ORIGINAL,

ADDRESS

BY
C. Everett Koop, MD, ScD
SURGEON GENERAL
OF THE
U. S, Pupiic HEALTH SERVICE
AND
Deputy ASSISTANT SECRETARY OF HEALTH
U. S,. DEPARTMENT OF HEALTH AND HUMAN SERVICES

on.

<a
————

PRESENTED AT THE INSTITUTE OF POLITICS
JOHN F, KENNEDY SCHOOL OF GOVERNMENT
HARVARD UNIVERSITY
CAMBRIDGE, MASSACHUSETTS
Fepruary 10, 1987
(GREETINGS TO HOSTS, GUESTS, FRIENDS, ETC.)

I’M DELIGHTED TO RETURN TO THIS PODIUM ONCE AGAIN. THIS TIME I’M
GOING TO TALK -- NOT ABOUT SMOKING -- BUT ABOUT ANOTHER QUITE SERIOUS
PUBLIC HEALTH MATTER. LIKE SMOKING, THE THREAT OF AIDS ALSO TURNS ON
THE PERSONAL BEHAVIORS OF MILLIONS OF AMERICANS...BUT. UNLIKE SMOKING,
AIDS IS STILL A MYSTERY,

 

WITH YOUR INDULGENCE, LET ME TOUCH LIGHTLY ON THE RECENT HISTORY
OF THE DISEASE AND THEN I WANT TO EXPLORE SOME OF THE KEY QUESTIONS IT
POSES TO SOCIETY... TODAY. I’LL DO THAT IN THE COURSE OF TELLING YOU A
LITTLE BIT ABOUT MY REPORT ON AIDS,

FIRST,..A LITTLE HISTORY.
ALMOST SIX YEARS AGO, IN JUNE 1981, THE PUBLIC HEALTH SERVICE
OFFICE IN ATLANTA, WHICH COLLECTS INFORMATION FROM STATE HEALTH
AGENCIES, BEGAN TO GET SOME RATHER ALARMING REPORTS. IT WAS INFORMED
OF 5 CASES OF PNEUMOCYSTIS CARINII] PNEUMONIA IN LOS ANGELES,

FIVE CASES IS NOT MUCH...BUT THIS LETHAL DISEASE IS SO RARE THAT
A HANDFUL OF CASES IN A SINGLE YEAR IS LIKE AN EPIDEMIC, SOON THE
REPORTS TRICKLED IN OF OTHER SUCH CASES OCCURRING IN OTHER CITIES AS
WELL,

OUR PEOPLE INVESTIGATED AND THE TRAIL LED TO MANY PEOPLE WHO, FOR
SOME MYSTERIOUS REASON, WERE SICK AND THEIR BODIES WERE NOT FIGHTING
BACK AS YOU'D EXPECT THEM 10,

AS A RESULT, THEY WERE NOT ONLY SICK WITH THIS VERY DANGEROUS
FORM OF INFECTIOUS PNEUMONIA... THEY WERE DYING FROM IT...AND NO ONE
KNEW WHY,
IT APPEARED THAT OTHERWISE HEALTHY, NORMAL PEOPLE WERE ACQUIRING
SOME KIND OF “BUG” -- A VIRUS, MOST LIKELY -- THAT ATTACKED AND
APPARENTLY DESTROYED THE NAT'RAL IMMUNE SYSTEMS OF THESE VICTIMS,

THE ODD THING WAS THAT THE VIRUS ITSELF WAS NOT KILLING PEOPLE:
PEOPLE WERE DYING OF EXTREMELY VIRULENT DISEASES BECANSE THIS VIRUS --
WHATEVER IT WAS -- PREVENTED THE BODY FROM FIGHTING THEM OFF.

WE’D NEVER COME UPON A SYNDROME Q'ITE LIKE IT BEFORE. AND SO WE
GAVE IT A SOMEWHAT AWKWAR” TITLE. WE CALLED IT THE “ACQUIRED IMMUNE
DEFICIENCY SYNDROME,” BUT WE SOON SETTLED JUST FOR THE INITIALS...
A.1.D.S....0R “AIDS.”

AND 17'S BEEN AIDS EVER SINCE.
YOU'VE READ THE STORIES AND SEEN IT ON TELEVISION, 1’M SURE, SO I
WON'T GO THROUGH THE ENTIRE 6-YEAR HISTORY ALL OVER AGAIN. INSTEAD,
I’LL JUST TOUCH ON A FEW KEY POINTS:

FIRST OF ALL, WE’RE TALKING ABOUT A DISEASE THAT IS SPREADING,
THE NUMBER OF VICTIMS IS DOUBLING IN LITTLE MORE THAN A YEAR. FOR
EXAMPLE, AS OF JANUARY 1986, WE HAD A CUMULATIVE TOTAL OF 16,000
REPORTED CASES,

TODAY THAT TOTAL IS 30,000. BY THE WAY, OVER HALF OF THEM HAVE
ALREADY DIED OF THE DISEASE...AND THE REST WILL.

LAST YEAR WE HAD OVER 13,000 NEW CASES ADDED TO THE TOTAL. THIS
YEAR WE EXPECT ANOTHER 23,000 NEW CASES,

BY THE END OF 1990 THE CUMULATIVE TOTAL WILL BE CLOSE 10 270,000,
MAKE NO MISTAKE ABOUT IT, AIDS IS SPREADING AMONG MORE PEOPLE...
AND IT IS FATAL.

AFTER LOOKING AT ALL THE INFORMATION WE NOW HAVE. MY BOSS, DR,
OTIS R. BOWEN, THE SECRETARY OF HEALTH AND HUMAN SERVICES, LIKENED THE
SPREADING AIDS SITUATION TO THE ARRIVAL AND SPREAD OF SMALLPOX AND THE
BUBONIC PLAGUE IN EUROPE SEVERAL CENTURIES AGO,

SECOND POINT: EVEN THOUGH SCIENTISTS HAVE HAD A LOOK AT THE AIDS
VIRUS, WE DON’T REALLY KNOW WHAT IT TS. AND UNLESS WE KNOW THAT, WE
HAVE NO WAY OF STOPPING IT, YES, WE’RE MAKING PROGRESS IN THE
RESEARCH EFFORT, BUT IT'S VERY SLOW GOING,

IN 1984 THE SEARCH WAS NARROWED DOWN TO SOMETHING CALLED A HUMAN
RETROVIRUS AND OUR 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 III,” OR SIMPLY “HTLV-II.”
APPARENTLY 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 “HT.V."

THIS WAS A VERY IMPORTANT STEP, BECAUSE WE KNEW WHERE THE VIRUS
WAS, WE WERE THEN ABLE TO RECOGNIZE THE PRESENCE OF ANTIBODIES
SPECIFIC TO THE AIDS VIRUS IN AN INDIVIDUAL‘S BLOOD SERUM. OF COURSE,
THOSE ANTIBODIES AREN’T VERY EFFECTIVE, BUT THEY'RE PRESENT NEVERTHE-
LESS,

AS OF 1985 WE’VE HAD A TEST THAT CAN DETECT THE PRESENCE OF THESE
ANTIBODIES IN A PERSON’S BLOODSTREAM. ON THE BASIS OF SUCH TESTING 30
FAR, PLUS OTHER EPIDEMIOLOGICAL STUDIES, WE BELIEVE THERE ARE BETWEEN
A MILLION AND A MILLION-AND-A-HALF AMERICANS WITH THE AIDS VIRUS IN
THEIR SYSTEMS,
THEY HAVE AIDS...BUT THEY AREN’T YET SICK WITH AN AIDS-RELATED
DISEASE, SUCH AS PNEUMOCYSTIS CARINII PNEUMONIA OR KAPOSI’S SARCOMA OR
ONE OF THE VIRULENT MEGALOVIRAL DISEASES,

ONE MAJOR COMPLICATION IS THE LENGTH OF THE INCUBATION PERIOD.
IT APPARENTLY CAN BE ANYWHERE FROM A YEAR OR SO IN SOME PEOPLE 10 i0
YEARS IN OTHERS, IF OUR COMPUTATIONS ARE CORRECT. SO WE STILL CAN'T
PREDICT DEFINITELY WHICH H.I.V, CARRIER WILL OR WILL NOT GET AN AIDS-
RELATED DISEASL.

BUT THE RISK IS VERY, VERY HIGH, IN FACT, SOME RESEARCHERS NOW
FEEL THAT ANYONE WITH THE AIDS VIRUS WILL EVENTUALLY CONTRACT AN AIDS-
RELATED DISEASE,

 

AND THE MORTALITY RATE FOR PEOPLE WITH AIDS-RELATED DISEASES
APPEARS TO BE 100 PERCENT,
THERE'S OTHER RESEARCH GOING ON AS WELL. I’M SURE YOU'VE READ
ABOUT THIS OR THAT DRUG BEING TESTED ON AIDS PATIENTS, THE MEDIA, FOR
EXAMPLE, HAVE GIVEN MUCH COVERAGE TO ONE DRUG, AZIDOTHYMIDINE, OR
A.Z.T., THAT SEEMS TO PROLONG THE LIVES OF SOME AIDS VICTIMS DYING OF
PNEUMOCYSTIS CARINII PNEUMONIA,

BUT I'M AFRAID THAT'S ALL A,Z.T. DOES...1T PROLONGS SOME LIVES,
IT DOES NOT SAVE THEM,

PEOPLE ASK ME, “DR, KOOP, WHEN CAN WE EXPECT AN EFFECTIVE VACCINE
TO BE AVAILABLE?” AND I HAVE TO TELL THEM THAT I DON’T SEE ONE IN THE
FORESEEABLE FUTURE.. IT TOOK 19 YEARS TO DEVELOP THE HEPATITIS B
VACCINE AND THAT WAS A COMPARATIVELY EASY VIRUS TO UNDERSTAND,

VACCINE DEVELOPMENT IS ALSO A VERY DIFFICULT SCIENTIFIC
ACHIEVEMENT, IF NOT PRODUCED WITH GREAT CARE, A VACCINE CAN CAUSE AS
MUCH ILLNESS AND DEATH AS THE DISEASE IT’S SUPPOSED TO ATTACK,
BY THE WAY, SOME OF OUR SCIENTISTS PREDICT THAT WE’LL BE ABLE TO
TAKE THE VERY FIRST STEP IN VACCINE DEVELOPMENT LATER THIS YEAR,
TESTS WILL BE MADE TO DETERMINE THE SAFETY THRESHHOLD FOR A KIND OF
VACCINE WHICH DOES NOT ITSELF SEEM VERY PROMISING BUT WHICH MAY, ON
THE OTHER HAND, LEAD US TO THE ULIMTATE SAFE AND EFFECTIVE VACCINE
WE’RE ALL LOOKING FOR,

NOW, FOR MY THIRD POINT:

WE DON’T KNOW VERY MUCH ABOUT AIDS,.,.BUT WE DO KNOW WITH COMPLETE
CERTAINTY THAT THE VIRUS 1S TRANSMITTED FROM ONE PERSON TO ANOTHER
EITHER IN BLOOD OR IN SEMEN. IT’S A PECULIAR TRAIT FOR A VIRUS, BUT
THERE IT IS,
10

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 HOMOSEXUAL AND BISEXUAL MEN, SOME HOMOSEXUAL SEX
PRACTICES NOT ONLY PRODUCE SEMEN BUT MAY ALSO CAUSE SOME BLEEDING...
AND, AGAIN, BLOOD AND SEMEN ARE THE ONLY TWO BODY FLUIDS THAT CARRY
THE LIVE AIDS VIRUS IN QUANTITIES SUFFICIENT TO BE TRANSMISSABLE,

THAT INFORMATION ALSO EXPLAINS WHY 17 PERCENT OF ALL AIDS CASES
ARE INTRAVENOUS DRUG ABUSERS WHO USE A DIRTY NEEDLE THEY'VE BORROWED
FROM ANOTHER ADDICT WHO ALREADY HAS AIDS,

WHEN WE FIRST BEGAN TO CONFRONT THE AIDS EPIDEMIC, THE PEOPLE AT
HIGHEST RISK WERE HOMOSEXUAL AND BISEXUAL MEN. I’M AFRAID THEY STILL
ARE: 2 OF EVERY 3 CASES INVOLVE THESE MEN, EVEN THOUGH THEY’VE BECOME
MUCH MORE CAUTIOUS ABOUT THEIR SEXUAL PRACTICES BECAUSE OF THEIR FEAR
OF AIDS.
ll

BUT NOWADAYS WE’RE RECEIVING MORE AND MORE REPORTS OF THE AIDS
VIRUS UCCURRING AMONG HETEROSEXUAL MEN AND WOMEN WHO ARE NOT I,V. DRUG
ABUSERS, IN FACT, THEIR HETEROSEXUAL ACTIVITY SEEMS TO BE THEIR ONLY
RISK FACTOR,

AS OF LAST WEEK, 4 PERCENT OF ALL REPORTED AIDS CASES WERE OF
HETEROSEXUAL MEN AND WOMEN...A PERCENTAGE, BY THE WAY, THAT’S
CLIMBING,

AS 1 MENTIONED EARLIER, THE NUMBERS OF AIDS CASES WILL INCREASE
ABOUT 9-FOLD BETWEEN NOW AND THE YEAR 1991, BUT THE NUMBER OF AIDS
CASES INVOLVING HETEROSEXUAL PERSONS WILL INCREASE ABOUT 20-FOLD,

OVER THE PAST 5 YEARS, WHEN IT LOOKED AS IF THE KEY GROUP AT RISK
WERE HOMOSEXUAL AND BISEXUAL MEN, WE BEAMED TO THEM VIRTUALLY ALL OUR
INFORMATION AND EDUCATION EFFORTS, IT WAS EFFECTIVE...AND THEIR
BEHAVIOR SEEMS TO HAVE CHANGED,
BUT NOW THAT THE RISE IN THIS DISEASE IS OCCURRING AMONG
HETEROSEXUAL MEN AND WOMEN, WE NEED TO DIRECT OUR INFORMATION AND
EDUCATION EFFORTS OUT TO THE SOCIETY AT LARGE,

THAT’S VERY HARD TO DO IN THIS COUNTRY. WE’RE A VERY LARGE AND
VERY DIVERSE SOCIETY AND THE COST OF SENDING A MESSAGE TO EVERYONE
WOULD BE ASTRONOMICAL...IF, IN FACT, IT COULD BE ACHIEVED,

BUT GOVERNMENT HAS A PARTICULARLY DIFFICULT TIME BECAUSE -- FOR
REASONS BEST KNOWN TO THE PEOPLE HERE AT THE KENNEDY SCHOOL --
AMERICANS DON’T WANT THEIR GOVERNMENT TO BE THAT MUCH OF A “BIG
BROTHER”... REGARDLESS OF HOW WORTHY ITS OBJECTIVE.

SO WE’VE HAD TO SET SOME PRIORITIES AND MAKE SOME TOUGH CHOICES.
AND I THINK WE MADE THE RIGHT CHOICE, WHEN WE DECIDED TO FOCUS ON
INFORMING YOUNG PEOPLE ABOUT THE DANGERS OF AIDS,
13

HETEROSEXUAL YOUNG PEOPLE ARE NOW AT HIGH RISK, THAT'S TRUE. BUT
ALSO THEIR SEXUAL ACTIVITY OVER A LONG PERIOD OF TIME WILL ACTUALLY
DETERMINE WHETHER OUR SOCIETY CAN SURVIVE THIS DEVASTATING DISEASE...
OR NOT,

WHAT WE’RE DOING, THEN, IS SORTING OUT ALL THE INFORMATION THAT
CAN BE LIFE-SAVING FOR SEXUALLY ACTIVE PEOPLE -- AND THAT MEANS ANY
MALE OR FEMALE BETWEEN THE AGES OF 12 AND 80,

AND THEN WE‘RE FOCUSING ON THOSE PIECES OF INFORMATION THAT ARE
ESPECIALLY PERTINENT TO -- AND CAN BE READILY UNDERSTOOD BY -- YOUNG
PEOPLE,

THAT WAS THE UNDERLYING PLAN FOR THE SURGEON GENERAL‘S REPORT ON
IDS, WHICH I RELEASED LAST OCTOBER. LET ME TAKE JUST A MINUTE HERE

TO EXPLAIN HOW THAT REPORT CAME ABOUT,
14

WE HAD BEEN ROUTINELY KEEPING THE PRESIDENT INFORMED OF DEVELOP-
MENTS ON THE AIDS FRONT. AND THEN, IN LATE 1985, THE TREND LINES
BEGAN TO MOVE SHARPLY UPWARD AND OUR CONCERNS DEEPENED. BUT THE
AMERICAN PEOPLE STILL SEEMED UNCLEAR ABOUT THE SIGNIFICANCE OF THE
DISEASE,

IN FEBRUARY 1986, ON THE DAY AFTER PRESIDENT REAGAN DELIVERED HIS
"STATE OF THE UNION” ADDRESS, HE VISITED OUR DEPARTMENT AND ANNOUNCED
THAT HE WAS INSTRUCTING THE SURGEON GENERAL TO PULL TOGETHER
EVERYTHING WE KNEW ABOUT AIDS AND PUT IT INTO A PLAIN-ENGLISH REPORT
TO THE AMERICAN PEOPLE.

FOR THE NEXT 8 MONTHS I MET WITH CONCERNED INDIVIDUALS AND GROUPS
FROM ACROSS THE SPECTRUM OF SOCIETY...
15

GROUPS LIKE THE NATIONAL EDUCATION ASSOCIATION AND THE NATIONAL
Pit Arias

THE NATIONAL COUNCIL OF CHURCHES AND THE CHRISTIAN LIFE COMMISSION
OF THE SOUTHERN BAPTIST CONVENTION...

THE SYNAGOGUE COUNCIL OF AMERICA AND THE NATIONAL CONFERENCE OF
CATHOLIC BISHOPS...

I TALKED WITH THE NATIONAL COALITION OF BLACK AND LESBIAN GAYS AND
THE WASHINGTON BUSINESS GROUP ON HEALTH.

I MET WITH THE REPRESENTATIVES OF LOCAL, COUNTY. AND STATE AND
TERRITORIAL HEALTH OFFICIALS, ALSO...26 GROUPS IN ALL.
lo

THEY WERE ALL EXTRAORDINARILY CANDID, AND EACH ONE ALSO PLEDGED
TO HELP GET MY REPORT INTO THE HANDS OF EVERY AMERICAN,

AFTER 8 MONTHS OF LISTENING AND WRITING, I DELIVERED MY REPORT TO
THE CABINET AND TO THE PRESIDENT. IT WAS ACCEPTED...AND I RELEASED IT
ON OCTOBER 22, 1986.

INCIDENTALLY. AT NO TIME DID ANYONE SUGGEST TO ME THAT I MAKE A
LITTLE CHANGE HERE OR A LITTLE CHANGE THERE. THE FINAL REPORT 1
RELEASED IN OCTOBER WAS THE EXACT SAME REPORT THAT I PERSONALLY WROTE
BETWEEN FEBRUARY AND SEPTEMBER OF LAST YEAR.

 

AND 1 CAN FURTHER ASSURE YOU THAT SINCE THAT TIME 1 HAVE HAD NO
MISGIVINGS ABOUT ANYTHING I WROTE.

IT’S TRUE. AND IT STANDS,
17

I HOPE YOU'VE ALL READ IT, IF NOT, PLEASE GET OUT A PENCIL AND
TAKE DOWN THIS ADDRESS:

AIDS..,.POST OFFICE BOX 14252... WASHINGTON. D.C....20044

OR PICK UP THE PHONE AND CALL AREA CODE 301...443-0292,

LET ME REPEAT THAT FOR YOU:

AIDS..,POST OFFICE BOX 14252,, WASHINGTON, D.C....20044

OR CALL AREA CODE 301...443-0292,
THERE TS MUCH SCIENTIFIC AND PUBLIC HEALTH INFORMATION IN THAT
REPORT, BUT ON THE BEHAVIORAL SIDE, THERE ARE ESSENTIALLY JUST TWO
MESSAGES AND I HOPE THEY REACH EVERY ONE OF THIS COUNTRY’S YOUNGSTERS,

THE FIRST MESSAGE IS SIMPLE ENOUGH. IT SAYS...

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 IS TO MAINTAIN A FAITHFUL, MONOGAMOUS RELATIONSHIP IN
WHICH YOU HAVE ONLY ONE CONTINUING SEXUAL PARTNER...AND THAT PERSON IS
AS FAITHFUL AS YOU ARE,

MY ADVOCACY OF MONOGAMY MAY SOUND LIKE A MORALITY LESSON, BUT
THIS IS A SITUATION IN WHICH MORALITY AND SCIENCE HAPPEN TO WALK HAND-
TN-HAND,
MY SECOND MESSAGE IS FOR PEOPLE WHO DON’T YET HAVE A FAITHFUL
MONOGAMOUS RELATIONSHIP FOR WHATEVER REASON. THE MESSAGE IS...
CAUTION: 17'S IMPORTANT THAT YOU KNOW WITH ABSOLUTE CERTAINTY THAT
NEITHER YOU NOR YOUR PARTNER IS CARRYING THE AIDS VIRUS. IF YOU‘RE
NOT ABSOLUTELY CERTAIN, THEN YOU MUST TAKE PRECAUTIONS.

LOOK AT IT THIS WAY: STRICTLY FROM THE POINT OF VIEW OF EPIDEMI-
OLOGY, WHEN YOU HAVE SEX WITH SOMEONE, YOU’RE ALSO HAVING SEX WITH
EVERYONE ELSE WITH WHOM THAT PERSON HAS HAD SEX, AND, CONSIDERING THE
LONG INCUBATION PERIOD FOR THE AIDS VIRUS, WE’RE TALKING ABOUT THAT
PERSON’S HISTORY OF SEXUAL RELATIONS GOING BACK 10 YEARS,

EVEN WITH THIS KIND OF INFORMATION AVAILABLE, THERE WILL ALWAYS
BE SOME PEOPLE WHO WON’T ABSTAIN YET WON‘T ACHIEVE A FAITHFUL MONOGA-
MOUS RELATIONSHIP EITHER. THEREFORE, THEY MAY EXPOSE THEMSELVES AND
OTHERS TO THE AIDS VIRUS,
20

TO SUCH FOOL-HARDY INDIVIDUALS I OFFER THE FOLLOWING ADVICE:

* DON'T HAVE SEX WITH SOMEONE WHO ALREADY HAS AIDS, ThAT’S
OBVIOUS ENOUGH,

 

* DON’T HAVE SEX WITH SOMEONE WHO COULD BE CARRYING THE AIDS
VIRUS...A PERSON, FOR EXAMPLE, WHO PRACTICES HIGH-RISK BEHAVIOR,
THAT INCLUDES HOMOSEXUALS, INTRAVENOUS DRUG USERS, PROSTITUTES AND
OTHER PERSONS WHO HAVE MANY DIFFERENT SEX PARTNERS. AND THE SAME
MESSAGE GOES TO ANY OF THOSE HIGH-RISK INDIVIDUALS.

* AND FINALLY, IF YOU DO DECIDE TO HAVE SEX WITH SUCH A PERSON
ANYWAY, THEN -- IF YOU’RE A MAN -- USE A CONDOM FROM START TO
FINISH. IF YOU’RE A WOMAN, MAKE SURE YOUR MALE PARTNER USES A
CONDOM,..AGAIN, FROM START TO FINISH,
pal

A CONDOM WON'T PROVIDE 100 PERCENT PROTECTION -- FEW THINGS IN
LIFE DO -- BUT SO FAR IT SEEMS TO BE THE BEST PROTECTION
AVAILABLE,

IF SEXUALLY ACTIVE PEOPLE WILL HEED THESE MESSAGES, THEY WILL
ACHIEVE A HIGH DEGREE OF PROTECTION AND WILL MOST LIKELY NOT BE
INFECTED WITH THE AIDS VIRUS,

WHAT ELSE CAN WE DO TO COMBAT THIS TERRIBLE DISEASE?

IN MY REPORT ON AIDS, I ALSO ADVISE PEOPLE TO AVOID CERTAIN
SPECIFIC SEX PRACTICES INVOLVING PARTNERS WHO ARE AT HIGH RISK. SUCH
PRACTICES INCLUDE MOUTH CONTACT WITH THE PENIS. VAGINA, AND RECTUM...
ANY PRACTICES WHICH CAN CAUSE CUTS OR TEARS IN THE LININGS OF THE
RECTUM, VAGINA, OR PENIS,..AND HAVING SEX WITH FEMALE OR MALE
PROSTITUTES,
ZZ

I ALSO STRONGLY ADVISE PEOPLE TO STAY CLEAR OF DRUGS AND ALCO-
HOL, BECAUSE THESE SUBSTANCES LOWER YOUR ABILITY TO THINK CLEARLY AND
PROTECT YOURSELF FROM DANGER...ESPECIALLY THE DANGER OF HAVING SEX
WITH AN AIDS-INFECTED PARTNER,

SOME PEOPLE OBJECT TO MY ADVICE BECAUSE ITS SOUNDS TOO MUCH LIKE
A LESSON IN MORALITY. AND I GUESS IT DOES. BUT 1 HONESTLY DO
RECOGNIZE THAT MY JOB AS SURGEON GENERAL IS NOT PRIMARILY TO MAKE
EVERYBODY A MORAL PERSON, MUCH AS I PERSONALLY MIGHT WANT THAT,

RATHER, I’M OFFERING MY ADVICE SO THAT EVERYBODY WILL BE A LIVE
PERSON, AND HELPING YOU PROTECT YOUR LIFE IS MY JOB.

NOW, LET ME PAUSE FOR A MOMENT AND FOCUS ON AN ISSUE THAT IS
GAINING ALMOST AS MUCH ATTENTION AS THE AIDS VIRUS ITSELF, THE ISSUE
IS,..HOW SHOULD WE EDUCATE OUR YOUNG PEOPLE ABOUT AIDS AND ABOUT THEIR
SEXUALITY. HOW SHOULD WE DO IT? WHO SHOULD DO IT? AND WHEN?
23

WHEN 1 TALK TO ADULTS ABOUT THE AIDS PROBLEM AND I MAKE SOME OF
THESE DETAILED REFERENCES TO CERTAIN HIGH-RISK SEX PRACTICES, I GET A
VARIETY OF REACTIONS: DISMAY, SADNESS, EMBARRASSMENT, DISCOMFORT, OR
ANGER,

BUT THE REACTION I GET MOST OFTEN FROM YOUNG PEOPLE IS CURIOSITY
AND EAGERNESS FOR MORE KNOWLEDGE:

THEY’RE STILL LEARNING ABOUT THEIR BODIES AND THEIR EMOTIONS...
THEY’RE STILL UNSURE ABOUT THEIR OWN SEXUALITY...
AND THEY STILL HAVE THAT PRICELESS OPTIMISM ABOUT THE WORLD AND

THE PEOPLE IN IT, AN OPTIMISM THAT MOST ADULTS HAVE HAD TEMPERED
BY THE FACTS OF DAY-TO-DAY LIVING IN THE REAL WORLD,
24

I PREFER TO SPEAK ABOUT THE NEED FOR “AIDS EDUCATION.” AND I
TRULY BELIEVE WE NEED SUCH EDUCATION AT THE APPROPRIATE AGE LEVEL IN
THE SCHOOLS OF AMERICA,

BUT I ALSO RECOGNIZE THAT, FOR MANY YOUNG PEOPLE. SUCH EDUCATION
MAY BE FRIGHTENING,..OR PUZZLING...OR BOTH,

HENCE, 1 BELIEVE THAT THE MOST SIGNIFICANT ACTION OUR SOCIETY
MIGHT TAKE TO PROTECT ITS YOUNG PEOPLE FROM THE MORTAL THREAT OF AIDS
TS TO PROVIDE THEM WITH EDUCATION CONCERNING THEIR OWN SEXUALITY...
EDUCATION THAT IS FACTUALLY CORRECT, PERSONALLY SENSITIVE, AND MORALLY
STRONG,

THE TERM “SEX EDUCATION” IS ONE I’M NOT AT ALL COMFORTABLE WITH
BECAUSE IT TENDS TQ POLARIZE THE AUDIENCE. ALSO, IN MY VIEW, “SEX
EDUCATION” USUALLY MEANS A COURSE OF INSTRUCTION THAT IS MUCH 100
LIMITED. LET ME EXPLAIN WHAT I MEAN BY THAT.
25

MOST OF THE TIME, WHEN YOU HEAR THE PHRASE, “SEX EDUCATION,” YOU
IMMEDIATELY THINK OF CLASS HOURS DEVOTED TO HUMAN REPRODUCTIVE
BIOLOGY, INCLUDING CAREFULLY PHRASED EXPLANATIONS ABOUT THE USE AND
ABUSE OF THE MALE AND FEMALE GENITALIA,

I’M TOLD THAT YOUNG PEOPLE CALL THESE CLASSES "ORGAN RECITALS.”

MOST SCHOOLS NOW OFFER THIS MINIMUM KIND OF SEX EDUCATION SOME
TIME DURING THE JUNIOR HIGH OR MIDDLE SCHOOL YEARS AND THAT’S A GOOD
THING, ALTHOUGH IT MIGHT BE A LITTLE LATE. 1 PERSONALLY WOULD URGE
THAT THE MATERIAL BE PRESENTED EARLIER, AMONG THE 9-, 10-. AND I1-
YEAR-OLDS,

OF COURSE, DEVELOPMENTAL AGE IS MORE IMPORTANT THAN CHRONOLOGICAL
AGE, ALSO, COMMUNITY STANDARDS, WHICH VARY FROM PLACE TO PLACE, MUST
BE TAKEN INTO ACCOUNT,
26

NEVERTHELESS, CHILDREN FROM 4 TO 6 ASK QUESTIONS ABOUT SEX, BUT
THESE QUESTIONS USUALLY INVOLVE THEIR OWN ANATOMY AND THE MYSTERY OF
"WHERE DO BABIES COME FROM?”

THEN FOR SEVERAL YEARS. UNTIL ABOUT AGE 9, CHILDREN SEEM 10 LOSE
INTEREST IN MATTERS INVOLVING SEX. BUT AT AGE 9 OR SO A NEW INTEREST
DEVELOPS, AND THEIR QUESTIONS -- IF THEY ARE EVEN ASKED -- MAY BE
QUITE SOPHISTICATED.

I’M NOT RIGID ABOUT THE AGES, DEVELOPMENTAL AGE IS MUCH MORE
IMPORTANT A MEASURE THAN CHRONOLOGICAL AGE ANYWAY,

IN ANY CASE, GRADE-SCHOOL CHILDREN ARE EXTREMELY CURIOUS ABOUT
THEMSELVES, THEY ARE ALSO KINDER AND MORE GENEROUS THAN OLDER
CHILDREN,..OR EVEN MOST ADULTS, FOR THAT MATTER. AND THEY ARE, ABOVE
ALL, SUSCEPTIBLE TO BEING LOVED AND TO OFFERING MUCH LOVE IN RETURN,
2/7

AND SEX EDUCATION WITHOUT THE CONCEPT OF LOVE AND RESPONSIBILITY
IS LIKE A PIECE OF PIE THAT’S ALL CRUST AND NO FILLING,

MY OWN PREFERENCE, THEREFORE, WOULD BE TO HAVE OUR ELEMENTARY
SCHOOLS INTRODUCE CHILDREN TO THE SUBJECT OF REPRODUCTIVE BIOLOGY
WITHIN A MORE GENERAL DISCUSSION OF THE NATURE OF SENSITIVE AND
AFFIRMATIVE HUMAN RELATIONS.

THAT'S EASIER TO SAY THAN TO DO, I KNOW, AND FURTHERMORE, SOME
PARENTS GET UNEASY ABOUT HAVING THE SCHOOLS IMPART CERTAIN HUMAN
VALUES TO THEIR CHILDREN. THEY THINK THAT SUCH INSTRUCTION SHOULD BE
DONE AT HOME,

AND | AGREE, I ALWAYS HAVE, AND THIS GOES BACK MANY YEARS DURING
ALL THE TIME I PRACTICED MEDICINE. MY ADVICE TO PARENTS WAS ALWAYS
THE SAME:
28

THE SOCIAL AND SPIRITUAL DEVELOPMENT OF YOUR CHILDREN IS YOUR
BUSINESS, DON'T PASS IT UP...DON'T PASS IT BY...PASS IT ON,

 

AND MOST PARENTS WOULD AGREE WITH ME 100 PERCENT. BUT MANY OF
THEM, I HAVE TO CONFESS, NEVER DID MUCH MORE THAN AGREE WITH ME,

THAT'S BEEN A DISAPPOINTMENT, AND LATELY. IN LIGHT OF AIDS. I'VE
WONDERED WHY THIS WAS SO,

I] DON’T HAVE THE ULTIMATE ANSWER. BUT 1 THINK I HAVE A SENSE OF
THE PROBLEM,

I’M SURE MANY PARENTS HAVE TROUBLE DEALING WITH THE PHYSIOLOGY
AND BIOLOGY OF SEX MAINLY BECAUSE THEY DIDN’T GET ANY OF THIS
INFORMATION WHEN THEY WERE KIDS EITHER. AND THEY FEEL INADEQUATE,
29

TO PARAPHRASE THE WINE-TASTER’S BASIC COMMENT:

"IT'S A GOOD EXCUSE...BUT IT’S NOT A GREAT EXCUSE,”

MANY PARENTS ALSO REGARD ANY TALK ABOUT SEX AS A KIND OF INVASION
OF PRIVACY -- THEIR OWN AS WELL AS THEIR CHILDREN’S, TALK ABOUT SEX
IS BEDROOM AND BATHROOM TALK...AND THOSE TWO ROOMS ARE UNIVERSALLY
REGARDED AS THE TWO MOST PRIVATE ROOMS IN ANYONE’S HOUSE.

SO PARENTS’ UNCERTAINTY ABOUT THE BIOLOGY OF SEX AND THEIR
SENSITIVITY TO THE PRIVACY OF SEX SEEM TO BE TWO REASONS WHY THEY HAVE
A HARD TIME WITH “SEX EDUCATION,”

 

 

BUT THERE'S A THIRD REASON, ALSO, WHICH MAY BE THE MOST IMPORTANT

REASON OF ALL AND THE MOST DIFFICULT ONE TO DEAL WITH. IT HAS TO DO
WITH THE NATURE AND THE QUALITY OF OUR ADULT HUMAN RELATIONSHIPS,
30

AS I INDICATED EARLIER, “SEX EDUCATION” MEANS MORE TO ME THAN
JUST ANOTHER “ORGAN RECITAL.” “SEX EDUCATION” OUGHT TO DEAL WITH
RELATIONSHIPS BETWEEN MEN AND WOMEN THAT ARE LOVING, CARING, RESPECT-
FUL, AND TOLERANT.

SUCH RELATIONSHIPS INCLUDE SOME FULFILLING SEXUAL ACTIVITY, BUT
THEY ARE NOT DEFINED ONLY BY THAT ACTIVITY. THERE’S MUCH MORE TO
HUMAN RELATIONSHIPS THAN JUST “GOOD SEX.” AND YOUNG PEOPLE OUGHT TO
BE ADVISED OF THAT.

 

FOR MOST ADULTS, A SATISFYING RELATIONSHIP HOLDS IN A COMFORTABLE
BALANCE THE EMOTIONAL, INTELLECTUAL, PHYSICAL. AND SEXUAL FACTORS THAT
MAKE UP THAT RELATIONSHIP,

EVERYONE DREAMS OF SUCH A RELATIONSHIP. IF WE MEET A MAN OR
WOMAN WHO CAN GIVE US THAT KIND OF RELATIONSHIP, WE WILLINGLY GIVE HIM
OR HER OUR LIFELONG PROMISE.
31

NOVELISTS CALL IT “TRUE LOVE.” SOCIOLOGISTS CALL IT “MARITAL
FIDELITY.” THE SURGEON GENERAL CALLS IT “MONOGAMY,” BUT WHATEVER YOU
CALL IT, WE ALL WANT THAT WELL-ROUNDED, BALANCED, LOVING, AND FULLY
CONSIDERATE RELATIONSHIP...A RELATIONSHIP THAT’S ENRICHED BY SEX, NOT
OVERWHELMED BY IT OR DEVOID OF IT EITHER.

FOR MANY PEOPLE, SUCH A BALANCED RELATIONSHIP IS AN IDEAL... BUT
MREAL LIFE” ISN’T ALWAYS LIKE THAT. IT’S IMPERFECT...1T’S GIVE-AND-
TAKE,

GROWN-UPS KNOW ABOUT HUMAN IMPERFECTION. BUT CHILDREN DON’T.

AND GROWN-UPS CAN DEAL WITH HUMAN IMPERFECTION, BUT CHILDREN
CAN’T,..UNLESS WE HELP THEM.

WITHOUT A COMPASSIONATE UNDERSTANDING OF THE IMPERFECT NATURE OF
MANY HUMAN RELATIONSHIPS, A CHILD'S EDUCATION WILL BE... ITSELF... VERY
IMPERFECT,
SO IF PARENTS ARE TO EDUCATE THEIR CHILDREN ABOUT HUMAN RELATION-
SHIPS -- SEXUAL AND OTHERWISE -- THEY MUST FIRST UNDERSTAND AND ACCEPT
THE NATURE OF THEIR OWN. FOR MANY, THAT’S HARD TO DO.

PARENTS -- ADULTS -- ARE NOT VERY GOOD ABOUT TALKING JO EACH
QTHER ABOUT THEIR SEXUALITY. THEY FEEL FRUSTRATED, GUILTY. AND EVEN
ANGRY ABOUT THEIR INABILITY TO DO THE THING THAT THEY KNOW --
INTELLECTUALLY AND EMOTIONALLY -- THEY SHOULD DO.

 

BUT THEY CAN’T.

IS IT ANY WONDER, THEN, THAT MANY PARENTS HAVE DIFFICULTY TELLING
CHILDREN ABOUT THE FULL-DIMENSIONAL NATURE OF AN IDEAL HUMAN RELATION-
SHIP.
33

NEVERTHELESSS, I WANT PARENTS TO TRY. 1 WANT PARENTS TO DO THIS
WITH COMPASSION... .WITH RESPECT AND WITH LOVE...AND WITH SOME UNDER-
STANDING NOT JUST OF THE CHILD WHO’S LISTENING...BUT ALSO OF THE ADULT
WHO IS SPEAKING, AND THAT’S EVEN HARDER TO DO.

 

STILL, IT RENMAINS AS MY SINCEREST WISH THAT THE PARENTS OF THIS
COUNTRY WILL BE THE PRIMARY TEACHERS OF SEX AND HUMAN RELATIONS TO THE
CHILDREN OF THIS COUNTRY.

 

1 SAY THAT, KNOWING FULL WELL THAT SOME PARENTS SIMPLY CAN‘T DO
IT. WHEN THAT’S THE CASE, THEN I BELIEVE THERE’S A COMPELLING SOCIAL
NEED FOR OUR SCHOOLS, CHURCHES, SYNAGOGUES, AND OTHER COMMUNITY INSTI-
TUTIONS TO DO WHATEVER POSSIBLE TO PROVIDE OUR CHILDREN WITH THE MOST
HELPFUL KINDS OF INFORMATION,
34

OUR CHILDREN DON’T LIVE IN A VACUUM, AS WE ALL KNOW, THEY LIVE
IN A REAL WORLD OF PLEASURE AND DANGER, ALONG WITH THE REST OF US,

BUT WE HAVE SOME EXPERIENCE WITH IT AND SOME SENSE OF HOW TO
SURVIVE IN IT WITH OUR LIVES AND OUR VALUES INTACT.

I BELIEVE, THEREFORE, THAT EACH OF US -- IN OUR HOMES OR IN OUR
SCHOOLS -- HAS THE MORAL RESPONSIBILITY TO PASS THAT INFORMATION ON 10
OUR CHILDREN,

I CAN TELL YOU THAT THE GOVERNMENT -- THE U.S. PUBLIC HEALTH
SERVICE IN PARTICULAR -- WILL HELP IN ANY WAY WE CAN. AS THE SURGEON
GENERAL, I’LL CONTINUE TO TRY TO GIVE THAT EFFORT SOME LEADERSHIP,
ALSO,
BUT THERE ARE LIMITS TO WHAT THE GOVERNMENT CAN AND OUGHT TO
DO. THE TASK BASICALLY BELONGS TO THE HOME AND TO LOCAL SCHOOLS AND
OTHER COMMUNITY INSTITUTIONS. IT SHOULD NOT BE LEFT. BY DEFAULT, TO
THE MOVIES, TELEVISION, OR THE STREET-CORNER. WE CAN’T DO THAT, AND
STILL PROTECT THE MILLIONS OF YOUNG LIVES THAT ARE AT RISK OF AIDS,

THIS HAS BEEN A GRIM MESSAGE AND I GUESS I AM A GRIM COURTER, I
ONLY HOPE THAT EVERY AMERICAN WHO HEARS OR READS MY MESSAGE. WILL
BELIEVE IT AND DO HIS OR HER PART TO STOP THE SPREAD OF AIDS...PROTECT
AND SAVE THE LIVES OF PEOPLE AT RISK, INCLUDING UNSUSPECTING YOUNG
PEOPLE...AND RETURN HUMAN SEXUALITY BACK TO ITS RIGHTFUL PLACE: PART
OF THE TOTAL COMPLEX OF HUMAN, CARING INTERPERSONAL RELATIONS,
56

SUCH RELATIONS OUGHT TO BE POSITIVE, HOPEFUL, AND SAFE. IN MY
BOOK, THAT'S THE MEANING OF THE PHRASE “TRUE LOVE.”

WHICH LEADS ME TO MY FINAL WORD, IT’S NOT MINE REALLY. IT’S THE
LAST SENTENCE OF THE BRIDGE OF SAN LUIS REY, THE LITTLE NOVEL WRITTEN
BY THORNTON WILDER. WHO FOR A WHILE WAS A FAVORITE LECTURER HERE AT
HARVARD. WILDER CONCLUDED THAT NOVEL BY OBSERVING...

"THERE IS A LAND OF THE LIVING AND A LAND OF THE DEAD AND THE ONLY
BRIDGE 1S LOVE...THE ONLY SURVIVAL, THE ONLY MEANING.”
THANK YOU,

ttt # #