ORIGINAL

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AIDS AND THE SOCIAL ORDER
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

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PRESENTED TO THE FORUM FOR KALAMAZOO COUNTY

 

KALAMAZOO, MICHIGAN
FEBRUARY 16, 1988
(GREETINGS TO HOSTS, GUESTS, FRIENDS, ETC.)

I APPRECIATE THIS OPPORTUNITY TO ADDRESS THIS FORUM ON A
TOPIC OF SUCH MAJOR IMPORTANCE AS THE EPIDEMIC OF AIDS.

I WANT TO THANK MR. CHEN, YOUR EXECUTIVE DIRECTOR, AND MR,
PHILLIP CARRA AND DR. JACK HOPKINS FOR EXTENDING THE INVITATION,
AND A SPECIAL WORD OF THANKS TO MY FRIEND AND VALUED COLLEAGUE,
DR. TED COOPER.
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I’VE TOLD HIM IN PRIVATE BUT I’D LIKE TO SAY IT PUBLICLY AS

WELL. I BRING DR. COOPER THE GREETINGS OF HIS MANY FRIENDS IN
THE CAREER SERVICE WHO STILL LABOR AT N.I.H. AND ON THE 7TH FLOOR
OF THE HUBERT HUMPHREY BUILDING, THE HEADQUARTERS FLOOR OF THE
U.S. PUBLIC HEALTH SERVICE,

THIS EVENING I WOULD LIKE TO SHARE WITH YOU MY PERCEPTION
OF WHAT EFFECT THE EPIDEMIC OF AIDS IS HAVING UPON THE WAY
AMERICANS THINK ABOUT DISEASE ... ABOUT HEALTH ... AND ABOUT
RESPONSIBILITY, BOTH PERSONAL AND SOCIAL.
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MAKE NO MISTAKE ABOUT IT. AIDS IS NOT JUST A DISEASE

AFFECTING THE BODIES AND MINDS OF A FEW THOUSAND PEOPLE. HERE IN
MICHIGAN, CLOSE TO 530 PEOPLE HAVE BEEN REPORTED AS HAVING AIDS,

SINCE THE RECORD-KEEPING BEGAN BACK IN 1981. THAT‘S NOT A GREAT

NUMBER, RELATIVE TO THE NATIONAL TOTAL OF ALMOST 53,000.

BUT IF YOU LOOK AT NUMBERS ALONE, YOU'LL MISS THE REAL
STORY OF THIS DISEASE, FOR AIDS HAS BURROWED ITS WAY INTO THE
FABRIC OF AMERICAN LIFE AND, UNLESS WE RECOGNIZE THE DAMAGE IT
COULD DO THERE, WE CAN LOSE MORE THAN HUMAN LIVES. AND BOTH
EFFECTS ARE CATASTROPHES, OF COURSE.
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HERE IN THE UNITED STATES AS WELL AS IN OVER 100 COUNTRIES

AROUND THE WORLD, THE DISEASE OF AIDS THREATENS NOT ONLY THE
LIVES OF ORDINARY CITIZENS, BUT ALSO A NATION'S SOCIAL COHESION
AND NATIONAL PURPOSE,

OUR JOB -- AS CITIZENS, COMMUNITY LEADERS, AND AS PHYSICIANS
-- MUST BE TWO-FOLD: TO SAVE THOSE INDIVIDUAL HUMAN LIVES ... AND
TO SAVE OUR COUNTRY.

WHY IS THIS THE CASE? WHAT MAKES THIS DISEASE SO
THREATENING?
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AS A BEGINNING, LET ME BRIEFLY REMIND YOU OF THREE ASPECTS

OF THE DISEASE THAT COLOR EVERYTHING DONE AND SAID ABOUT IT.

FIRST, AIDS IS STILL A MYSTERY. WE KNOW SOME THINGS ABOUT
IT. BUT WE DON’T KNOW ENOUGH ABOUT IT TO PRODUCE A VACCINE TO
PREVENT ITS SPREAD OR A DRUG TO STOP IT IN ITS TRACKS,

TWO, IT’S FATAL. IN FACT, IT SEEMS TO HAVE ONE OF THE
HIGHEST FATALITY RATES OF ANY INFECTIOUS DISEASE WE’VE EVER COME
ACROSS.
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AND THREE, THE AIDS VIRUS IS TRANSMITTED BY CERTAIN

BEHAVIORS THAT MOST PEOPLE DON’T ENGAGE IN OR APPROVE OF: ANAL
INTERCOURSE, FOR EXAMPLE, AND THE SHARING OF NEEDLES BY DRUG
ADDICTS,

THESE THREE KEY ASPECTS OF THE DISEASE MAKE THE AMERICAN
PEOPLE VERY EDGY ABOUT AIDS -- AND WHO CAN BLAME THEM?

WE HAVE EVERY REASON TO BE CAUTIOUS. BUT NO REASON TO
BECOME PARALYZED. YET, SOME AMONG US ARE INDEED PARALYZED BY IT:
SCHOOL OFFICIALS WHO HAVE BARRED CHILDREN WITH AIDS FROM PUBLIC
CLASSROOMS, PHYSICIANS AND HOSPITAL ADMINISTRATORS WHO TURN AWAY
AIDS PATIENTS, AND EMPLOYERS WHO SUMMARILY DISMISS ANY WORKER
WHO HAS AIDS.

JUST THE OTHER DAY I SAW THE RESULTS OF A SURVEY CONDUCTED
BY THE CENTER FOR WORK PERFORMANCE PROBLEMS AT GEORGIA TECH:
/
TWO-THIRDS OF THE WORKERS SURVEYED SAID THEY WOULD BE

“CONCERNED” ABOUT SHARING A RESTROOM AT WORK WITH A
COLLEAGUE WHO HAD AIDS.

FORTY PERCENT WEREN’T SURE ABOUT THE WISDOM OF EATING IN THE
SAME CAFETERIA WITH PERSONS WITH AIDS.

AND 37 PERCENT WOULD NOT SHARE TOOLS OR EQUIPMENT WITH
PEOPLE WHO HAD THE AIDS VIRUS.

THESE ARE IRRATIONAL AND DISCRIMINATORY RESPONSES. AND WE
NEED TO RECOGNIZE THEM FOR WHAT THEY ARE AND WE MUST CONVINCE OUR
COLLEAGUES NOT TO ADOPT THEM.

I SAY THESE RESPONSES ARE IRRATIONAL BECAUSE THEY ARE MADE
IN THE NAME OF PROTECTION AGAINST DANGER. BUT IN ALL THOSE
SITUATIONS, NEITHER THE DISEASE NOR THE PERSON WHO HAS IT
PRESENTS ANY CLEAR OR PRESENT DANGER.
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AS I INDICATED EARLIER, A PERSON HAS TO KNOWINGLY DO CERTAIN

THINGS TO BECOME INFECTED WITH THE VIRUS. NOW, IF THOSE KINDS OF
THINGS ARE GOING ON IN YOUR SCHOOL ... YOUR HOSPITAL ... OR YOUR
PLACE OF BUSINESS, BELIEVE ME, AIDS IS THE LEAST OF YOUR
PROBLEMS,

AT ANY RATE, TWO YEARS AGO THE PUBLIC HEALTH SERVICE
RELEASED A SET OF PRACTICAL GUIDELINES WHICH, IF FOLLOWED, WILL
PROTECT ANY HEALTH WORKER FROM BECOMING CONTAMINATED OR INFECTED
WITH THE AIDS VIRUS.
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AND THEY’RE EFFECTIVE, SO FAR, OUT OF A TOTAL HEALTH

WORKFORCE OF NEARLY 7 MILLION PERSONS, FEWER THAN A DOZEN HAVE
BECOME INFECTED WITH THE AIDS VIRUS ON THE JOB.

AND IN EACH OF THOSE CASES, I THINK YOU WILL SEE A POINT
WHERE VIGILANCE WAS RELAXED AND THE VIRUS FOUND A WAY IN,

DESPITE THIS EXTRAORDINARY RECORD OF SAFETY, WE HEAR ALMOST
DAILY SOME STORY INVOLVING A HEALTH PROFESSIONAL -- OR A GROUP OF
PROFESSIONALS -- WHO REFUSE TO TREAT SOMEONE WITH AIDS ... OR
THEY REFUSE EVEN TO TREAT SOMEONE WHOM THEY SUSPECT OF HAVING
AIDS.

 
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I DO NOT FOR A MOMENT BELIEVE THAT THIS IS THE

CHARACTERISTIC BEHAVIOR OF ALL HEALTH PROFESSIONALS. QUITE THE
CONTRARY: THE OVERWHELMING MAJORITY OF MY COLLEAGUES HAVE
PROVIDED -- AND I AM CERTAIN WILL CONTINUE TO PROVIDE -~-
QUALITY, COMPASSIONATE CARE TO PERSONS DYING OF AIDS WHEREVER
THAT MAY BE OCCURRING,

BUT THE GOOD CONDUCT OF THE MAJORITY SHOULD NOT IN ANY WAY
SHIELD THE POOR CONDUCT OF A FEARFUL AND IRRATIONAL MINORITY.

I RAISE THIS ISSUE WITH YOU, BECAUSE THIS IS NOT A PROBLEM
THAT ONLY GOVERNMENT CAN SOLVE.
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FORTUNATELY, THE RESPONSE OF MANY PRIVATE ORGANIZATIONS 10

THE DANGER OF IRRATIONAL BEHAVIOR HAS BEEN MOST ENCOURAGING:

* THE AMERICAN MANAGEMENT ASSOCIATION HAS DEVELOPED
BRIEFING MATERIALS ON AIDS WHICH EXPLAINS THE NATURE OF THE
DISEASE ... HELPS MANAGERS PREPARE AN EDUCATIONAL PROGRAM ON THE
SUBJECT ... AND OFFERS SOME ADVICE FOR DEALING WITH AN EMPLOYEE
WITH THE DISEASE IN A HUMANE, DECENT WAY,

* THE NATIONAL EDUCATION ASSOCIATION HAS DONE THE SAME
FOR ITS MEMBERS, PROVIDING GUIDELINES FOR BOTH THE ADMISSION OF
SCHOOL CHILDREN WITH AIDS AND THE HIRING AND SUPERVISION OF
EMPLOYEES WITH AIDS.
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* INDIVIDUAL BUSINESSES, SUCH AS AT&T, WESTINGHOUSE, AND

THE SAN FRANCISCO-BASED WELLS FARGO AND BANKAMERICA WERE AMONG
THE FIRST OF MANY TO DO SOMETHING POSITIVE ABOUT AIDS EDUCATION
AND EMPLOYEE POLICIES FOR THEIR OWN COMPANIES.

AS A MATTER OF FACT, THERE IS STILL A GREAT DEAL THAT
LOCAL, COMMUNITY LEADERS, SUCH AS YOURSELVES, CAN DO TO MAINTAIN
A RATIONAL, COMPASSIONATE APPROACH TO THIS PROBLEM,

AND I DO NOT FOR A MINUTE BELIEVE THAT YOU NEED TO
COMPROMISE IN ANY WAY JUST HOW YOU FEEL ABOUT THE KINDS OF
BEHAVIOR THAT MAKES AIDS POSSIBLE,
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BUT WE MUST KEEP OUR PRIORITIES STRAIGHT. WE ALWAYS HAVE IN

THE PAST, WE OUGHT TO DO THE SAME NOW. THE FIRST PRIORITY IS T0
FIGHT THE DISEASE AND NOT THE PEOPLE WHO HAVE IT. THE SECOND
PRIORITY IS TO EDUCATE EVERYONE ABOUT THE DISEASE SO THAT IT WILL
NOT BE SPREAD.

HOW DO YOU ACCOMPLISH PRIORITY ONE? AGAIN, WITH GOOD
INFORMATION. YOU NEED TO UNDERSTAND, FOR EXAMPLE, THAT EACH
PERSON CAN AVOID THE RISK OF CONTAMINATION OR INFECTION BY USING
COMMON SENSE AND FOLLOWING A FEW SIMPLE RULES...
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AND YOU NEED TO AGREE THAT NO ONE SHOULD BE ABLE TO USE THE

FEAR OF AIDS AS A SHIELD BEHIND WHICH HE OR SHE CAN VIOLATE THE
ETHICS OF MEDICINE OR EDUCATION OR SOCIAL SERVICE. NO ONE
SHOULD HAVE THE LEEWAY TO ESCAPE THE MORAL IMPERATIVE IN OUR
SOCIETY THAT WE MUST SERVE PEOPLE WHO ARE IN NEED.

NOW I WANT TO BRING UP AN OTHER, RELATED ISSUE ... ONE THAT
IS EVEN MORE DIFFICULT TO HANDLE. AND THAT’S THE ISSUE OF COSTS
.++ MORE SPECIFICALLY, THE COST OF CARE FOR AIDS PATIENTS.
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THIS IS NOT A THEORETICAL OR ACADEMIC QUESTION AT ALL,

BECAUSE THE COST OF PATIENT CARE IN THIS NEW AND EXPANDING AREA
IS ALREADY HIGH -- AND IT’S GOING TO GET HIGHER.

AT THIS POINT THE TOTAL ANNUAL EXPENDITURE FOR THE MEDICAL
CARE OF AIDS PATIENTS IS 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.

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.
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ORDINARILY WE DON’T WORRY ABOUT THIS. WE‘VE HAD A BILLION-

DOLLAR PROGRAM TO FIGHT CANCER ... WE‘’VE PUT HUNDREDS OF MILLIONS
OF DOLLARS INTO KIDNEY DIALYSIS ... AND, ON THE WHOLE, THESE
KINDS OF EXPENDITURES HAVE BEEN SUPPORTED WITH MUCH GOOD GRACE BY
THE AMERICAN TAXPAYER.

MOST OF THOSE BIG- AND SMALL-TICKET PUBLIC HEALTH PROGRAMS,
HOWEVER, HAVE HAD A COMMONALITY OF SORTS:

MOST OF THEM EITHER HELP PROMOTE OR MAINTAIN AN

INDIVIDUAL’S GOOD HEALTH ... OR THEY HELP AN AILING

INDIVIDUAL RETURN TO A STATE OF GOOD HEALTH,
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JUST THINK ABOUT IT FOR A MOMENT AND I’M SURE YOU WILL

AGREE. THERE’S THE MATERNAL AND CHILD HEALTH PROGRAM ... OUR
ALCOHOLISM PROGRAMS ..,. DRUG ABUSE ... HYPERTENSION SCREENING ...
AND SO ON,

BUT THE PROGRAM TO SUPPORT CARE FOR AIDS PATIENTS IS QUITE
DIFFERENT. IT’S VERY EXPENSIVE, AS I’VE ALREADY INDICATED. THE
ANNUAL COST PER PATIENT IS NOW RUNNING BETWEEN $20,000 AND
$50,000, DEPENDING ON THE CITY AND THE TYPE OF AIDS-RELATED
CONDITION THE PERSON HAS.
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BUT THEN, AFTER CONSUMING TENS OF THOUSANDS OF DOLLARS

WORTH OF MEDICAL CARE AND SOCIAL SERVICES ... THE AIDS PATIENT
DIES, WE KNOW IT’S GOING TO HAPPEN, SOME OF THE COST IS SPENT
ON HOSPICE CARE AS IT IS.

THIS IS A TERRIBLY IMPORTANT ISSUE FOR THIS COUNTRY. WE
HAVE A TRULY ENVIABLE TRADITION OF ALTRUISM IN AMERICA ... A
KIND OF NATIONAL ETHOS OF BENEVOLENCE ... AND IT’S A PRECIOUS
TRADITION.
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AIDS HAS THE POTENTIAL OF PUTTING THAT TRADITION AT RISK.

IT IS A VIRTUALLY FATAL DISEASE THAT A PERSON CONTRACTS BY
INDULGING IN BEHAVIOR THAT MOST AMERICANS WILL NOT CONDONE. YOU
CAN SAY THE SAME THING FOR ALCOHOLISM, DRUG ABUSE, RECKLESS
DRIVING, VENEREAL DISEASE, AND TEENAGE PREGNANCY.

BUT AIDS PROVOKES A QUITE DIFFERENT RESPSONSE, I CAN TELL
YOU FROM MY OWN PERSONAL EXPERIENCES DURING THE EIGHT MONTHS 1
TOOK TO PREPARE THE “SURGEON GENERAL’S REPORT ON AIDS.” MOST
PEOPLE CAME TO ME AND OFFERED THEIR ADVICE, BUT IT TENDED TO BE
WITHIN THE GENERAL FRAMEWORK OF OUR TRADITION OF TOLERANCE ALMOST
TO A FAULT, |
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BUT OTHERS WERE NOT SO GENEROUS. AND I HEAR ECHOES OF THEIR
IRRATIONAL AND EVEN HATEFUL RESPONSE TO AIDS AND THE PEOPLE WITH
AIDS, AS A 1 MENTIONED A FEW MOMENTS,

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 SEEK RELIEF -- WHICH WILL BE NEW FOR OUR
SOCTETY -- WHAT AFFECT WILL THAT HAVE ON ACCESSIBILITY TO
MEDICAL CARE...OR ON THE QUALITY OF CARE...FOR AIDS PATIENTS?
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MY GUESS IS THAT THE EFFECT WILL NOT BE GOOD FOR AIDS

PATIENTS IN THE SHORT RUN AND NOT GOOD FOR OUR COUNTRY IN THE
LOMNG RUN.

1‘D 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’M UNEASY ENOUGH TO CONFESS TO YOU RIGHT
NOW THAT -- HONESTLY -- I JUST DON’T KNOW,

AS A PHYSICIAN, I AM PROUD TO BE PART OF A TRADITION OF CARE
THAT GOES BACK MORE THAN TWO MILLENTA...A TRADITION THAT WILL NOT
ABANDON THE SICK AND THE DISABLED, WHOEVER THEY ARE AND WHATEVER
THEY MAY HAVE DONE TO HAVE ARRIVED IN SUCH A FIX.
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FINALLY, WE SEE MORE EVIDENCE EVERY DAY THAT THIS DISEASE IS

BECOMING THE PARTICULAR SCOURGE OF PEOPLE WHO ARE YOUNG, BLACK,
AND HISPANIC. AMONG PERSONS WITH AIDS WHO ARE UNDER 30 YEARS OF
AGE, 25 PERCENT ARE BLACK AND 14 PERCENT ARE HISPANIC,

THESE PERCENTAGES ARE TWICE THE RATES AT WHICH THESE GROUPS
APPEAR IN THE POPULATION AS A WHOLE.

AMONG WOMEN IT’S EVEN WORSE: 52 PERCENT OF ALL WOMEN WITH
AIDS ARE BLACK ... 20 PERCENT ARE HISPANIC.

 
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HOW TRAGIC FOR THEM,

AND HOW TRAGIC FOR ALL OF US.

ANYONE WHO HAS LIVED THROUGH THE LAST TWO DECADES OF SOCIAL
CHANGE IN THIS COUNTRY HAS GOT TO BE PROUD OF THE WAY THIS
COUNTRY HAS FACED THE CHALLENGE OF FAIRNESS TO ALL ITS CITIZENS,
REGARDLESS OF RACE, COLOR, CREED, AGE, SEX, OR NATIONAL ORIGIN,

IT HASN'T BEEN EASY AND IT HASN‘T BEEN PERFECT. BUT GRAEAT
STRIDES HAVE BEEN MADE.
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WILL THE DISEASE OF AIDS -- ALL BY ITSELF -- REVERSE THIS

TREND IN RECENT HUMAN HISTORY? WILL THIS DISEASE -- BY ITSELF --
RAISE ONCE AGAIN THE ARTIFICIAL BARRIERS BETWEEN OUR CITIZENS
THAT IT TOOK SO MUCH WORK AND COURAGE TO TEAR DOWN?

WE HOPE AND PRAY THAT IT WILL NOT. BUT HOPES AND PRAYERS MAY
NOT BE ENOUGH. WE WILL NEED TO REINFORCE THOSE HOPES AND
PRAYERS WITH THE HELP OF COURAGEOUS LEADERSHIP AT ALL LEVELS OF
GOVERNMENT AND THROUGHOUT ALL OUR SOCIAL AND POLITICAL
INSTITUTIONS,

 
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YES, IT IS TRUE THAT THE GREAT MAJORITTY OF AIDS PATIENTS SO

FAR HAVE BEEN HOMOSEXUALS, DRUG ADDICTS, BLACKS, AND HISPANICS,
ABOUT 47,000 OF THEM,

AND SO WE MUST ASK IF WE ARE TRULY MATURE ENOUGH TO BE
COLOR-BLIND IN THIS WAR AGAINST AIDS?

CAN WE BE “VIROPHOBIC” WITHOUT BEING HOMOPHOBIC?

ARE WE SECURE ENOUGH TO STRIVE TO EXTEND OUR VERY BEST
MEDICAL CARE TO THE EVERY CITIZEN WHO NEEDS IT?
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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.

] 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,

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