ORIGINAL
AIDS AND THE SOCIAL ORDER 35 "an

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

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PRESENTED TO THE WASHINGTON FORUM
WASHINGTON, D.C.
Octoper 15, 1987
(GREETINGS TO HOSTS, GUESTS, FRIENDS, ETC.)

1 APPRECIATE THIS OPPORTUNITY TO ADDRESS THIS DISTINGUISHED
GROUP OF ECONOMISTS, INVESTORS, AND OTHERS WITH SPECIAL CONCERNS FOR
THE WORLD AND ITS BUSINESS.

I ALSO WANT TO THANK OUR HOSTS, THE WASHINGTON FORUM, NOT ONLY
FOR INCLUDING THE TOPIC OF AIDS ON THIS YEAR‘S AGENDA, BUT ALSO FOR
ASKING THAT I SHARE WITH YOU MY PERCEPTION OF WHAT THE SOCIAL,
ECONOMIC, AND CULTURAL EFFECTS MIGHT BE OF THE EPIDEMIC OF AIDS.

I WANT TO SPEND A FEW MOMENTS REVIEWING FOR YOU -- ALBEIT IN A
BRIEF MANNER -- SOME OF THE DIFFICULT CHOICES THAT MAY LIE AHEAD FOR
THE LEADERS OF NATIONS AROUND THE WORLD,
FIRST, LET ME EXPLAIN THAT, HERE IN THE U.S,, THERE ARE THREE
ASPECTS OF AIDS THAT COLOR EVERYTHING DONE AND SAID ABOUT THE

DISEASE:

FIRST, IT IS STILL A MYSTERY...

TWO, IT IS FATAL...

AND THREE, PEOPLE GET AIDS BY DOING THINGS THAT MOST PEOPLE
DON'T DO AND DON’T LIKE.
WE NEED TO KEEP THESE THREE ASPECTS OF THE DISEASE IN MIND,
BECAUSE THEY TEND TO FOCUS OUR ATTENTION ON THE MORE VOLATILE ISSUES
OF LAW, ETHICS, ECONOMICS, MORALITY, AND SOCIAL COHESION THAT
SURROUND AIDS. AS A RESULT THEY OBSCURE THE MANY SCIENTIFIC ISSUES
SURROUNDING AIDS,

HERE IN THE UNITED STATES, AN EXTRAORDINARY PERCENTAGE OF THE
AMERICAN PEOPLE KNOW THERE 1S SUCH A THING AS AIDS...98 TO 99
PERCENT, SOME POLLS SHOW.

BUT AS MUCH AS A THIRD OF THE PUBLIC ARE STILL UNCLEAR ABOUT
THE WAY THE DISEASE IS TRANSMITTED, THEY CORRECTLY RECOGNIZE
HOMOSEXUAL SEX PRACTICES AND SHARED NEEDLES, BUT THEY INCORRECTLY
ADD TOILET SEATS, SNEEZING AND COUGHING, FOOD HANDLING, AND KISSING
TO THE LIST AS WELL.
OBVIOUSLY, FEAR HAS SKEWED THE TRUTH IN THE MINDS OF THESE
PEOPLE...ESTIMATED TO BE ONE-THIRD OF THE U.S. POPULATION,

THE IRRATIONAL SIDE OF AIDS 1S ALSO EVIDENT IN THE WAY ThE
EPIDEMIC HAS AFFECTED THE WORLDWIDE SYSTEM OF MEDICAL INTELLIGENCE
ITSELF.

THE PRESENCE OF AIDS 1S A PROFOUND EMBARRASSMENT -- TO SAY THE
LEAST -- FOR MANY NATIONS OF THE WORLD.

WORSE, ITS PRESENCE IS SEEN AS AN AFFRONT TO THE MORAL
STANDARDS OF MANY OTHER SOCIETIES. AND I SUSPECT THAT, FOR THESE
REASONS, SOME HAVE CHOSEN TO MAKE THE DISEASE DISAPPEAR BY SIMPLY
NOT REPORTING ITS PRESENCE,
THAT, OF COURSE, WAS THE FATE OF SMALL-POX DATA DID AND, MORE
RECENTLY, OF MALARIA AND TUBERCULOSIS DATA, 100,

AS OF AUGUST, THE WORLD HEALTH ORGANIZATION REPORTED THE TOTAL
AIDS CASE-LOAD IN COUNTRIES OTHER THAN THE UNITED STATES TO BE
14,600, A FIGURE THAT SEEMS TO BE WELL BELOW WHAT WE MIGHT HAVE
EXPECTED,

AND INDEED, SOME COUNTRIES HAVE REPORTED 1 CASE OR NO CASES AT
ALL, WHILE OTHER COUNTRIES -- SOME SHARING COMMON BORDERS -- REPORT
SEVERAL HUNDRED...OR A THOUSAND OR MORE.
1 UNDERSTAND WHY THE POLITICAL AND PUBLIC HEALTH LEADERS IN
SOME COUNTRIES DO NOT WANT TO COLLECT AND PUBLISH SUCH DATA. BUT |
URGE THEM TO RELENT, SINCE WE CANNOT TRULY UNDERSTAND A DISEASE --
MUCH LESS STOP IT -- IF WE DON’T KNOW WHERE IT IS AND HOW IT IS
ACTING,

NATURALLY, YOU CAN‘’T QUANTIFY THESE THINGS, BUT I AM
NEVERTHELESS PERSUADED THAT THE UNDER-REPORTING OF THE PREVALENCE OF
AIDS IS A FACTOR HOLDING BACK OUR PROGRESS IN THE FIGHT AGAINST THIS
DISEASE.
THE DISEASE IS NOT SLOWING DOWN. ALL TOTALS ARE GETTING
LARGER. AND THEREFORE IT 1S CRITICAL THAT EVERY NATION REPORT AS
FULLY AND AS ACCURATELY AS POSSIBLE THE EXTENT TO WHICH THE DISEASE
IS PRESENT WITHIN ITS BORDERS -- DESPITE THE DISCOMFORT THIS MAY
CAUSE FOR THE CITIZENS AND THE POLITICAL AND PUBLIC HEALTH LEADERS
OF EACH NATION,

THE DISEASE OF AIDS IS ALSO TESTING THE DEGREE T0 WHICH HEALTH
WORKERS -- PHYSICIANS, NURSES, TECHNICIANS, AND OTHERS -- UNDERSTAND
AND ARE TRULY DEDICATED TO THE ETHICAL FOUNDATION OF HEALTH CARE
ITSELF.
WE ARE HEARING EVERY DAY SOME STORY OR OTHER INVOLVING A HEALTH
PROFESSIONAL -- OR A GROUP OF PROFESSIONALS -- WHO REFUSE T0 TREAT
PERSONS WITH AIDS,..OR EVEN TO TREAT PERSONS WHOM THEY SUSPECT OF
HAVING AIDS.

I DO NOT FOR A MOMENT BELIEVE THAT THIS IS THE CHARACTERISTIC
BEHAVIOR OF HEALTH PROFESSIONALS. THE OVERWHELMING MAJORITY OF MY
COLLEAGUES HAVE PROVIDED -- AND WILL CERTAINLY CONTINUE TO PROVIDE
-~- QUALITY, COMPASSIONATE CARE TO PERSONS DYING OF AIDS WHEREVER
THEY ARE,
BUT THE GOOD CONDUCT OF THE MAJORITY SHOULD NOT IN ANY WAY
SHIELD THE POOR CONDUCT OF A FEARFUL AND IRRATIONAL MINORITY.

THE BURDEN OF GUILT SHOULD NOT BE BORNE ONLY BY THE HEALTH
PROFESSIONS, HOWEVER. 1 KNOW OF INSTANCES IN WHICH PROSPECTIVE
PATIENTS -- ESPECIALLY THOSE WITH FINANCIAL MEANS -- WILL AVOID
ADMISSION TO A CERTAIN HOSPITAL BECAUSE IT 1S KNOWN TO HAVE ACCEPTED
A LARGE NUMBER OF PERSONS WITH AIDS,

THOSE SAME HOSPITALS ARE ALSO SHOWING DECLINES IN THE NUMBERS
OF YOUNG PEOPLE SEEKING RESIDENCIES AND INTERNSHIPS THERE,
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BOTH DEVELOPMENTS ARE VERY BAD SIGNS FOR THE FUTURE OF THOSE
HOSPITALS.

THE DISEASE OF AIDS IS NOT INTRINSIC TO HOMOSEXUALITY, AS IT
NOT INTRINSIC TO HETEROSEXUALITY, YET, THAT DISTINCTION IS LOST ON
SOME PEOPLE. WITH THE RESULT THAT WE ARE SEEING -- IN OUR COUNTRY
AND ELSEWHERE IN THE WORLD -- A RISE IN HOMOPHOBIA: THAT IS, THE
HATRED OF -- AND VIOLENCE AGAINST -- HOMOSEXUALS AND BISEXUAL MEN.

 

HEALTH PROFESSIONALS MUST NOT IN ANY WAY CONTRIBUTE TO SUCH
BEHAVIOR. AND DENYING HEALTH SERVICES TO HOMOSEXUALS OR BISEXUAL
MEN -- WHETHER THEY HAVE AIDS OR NOT -- IS ALSO IRRATIONAL AND
CANNOT BE EXCUSED OR CONDONED.
1]

AS A PHYSICIAN, I AM PROUD TO BE PART OF A TRADITION OF CARE
THAT GOES BACK MORE THAN TWO MILLENIA...A TRADITION THAT WILL NOT
ABANDON THE SICK AND THE DISABLED...WHOEVER THEY ARE.

HENCE, I REGARD AS EXTREMELY SERIOUS THE REPORTS OF A FEW
PHYSICIANS AND OTHERS WHO ARE WITHHOLDING CARE FROM PERSONS WITH
AIDS OR PERSONS OF A PARTICULAR GROUP WHO NEVERTHELESS DO NOT HAVE
AIDS, THAT KIND OF CONDUCT THREATENS THE ETHICAL FOUNDATION OF
HEALTH CARE EVERYWHERE IN THE WORLD.

YET, WE MUST LOOK AT THIS PROBLEM OF RISK TO THE HEALTH
PROFESSIONAL. NOW IT IS VERY SMALL. WILL IT ALWAYS BE THAT WAY?
WE DON’T KNOW.
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] BELIEVE WE MUST ALL CONFRONT THIS ISSUE AND COME FORWARD WITH
SOME ANSWERS. HOW WE DECIDE THIS ISSUE FOR HEALTH PROFESSIONALS
WILL HAVE MAJOR IMPLICATIONS FOR HOW WE DECIDE IT FOR RAILROAD
ENGINEERS, AIRPLANE PILOTS, AIR TRAFFIC CONTROLLERS, AND SO ON,

ANOTHER ISSUE CONCERNS THE COST OF CARE FOR AIDS PATIENTS: WHAT
MIGHT THOSE COSTS BE? WHO SHOULD PAY THEM? GOVERNMENT? INSURANCE
COMPANIES? INDIVIDUAL PATIENTS AND THEIR FAMILES? WHO?

AS YOU KNOW, THE UNITED STATES ENJOYS A MIXED SYSTEM OF SUPPORT
FOR HEALTH CARE: PRIVATE METHODS OF PAYMENT EXIST SIDE-BY-SIDE WITH
PUBLICLY SUPPORTED SYSTEMS OF REIMBURSEMENT FOR CARE.
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AT THIS POINT THE TOTAL ANNUAL EXPENDITURE FOR THE MEDICAL CARE
OF AIDS PATIENTS 1S ABOUT $1.6 BILLION, HOWEVER, OF THAT TOTAL, THE
AMERICAN TAXPAYER CONTRIBUTES ABOUT 1 DOLLAR OF EVERY 4, OR
SOMETHING ON THE ORDER OF $400 MILLION THIS YEAR,

OF COURSE, THE AMERICAN TAXPAYER SUPPORTS A GREAT RANGE OF
PUBLIC HEALTH PROGRAMS. MOST OF THEM EITHER HELP PROMOTE OR MAIN-
TAIN AN INDIVIDUAL’S GOOD HEALTH, OR THEY HELP RETURN THE INDIVIDUAL
TO A STATE OF GOOD HEALTH.

BUT AIDS IS DIFFERENT.

IT’S VERY EXPENSIVE...WELL OVER $600 A DAY ON THE AVERAGE FOR
IN-PATIENT CARE, BUT THEN, AFTER CONSUMING TENS OF THOUSANDS OF
DOLLARS WORTH OF MEDICAL CARE AND SOCIAL SERVICES... THE AIDS PATIENT
DIES,
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WE ANTICIPATE THAT, OVER THE NEXT FOUR YEARS, THE ANNUAL AIDS
CASE-LOAD WILL MORE THAN DOUBLE AND THE ANNUAL COST OF CARE WILL
MORE THAN TRIPLE.

WILL THE AMERICAN PEOPLE CONTINUE TO SUPPORT HIGH-COST PATIENT
CARE FOR PEOPLE WITH AIDS? OR WILL THEY ASK FOR RELIEF? AND IF
THEY DO, WHAT WILL THAT DO TO THE ACCESSIBILITY OF MEDICAL CARE...OR
THE QUALITY OF MEDICAL CARE...FOR AIDS PATIENTS IN OUR COUNTRY?

1D LIKE TO THINK THAT THE AMERICAN TAXPAYER WILL DO THE RIGHT
THING AND CONTINUE TO SUPPORT QUALITY, ACCESSIBLE CARE FOR ALL AIDS
PATIENTS, BUT I DON’T KNOW,
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AND WHAT ABOUT MEDICAL CARE IN COUNTRIES NOT AS FORTUNATE AS
OURS? HOW WILL THEY RESPOND TO THE PRESSURE FOR MORE AND MORE
RESOURCES FOR THE MEDICAL CARE OF TERMINALLY ILL AIDS PATIENTS,

IT CAN'T ANSWER THAT AT ALL. AND I WONDER WHO AT THIS MEETING
CAN?

THEN THERE IS THE ISSUE OF INDIVIDUAL PRIVACY versus THE NEED
TO PROTECT THE COMMUNITY FROM DANGER, THIS ISSUE WAS TRIGGERED IN
1985 BY THE AVAILABILITY OF A RELIABLE BLOOD TEST FOR AIDS AND THE
CONSEQUENT NEED TO DECIDE ON THE CONFIDENTIALITY OF THE BLOOD TEST
RESULTS.

 
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1 DON’T BELIEVE EITHER SIDE OF THIS QUESTION REQUIRES AN
ABSOLUTE RESPONSE. BUT HOW MUCH LEEWAY DO WE REALLY HAVE?

THIS ISSUE, I’M AFRAID, IS TIED DIRECTLY TO THE WAY EACH
SOCIETY DEFINES ITS COMMITMENT TO INDIVIDUAL LIBERTY, THE MORE FREE
THE SOCIETY, THE MORE CONCERN THERE IS FOR THE INDIVIDUAL’S RIGHT TO
PRIVACY. THE LESS FREE. THE LESS CONCERN FOR THIS RIGHT.

CONVERSELY, IN THOSE SOCIETIES JUST EMERGING FROM COLONIALISM
AND TRYING TO FOLLOW THEIR OWN PATHWAYS TO A FREE AND DEMOCRATIC
FUTURE. THE PROTECTIVE DECISION BY A FEARFUL SOCIETY TO PROTECT
ITSELF FROM THE INFECTED INDIVIDUALS IN ITS MIDST, MAY, BY ITSELF,
DO MORE TO DEFINE THE NATURE OF THAT SOCIETY THAN ANY OTHER EFFORT
OR ACTIVITY.
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HOW TRAGIC IT WOULD BE, IF MANY OF THE EMERGING NATIONS OF
AFRICA AND ASIA DECIDE TO LIMIT THE RIGHTS OF INFECTED INDIVIDUALS.
IN ORDER TO GIVE SOCIETY AT LARGE A GREATER SENSE OF SECURITY.

FINALLY, AND PROBABLY MOST IMPORTANT OF ALL FOR THE PEOPLE OF
THE UNITED STTASES IS THAT WE SEE MORE EVIDENCE EVERY DAY THAT THIS
DISEASE IS BECOMING THE PARTICULAR SCOURGE OF PEOPLE WHO ARE YOUNG,
BLACK, AND HISPANIC.

HOW TRAGIC FOR THEM.

AND HOW TRAGIC FOR ALL OF US.
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WE MUST KEEP IN MIND THAT, THROUGHOUT VIRTUALLY EVERY EPIDEMIC
OR PLAGUE HUMAN HISTORY, IN HUMAN HISTORY, SOCIETY HAS FOUND A
CONVENIENT SCAPEGOAT. THE SCAPEGOAT IS USUALLY POOR, A MINORITY OF
SOME KIND -- RACIAL, RELIGIOUS, OR ETHNIC -- AND TOO WEAK 10 FIGHT
BACK.

DURING THOSE PERIODS OF THE GREAT EPIDEMICS, THE MAJORITY
GAINED A FEELING OF SECURITY AND SATISFACTION, IF IT COULD SOMEHOW
PUNISH A WEAKER AND VERY VISIBLE MINORITY BY OSTRACISM, QUARANTINE.
OR THE DENIAL OF BASIC HUMAN RIGHTS.

THE MARK OF MATURITY OF A PEOPLE, OF COURSE, IS THE DEGREE 10
WHICH THEY REJECT THIS KIND OF BEHAVIOR. AND I AM PROUD OF THE WAY
THE UNITED STATES HAS TACKLED THE ISSUE OF FAIRNESS 10 ITS
MINORITIES.
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WILL THE DISEASE OF AIDS -- ALL BY ITSELF -- REVERSE THIS TREND
IN RECENT HUMAN HISTORY? WE HOPE AND PRAY THAT IT WILL NOT,

BUT HOPES AND PRAYERS MAY NOT BE ENOUGH. WE WILL NEED
COURAGEOUS LEADERSHIP AT ALL LEVELS OF GOVERNMENT AND THROUGHOUT ALL
SOCIAL AND POLITICAL INSTITUTIONS TO REINFORCE THOSE HOPES AND
PRAYERS,

YES, IT 1S TRUE THAT THE GREAT MAJORITTY OF AIDS PATIENTS SO
FAR HAVE BEEN HOMOSEXUALS, DRUG ADDICTS, BLACKS, AND HISPANICS,
ABOUT 42,000 OF THEM.

AND IN SOME OTHER COUNTRIES THE PEOPLE WITH AIDS HAVE BEEN
DRAWN FROM THESE AND OTHER MINORITY GROUPS,
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SO WE MUST ASK IF WE ARE TRULY MATURE ENOUGH TO BE COLOR-BLIND
IN THIS WAR AGAINST AIDS? AND CAN WE OVERLOOK THE SOCIAL STATUS OF
THE INDIVIDUAL WITH AIDS?

ARE WE SECURE ENOUGH TO EXTEND OUR VERY BEST MEDICAL CARE EVEN
TO THE VERY LEAST OF OUR CITIZENS?

THESE AND OTHER QUESTIONS LIE ON THE HORIZON BEFORE US, BUT
THE HORIZON IS NOT THAT FAR AWAY,

I HOPE WE WILL NOT STUMBLE TOWARD IT AND ARRIVE UNPREPARED FOR
THE CHALLENGES THAT LIE BEYOND.
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1 HOPE THAT, INSTEAD, WE WILL MOVE FORWARD WITH GOOD SENSE AND
GOOD SCIENCE AND. TOGETHER, GIVE THE WORLD SOMETHING EVERY BIT AS
PRECIOUS AS THE MUCH-DESIRED AIDS VACCINE: WE WILL SHOW THE WORLD
HOW COMPASSION AND JUSTICE CAN TRIUMPH OVER DISEASE.

ONCE AGAIN... THANK YOU,

Hee HH