TO FOCUS INSTEAD ON THREE MAIN ASPECTS OF THE EPIDEMIC AND INDICATE HOW THEY ARE AFFECTING THE WAY AMERICANS THINK ABOUT DISEASE ... ABOUT EACH OTHER ... AND ABOUT RESPONSIBILITY: PROFESSIONAL, SOCIAL, AND PERSONAL RESPONSIBILITY. MAKE NO MISTAKE ABOUT IT. AIDS NOT ONLY ATTACKS THE CENTRAL NERVOUS SYSTEM OF ITS VICTIMS. IT ALSO HAS DISTURBED THE PEACE OF MIND OF THE REST OF OUR CITIZENS AND HAS BECOME A CONSTANT CHALLENGE TO AMERICA’S SOCIAL COHESION AND NATIONAL PURPOSE. 6 WHY IS THIS SO? WHAT MAKES AIDS SO THREATENING? FIRST, AIDS IS STILL A MYSTERY. AND NOTHING INSPIRES MORE FEAR THAN THE UNKNOWN. A MOMENT AGO I CONGRATULATED THE PRESS FOR KEEPING US SO WELL INFORMED ABOUT AIDS. YET, NONE OF THAT INFORMATION HAS BEEN THE FINAL WORD ON THE DISEASE. FAR FROM IT, IT’S TRUE THAT WE KNOW QUITE A BIT ABOUT AIDS. BUT UNFORTUNATELY WE DON’T YET KNOW ENOUGH TO PRODUCE A VACCINE TO PREVENT ITS SPREAD OR A DRUG TO STOP IT IN ITS TRACKS. 7 IT’S. NOT FOR LACK OF EFFORT. THE WORLD’S MOST TALENTED VIROLOGISTS AND IMMUNOLOGISTS HAVE BEEN WORKING ON THIS DISEASE FOR A HALF~DOZEN YEARS. BUT FOR ONLY A HALF-DOZEN YEARS. THEY STILL HAVE MUCH TO DO... AND MOST OF IT IS IN TOTALLY NEW AREAS OF INQUIRY. ] EMPHASIZE THIS POINT BECAUSE THERE IS A SMALL BUT VOCAL SEGMENT OF THE PUBLIC WHO HAS BEEN HIGHLY CRITICAL AND VERY IMPATIENT WITH GOVERNMENT AND THE SCIENTIFIC EFFORT IN GENERAL. THEY ARE CERTAINLY WELL-MEANING. BUT I’M AFRAID THEIR CRITICISMS REFLECT AN EXTRAORDINARY LACK OF UNDERSTANDING OF THE PROCESSES OF SCIENTIFIC INQUIRY. 8 ON THE OTHER HAND, WE IN THE WORLD OF BIOMEDICAL SCIENCE, NEED TO LOOK AGAIN AT OUR “CULTURE” ... WE OURSELVES NEED TO TURN A CRITICAL EYE UPON THE WAY WE CONTINUE TO FUNCTION WITHIN OUR OWN CAREFULLY DEFINED AREAS OF STUDY. FOR EXAMPLE, WE NEED TO STOP PAYING LIP-SERVICE TO INTER- DISCIPLINARY THINKING AND BEGIN TO MAKE IT PART OF OUR ROUTINE APPROACH TO ALL OUR PROBLEMS. FOR EXAMPLE, ONLY THIS FEBRUARY -- AND UNDER THE CO- SPONSORSHIP OF THE A.F.I.P., If WOULD ADD -- DID CLINICIANS AND PATHOLOGISTS COME TOGETHER FOR THE FIRST TIME IN ONE MEETING TO SHARE THEIR PERCEPTIONS OF THE DISEASE OF AIDS. 9 AND FOR THAT, WE CAN THANK DR. ABE MACHER OF THE A.F.I.P, AND DR. HAROLD GINZBURG OF N.I.H. GOOD FOR THEM. BUT WE OBVIOUSLY NEED MUCH MORE THAT INTERDISCIPLINARY CONSULTATION AND CERTAINLY WE NEED MUCH MORE MULTIDISCIPLINARY RESEARCH AND DEMONSTRATION, IF WE HOPE TO MAKE SIGNIFICANT PROGRESS AGAINST AIDS. YES, I REJECT MUCH OF THE IMPATIENT CRITICISMS OF THE PUBLIC. YET, I CANNOT EXCUSE US FROM OUR OWN SHORTCOMINGS EITHER. WE MUST BE PREPARED TO STRAY FROM THE NARROW PATHS OF OUR RESPECTIVE SPECIALTIES, IN ORDER TO EXPLORE MORE THOROUGHLY | ALL THE RAMIFICATIONS OF THE AIDS EPIDEMIC, 10 OF COURSE, THE AVERAGE PERSON WANTS SCIENCE TO PROVIDE A CLEAR-CUT “YES” OR “NO” ANSWER TO THE MOST PRESSING PERSONAL QUESTIONS IN REGARD TO AIDS. BUT ALL THE DESIRED CLEAR-CUT ANSWERS AREN’T YET AVAILABLE. IT’S HARD TO SAY THIS TO A GENERATION OF AMERICANS WHO'VE GROWN UP READING ABOUT THE CONQUESTS OF BIOMEDICAL SCIENCE -- NOT ITS DEFEATS ... A GENERATION, I MIGHT ADD, THAT HAS BEEN SUCCESSFULLY INOCULATED AGAINST POLIO AND MEASLES AND A HALF- DOZEN STRAINS OF THE FLU ... A GENERATION THAT MAY BE THE FIRST NEVER TO GO BALD. 11 IF SCIENCE CAN CONQUER BALDNESS AND WHAT THE ADVERTISING PEOPLE CALL “THE HEARTBREAK OF PSORIASIS,” THEN CERTAINLY AN AIDS CURE IS JUST AROUND THE CORNER. ISN'T IT? NO, IT ISN’T. AND IF THERE’S A HEARTBREAK IN MEDICINE ... THAT’S IT, SO, AIDS IS STILL A MYSTERY. AND THAT FACT HAS ALREADY PLACED GREAT STRAINS UPON THE RELATIONSHIP BETWEEN BIOMEDICAL SCIENCE AND THE GENERAL PUBLIC. 12 BUT AIDS HAS A SECOND AND EVEN MORE TERRIFYING ATTRIBUTE: AIDS IS VIRTUALLY FATAL. IN FACT, AIDS SEEMS TO HAVE ONE OF THE HIGHEST FATALITY RATES OF ANY INFECTIOUS DISEASE WE’VE EVER KNOWN, WHEN YOU LOOK AT ALL THE REPORTED CASES OF AIDS SINCE 1981 -- AND THE REPORTED DEATHS AS WELL -- THE MORTALITY RATE IS ABOUT 56 PERCENT ... WHICH IS BAD ENOUGH. BUT WHEN YOU RETURN JUST TO THOSE PERSONS WHO HAD AIDS BACK IN 1981, YOU DISCOVER THAT 93 PERCENT OF THEM HAVE SINCE DIED OF THE DISEASE, 13 AND .IN MY BOOK, A MORTALITY RATE OF 93 PERCENT IS AS BAD A RATE AS 100 PERCENT. WE HAVE NO VACCINE TO PROTECT ANYONE FROM THE HUMAN IMMUNO- DEFICIENCY VIRUS, OR H.1.V. AND I DON’T EXPECT US TO HAVE READILY AVAILABLE A SAFE AND EFFECTIVE VACCINE BEFORE THE END OF THE CENTURY, AND THE DRUGS WE HAVE IN THE DEVELOPMENT PIPELINE ARE MUCH LIKE THE ONE DRUG WE HAVE OUT IN THE MARKETPLACE NOW: A.Z.T. THEY WILL SLOW THE PROCESS OF DYING ... BUT NOT STOP IT. 14 SO, THE DISEASE IS A MYSTERY ... IT'S EATAL ... AND, THREE, THE AIDS VIRUS IS TRANSMITTED BY THE KIND OF BEHAVIOR THAT MOST PEOPLE DON’T ENGAGE IN -- OR APPROVE OF. THAT’S LESS OF A PROBLEM FOR BIOMEDICAL RESEARCH THAN IT IS FOR SOCIOLOGICAL, CULTURAL, AND ANTHROPOLOGICAL RESEARCH. AT ANY RATE, IT IS A SERIOUS ASPECT OF THE EPIDEMIC AND THE WAY IT IS PERCEIVED BY THE GENERAL PUBLIC, AS I’M SURE YOU KNOW BY NOW, THE HIGHEST CONCENTRATIONS OF THE AIDS VIRUS ARE FOUND IN BLOOD, SEMEN, AND IN VAGINAL SECRETIONS. 15 HENCE, THE SPECIFIC PERSONAL BEHAVIORS THAT PRODUCE THE HIGHEST RISK OF TRANSMISSION ARE UNPROTECTED ANAL INTERCOURSE -- PARTICULARLY AS PRACTICED BY HOMOSEXUALS AND BISEXUAL MALES -- THE SHARING OF NEEDLES BY INTRAVENOUS DRUG ABUSERS AND, TO A SOMEWHAT LESSER EXTENT, VAGINAL INTERCOURSE AS WELL. UNFORTUNATELY, THERE’S A GREAT DEAL OF UNINFORMED AND WRONG- HEADED TALK ABOUT OTHER MODES OF TRANSMISSION: TEARS AND MOSQUITOS AND WATER GLASSES AND TOILET SEATS AND SO ON. 16 IF ANY OF THESE REALLY DID PERMIT THE TRANSMISSION OF THE AIDS VIRUS, THE EPIDEMIC OF AIDS WOULD BY NOW HAVE WIPED OUT MANY MILLIONS OF AMERICANS -- AND TENS OF MILLIONS OF PEOPLE AROUND THE GLOBE. FORTUNATELY FOR THE HUMAN RACE, IT TAKES MORE THAN A CASUAL ACT TO PASS THOSE SPECIFIC BODY FLUIDS FROM ONE PERSON TO ANOTHER. FORTUNATELY FOR US, ALSO, IS THE FACT THAT THE OVERWHELMING MAJORITY OF AMERICANS OF ALL RACES AND PERSUASIONS DO NOT ENGAGE IN ANAL SEX AND 1I.¥. DRUG ABUSE. AND YOU DON’T HAVE TO BE A BOARD-CERTIFIED PROCTOLOGIST TO KNOW THAT THIS IS TRUE. 17 AIDS, THEN, LIKE OTHER SEXUALLY TRANSMITTED DISEASES -- AND LIKE SO MANY MAJOR PUBLIC HEALTH PROBLEMS IN OUR SOCIETY -- IS AN OUTCOME OF UNWISE PERSONAL BEHAVIOR, THUS FAR, THE AMERICAN PEOPLE HAVE BEEN VERY TOLERANT OF PEOPLE WHO GET SICK BECAUSE THEY DO SOMETHING THEY VERY LIKELY KNOW IS NOT A SMART THING TO DO. HENCE, WE’VE RELIED UPON GENERAL TAX REVENUES TO SUPPORT V.D. CLINICS, ALCOHOLISM AND DRUG TREATMENT CENTERS, DIET AND NUTRITION COUNSELING, FAMILY PLANNING, EMERGENCY MEDICAL SERVICES FOR HIGHWAY TRAUMA, AND SO ON. 18 IT’S HARD TO EXPLAIN PUBLIC SUPPORT IN A FEW WORDS, BUT I SUPPOSE IT BOILS DOWN TO THIS: THE AMERICAN PEOPLE KNOW THAT THE FLESH IS WEAK, BUT THEY ALSO BELIEVE IN REDEMPTION AND THEY’RE WILLING TO HELP PAY FOR IT: SYPHILITICS CAN BE CURED ... ALCOHOLICS CAN BE RESCUED ... HIGHWAY DAREDEVILS CAN BE REFORMED. BUT AIDS HAS ARRIVED ON THE SCENE AND HAS BECOME THE FIRST SERIOUS WEDGE TO BE DRIVEN INTO OUR REMARKABLE PUBLIC HEALTH COMPACT. THE REASON, I’M SORRY TO SAY, IS SIMPLE ENOUGH TO UNDERSTAND. 19 | * A PERSON BECOMES INFECTED WITH H.I.V. BY DOING THINGS THAT MOST PEOPLE DON’T DO. * IF THE INFECTION DEVELOPS INTO AIDS AND A LIFE- THREATENING CANCER OR INFECTIOUS DISEASE, A NUMBER OF PUBLIC PROGRAMS ARE AVAILABLE TO PROVIDE MEDICAL CARE AND CERTAIN SOCIAL SERVICES, ALSO. * RIGHT NOW, SUCH CARE IS RUNNING ABOUT $20,000 TO $30,000 PER YEAR PER AIDS PATIENT. * THE AVERAGE LENGTH OF TIME A PERSON WITH AIDS RECEIVES SUCH CARE IS 12 TO 18 MONTHS. * AND THEN THE PERSON DIES. 20 AFTER A PRODIGIOUS INVESTMENT OF PUBLIC FUNDS, THERE IS NO RESCUE ... NO REFORMATION OF CHARACTER ... NO ONE IS SAVED OR REDEEMED AND RETURNED TO SOCIETY, THIS DISEASE, THEREFORE, PRESENTS THE TOUGHEST CHALLENGE YET TO THE AMERICAN CONCEPT OF PUBLIC HEALTH. SO FAR, WE‘RE DOING ALL RIGHT. BUT, AS THE SAYING GOES, “THE NATIVES ARE GETTING RESTLESS.” AS MANY OF YOU KNOW, A HALF-MILLION CALIFORNIANS HAVE SIGNED A PETITION AND NOW HAVE A PLACE ON THE BALLOT NEXT NOVEMBER FOR AN AIDS-RELATED REFERENDUM, 21 IF THE LAW PASSES, CALIFORNIA WILL BECOME THE 13TH STATE TO REQUIRE PHYSICIANS AND OTHER HEALTH PERSONNEL TO REPORT THE NAMES OF PEOPLE WHO DO NOT YET HAVE AIDS BUT ARE H.I.V.- POSITIVE. FORTUNATELY, CALIFORNIA, HAS A STRONG CONFIDENTIALTY STATUTE THAT NOW APPLIES TO AIDS RECORDS AND WOULD APPLY TO H.I.V. RECORDS AS WELL. TEXAS HAS PROBABLY THE STRONGEST STATE LAW OF THIS KIND, EXEMPTING AIDS PATIENT INFORMATION FROM SUBPOENA. 22 BUT THE FEAR IS THAT INFORMATION ABOUT SEROPOSITIVITY COULD WELL ESCAPE THESE CONTROLS AND BE USED IN A DISCRIMINATORY WAY, IN REGARD TO EMPLOYMENT OR HOUSING OR EDUCATION. CALIFORNIA ITSELF, WHICH HAS BEEN IN THE VANGUARD OF THE BATTLE AGAINST AIDS, DOES NOT HAVE A STATEWIDE ANTI-DISCRIMINA- TION LAW. IN FACT, ONLY FOUR COMMUNITIES HAVE ENACTED LOCAL ANTI-DISCRIMINATION ORDINANCES TO COVER AIDS INFORMATION, THESE KINDS OF QUESTIONS WERE FIRST RAISED IN THE 1970s, WHEN HERPES, A REPORTABLE DISEASE UNDER FEDERAL AND STATE LAWS, WAS REACHING EPIDEMIC PROPORTIONS. HERPES, YOU REMEMBER, WHILE NOT FATAL, IS NEVERTHELESS A LIFELONG CONDITION WITH NO CURE. 23 BUT BEFORE SOCIETY COULD AGREE ON AN EQUITABLE WAY TO HANDLE THE HERPES PROBLEM, WE WERE CONFRONTED BY THE NEW AND LETHAL AIDS EPIDEMIC. AND THAT'S WHERE WE ARE NOW, STILL TRYING TO SORT OUT THE ISSUES ... THE PEOPLE ... THE SCIENCE ... AND THE ECONOMICS INVOLVED IN FIGHTING AIDS, AND DO SO WITHIN THE FRAMEWORK OF OUR 200-YEAR-OLD DEMOCRACY AND ITS COMMITMENT TO PROTECTING THE INDIVIDUAL CITIZEN, THAT CHALLENGE WAS STATED VERY SUCCINCTLY BY PRESIDENT REAGAN LAST YEAR AT THE AWARDS DINNER PUT ON BY THE AMERICAN FOUNDATION FOR AIDS RESEARCH. 24 THE PRESIDENT SAID WE HAD TO FIGHT THIS DISEASE WITH EVERYTHING AT OUR COMMAND. BUT HE WENT ON TO SAY... "IT'S ALSO IMPORTANT THAT AMERICA NOT REJECT THOSE WHO HAVE THE DISEASE, BUT CARE FOR THEM WITH DIGNITY AND KINDNESS. THIS IS A BATTLE AGAINST DISEASE, NOT AGAINST OUR FELLOW AMERICANS.” CAN WE DO THAT? I HOPE WE CAN, THESE AND OTHER ISSUES LIE ON THE HORIZON BEFORE US. BUT THE HORIZON IS NOT THAT FAR AWAY, 25 I HOPE WE WILL NOT STUMBLE ACROSS THAT TERRAIN, UNPREPARED FOR THE CHALLENGES THAT LIE BEYOND, I HOPE WE WILL BEGIN TO TALK ABOUT THESE ISSUES AS THE WISE AND FREE SOCIETY WE PROFESS TO BE. IF WE DO, WE MAY YET GIVE THE WORLD SOMETHING EVERY BIT AS PRECIOUS AS THE MUCH-DESIRED AIDS VACCINE: WE WILL SHOW THE WORLD HOW COMPASSION AND JUSTICE...IN ADDITION TO FIRST-CLASS SCIENCE...CAN TRIUMPH OVER THIS MYSTERIOUS, FATAL DISEASE. ONCE AGAIN... THANK YOU...AND BEST WISHES FOR THIS MEETING. HEH #