POO Udit o- far B

The Social Issues Behind th Major Health Problems
in the United States

_ Presented at "The Church's Challenge in Health"

The Carter Center, Emory University
Atlanta, Georgia

October 25, 1989
Speech by

C. Everett Koop, M.D.
MY ASSIGNMENT AT THIS OPENING PORTION OF
THE PROGRAM, IS TO SHARE WITH DR. MASON THE
OBLIGATION OF ENUMERATING FOR YOU THE MAJOR
HEALTH ISSUES IN THE UNITED sTATEs./ WHILE HE
HAS CONCENTRATED ON THOSE ISSUES HAVING TO DO
WITH THE SCIENCE OF HEALTH, I HAVE BEEN ASKED
TO TALK WITH YOU ABOUT THE SOCIAL ISSUES. |
INITIALLY, I HAD BEEN ASSIGNED THE ROLE OF
PRESIDER AT THIS SESSION ONLY TO BE ASKED TO
EXPAND MY, REMARKS TO FILL IN THE TIME VACATED
BY THE SECRETARY OF HEALTH AND HUMAN
SERVICES, DR. LOUIB SULLIVAN.

SO INSTEAD OF LEARNING,WITH YOU,HOW DR.
SULLIVAN SAW THE SOCIAL ISSUES BEHIND THE
HEALTH PROBLEMS, I HAD TO DECIDE WHAT THEY
WERE AND TRY TO PASS THEM ON TO YOU.
IN THE CIRCLES IN WHICH I TRAVEL, |
CONVERSATIONS ON THIS SUBJECT ARE CONSTANT. IT
ISN'T SO MUCH THAT THINGS ARE CHANGING AS IT IS
THAT THINGS HAVE CHANGED, BUT MANY PEOPLE ARE
TRYING TO PLAN THE FUTURE AS THOUGH IT WERE
INDEED YESTERYEAR.

IN THE PRACTICE OF MEDICINE, THE
DOCTOR - PATIENT RELATIONSHIP HAS DETERIORATED
OVER THE RECENT TWO DECADES TO THE POINT WHERE
SOME WONDER IF IT EVER CAN BE REPAIRED /IT IS MY
OWN OPINION THAT IT ALL BEGAN WHEN |
PROFESSIONALS IN THE DELIVERY OF __
MEDICAL CARE=DOCTORS, NURSES, OTHER TYPES OF
_ THERAPISTS AND SO ON--BEGAN TO ACCEPT THE
NOMENCLATURE OF PROVIDERS /THE PATIENTS OF
THESE PROFESSIONALS SLIPPED SEVERAL COGS WHEN
THEY PERMITTED THEMSELVES TOBECALLED _
CONSUMERS.
PEOPLE AREN'T HAPPY ABOUT BEING ILL, OR
NEEDING TO GO TO A PHYSICIAN. HAVING TO PAY A
HIGH PRICE FOR IT MAKES IT EVEN MORE
UNPLEASANT. BUT WE NEED TO SUBORDINATE THE
ECONOMIC ASPECT OF THE RELATIONSHIP TO THE
CLIMATE OF TRUST BETWEEN THE DOCTOR AND THE
PATIENT. IF THE PATIENT THINKS OF HIMSELF
PRIMARILY AS A CONSUMER, GETTING THE MOST FOR
HIS MONEY, HE AUTOMATICALLY PUTS THE DOCTOR IN
THE ROLE OF THE SELLER, GETTING THE MOST FOR HIS.
SERVICES.

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BRAw CEABHe IV FIFE SUPER MAAKET wd

OF Pheviotas pemPrvt GAS:
I AM SUFFICIENTLY CONCERNED ABOUT THIS
DETERIORATION IN RELATIONSHIPS TO HAVE ELECTED
TO TALK TO BOTH SIDES--SUGGESTING HOW THE
PROFESSIONALS CAN RISE A LITTLE HIGHER ON THE
SCALE OF EXPECTATION; WHILE TALKING TO THE
PUBLIC AND SUGGESTING THAT THEIR EXPECTATIONS
MIGHT BE TOO HIGH.

THE MOBILE SOCIETY THAT AMERICANS HAVE
BECOME, AND THE MANNER IN WHICH URBAN FOLKS
USE HOSPITAL EMERGENCY ROOMS AS THEIR
PRIMARY PHYSICIAN, IS NOT CONDUCIVE TO THE
RELATIONSHIPS BETWEEN DOCTOR AND PATIENT OF A
GENERATION AGO.
ALTHOUGH PUBLIC HEALTH IS NOT PRIVATE
MEDICINE, THE TWO ARE INEXTRICABLY |
INTERT WINED/NEVER IN MY LIFETIME HAVE I HEARD
THE DISSATISFACTION ABOUT HEALTH CARE COMING
FROM SO MANY QUARTERS.

OwLy

IT IS NOT,DOCTORS AND PATIENTS, IT IS NOT _
NURSES AND THERAPISTS, Sec/#4 WeeceeS sap PHARMA CSD,

IT IS BIG BUSINESS AND SMALL BUSINESS, IT IS
CONGRESS, IT IS THE ELDERLY AND THE YOUNG.

IN SHORT, OUR ASPIRATIONS FAR OUTDISTANCE
THE RESOURCES AVAILABLE TO PAY FOR THEM. OR TO
PUT IT ANOTHER WAY, THERE IS A HUGE GAP
BETWEEN THE DREAM OF IDEAL HEALTH CARE AND
THE REALITY OF ITS AVAILABILITY.
AGAINST THIS BACKDROP, LET ME ADDRESS SOME
eciar DIEFICUT To SEPARNIE nom /

OF THE,ISSUES BM HEALTH CARE ITSELF.
THE STRUGGLE BETWEEN OUR ASPIRATIONS AND OUR
RESOURCES HAS COME AT THE WORST POSSIBLE TIME,
A TIME WHEN DEMOGRAPHIC TRENDS ARE RUNNING
AGAINST US. | |

TODAY, FOR EXAMPLE, FOR EACH PERSON WHO IS
OVER THE AGE OF 65, THERE ARE 5 YOUNGER,
TAX-PAYING WAGE-EARNERS TO PAY FOR THAT ONE
PERSON'S MEDICARE COVERAGE.
IN ANOTHER 20 YEARS, HOWEVER, FOR EACH PERSON
OVER THE AGE OF 65, THERE WILL BE ONLY 3 YOUNGER,
TAX-PAYING WAGE-EARNERS CONTRIBUTING TO
MEDICARE. /IN A CLIMATE OF SCARCITY, AMERICANS
WILL HAVE TO WORK OUT AN EQUITABLE SHARING OF
NEEDED MEDICAL RESOURCES BETWEEN ONE POPULATION
GROUP THAT IS GROWING ss THAT IS, THE ELDERLY,
PEOPLE OVER THE AGE OF 65 «= AND THE POPULATION
GROUP THAT IS COMPARATIVELY SHRINKING sx THAT IS,
CHILDREN UNDER THE AGE OF 18.
OVER THE PAST 8 YEARS I'VE DEALT WITH
ADVOCATES FOR CHILDREN AND I'VE DEALT WITH
ADVOCATES FOR THE ELDERLY. THEY ARE BOTH VERY
DEDICATED AND VERY PERSUASIVE GROUPS. AND BOTH
WILL BE. QUITE RIGHTLY COMPETING FOR A LARGER PIECE

OF A SMALLER PIE.

THIS HAS CHILLING ETHICAL IMPLICATIONS, AND WE
MUST GUARD AGAINST LETTING OUR ETHICS BE
DETERMINED BY OUR ECONOMICS,

AND NOT THE OTHER WAY AROUND.

SOME CRITICS WILL SAY THAT THE CHIEF CAUSE FOR
THE CRUNCH IS THE BUDGET DEFICIT. ONCE WE GET RID OF
THE DEFICIT, SAY THESE CRITICS, WE WILL ALSO GET RID
OF THAT GAP BETWEEN ASPIRATIONS AND RESOURCES ...
BETWEEN DREAMS AND REALITY.

10
MAYBE ... BUT I DON'T THINK SO.

WELL BEFORE WE HAD A BUDGET PROBLEM, WE
ALREADY HAD A HEALTH CARE ECONOMY THAT
CONSISTENTLY RAN AT AN ANNUAL INFLATION RATE
THAT WAS 2 TO 3 TIMES THE INFLATION RATE FOR THE
REST OF THE AMERICAN ECONOMY.

BUT WE DIDN'T SEE IT ... OR, IF WE DID SEE IT, WE
PREFERRED NOT TO WORRY ABOUT IT.

TODAY, WE STILL HAVE AN INFLATED. HEALTH CARE
ECONOMY ... BUT WE ALSO HAVE INFLATED HEALTH CARE
ASPIRATIONS. AND WE SIMPLY CAN'T AFFORD ANY
INFLATION AT ALL. |

11.
WHEN I OR OTHER PEOPLE TALK LIKE THIS, OUR
CRITICS COME BACK AT US AND SAY THAT THINGS
REALLY AREN'T THAT BAD ... THAT ALL WE NEED TO DO IS
PUT A REIMBURSEMENT CAP ON THIS ... OR CHANGE THE
ELIGIBILITY REGULATIONS FOR THAT ... OR CUT BACK A
LITTLE HERE ...OR PRUNE BACK A LITTLE THERE.

12
DURING 8 YEARS AS YOUR SURGEON GENERAL, I
LISTENED TO THESE DEBATES AND I'VE THOUGHT ABOUT
THE TRUE HUMAN COSTS ASSOCIATED WITH THAT KIND OF
A PATCHWORK APPROACH.

AND TODAY I'M MORE CONVINCED THAN EVER THAT
OUR WHOLE HEALTH CARE SYSTEM NEEDS TO BE STUDIED
WITH AN EYE TO MAKING A NUMBER OF VERY MAJOR
corrections. Aow, I CAN ALREADY HEAR THE CRITICS
SAYING, "WAIT A MINUTE, DR. KOOP. THE SYSTEM AIN'T
BROKE, SO DON'T FIX IT."

TO WHICH I WOULD REPLY, "YOU'RE WRONG. THE
SYSTEM IS BROKEN ... AND IT MUST BE FIXED." BAND-AIDS
WON'T DO.

13
HOSPITAL COSTS ARE STILL CLIMBING ... AND NO ONE
CAN PROVE TO THE AMERICAN PEOPLE THAT THE QUALITY
OF HOSPITAL-BASED CARE IS UNIFORMLY GOING UP AS
WELL. ON THE CONTRARY, OUR PEOPLE COMPLAIN THAT
THEY ARE PAYING MORE AND MORE FOR MEDICAL CARE,
AND ARE GETTING LESS AND LESS.

WORSE STILL, AS THE COST OF HOSPITAL-BASED
‘CARE INCREASES, THE HOSPITALS THEMSELVES ARE
TRYING TO NARROW THEIR PATIENT POOL ... FOR EXAMPLE,
ELIMINATING THE NEED TO PROVIDE IN-PATIENT MEDICAL
CARE FOR POOR AND DISADVANTAGED AMERICANS. I SAY
THERE'S SOMETHING TERRIBLY WRONG WITH A SYSTEM OF
HEALTH CARE THAT SPENDS MORE AND MORE MONEY TO
SERVE FEWER AND FEWER PEOPLE.

14
I COULD PAINT FOR YOU MUCH THE SAME

SCENARIO IN RESPECT TO PHYSICIAN SERVICES AND
FEES. |‘M SeRrné Voy tun Free tw THe Reanes

THE ECONOMICS OF HEALTH CARE ARE PECULIAR.
WE HAVE A LAISSEZ-FAIRE ECONOMY IN REFERENCE
TO HEALTH CARE.

BUT IT'S NOT FREELY COMPETITIVE AND, HENCE, IT HAS
VIRTUALLY NO MODERATING CONTROLS WORKING ON
BEHALF OF THE CONSUMER, OR THE PATIENTAN MOST
OTHER AREAS OF OUR ECONOMY, THE MARKETPLACE DOES
EXERCISE SOME CONTROL OVER ARBITRARY RISES IN
CHARGES TO THE CONSUMER/THERE REALLY IS
COMPETITION.

15
HERE AND THERE IT MIGHT BE RATHER THIN ... BUT IT
DOES EXIST AND IT DOES PROVIDE SOME ASSURANCE THAT
| INEFFECTIVE, UNCOMPETITIVE, HIGH-COST, LOW-QUALITY
ENTERPRISES WILL FAIL /| BUT IN HEALTH CARE, RIGHT
ACROSS THE BOARD, PRICES HAVE GONE UP
IRRESPECTIVE OF THE QUALITY OF CARE BEING DELIVERED
OR OF ANY OTHER MARKETPLACE CONTROL.

TRY AS THEY MIGHT, I DON'T SEE THE MEDICAL

PROFESSION ACHIEVING MUCH SUCCESS IN SELF-
REGULATION. GRANTED, IT'S NO SIMPLE TASK.

16
PHYSICIANS CAN HELP PUT THE BRAKES ON SOME
GENERAL EXPENDITURES, BUT THERE ARE VERY FEW
PHYSICIANS WHO CAN HONESTLY AND EFFECTIVELY
CONTROL THE DELIVERY OF SERVICE -- MUCH LESS
CONTROL THE COSTS OF THAT SERVICE -- WHILE CARING
FOR A SPECIFIC, INDIVIDUAL PATIENT AT THE BEDSIDE.

WE SEEM TO HAVE, THEREFORE, A SYSTEM OF HEALTH
CARE THAT'S DISTINGUISHED BY A VIRTUAL ABSENCE OF
SELF-REGULATION ON THE PART OF THE PROVIDERS OF
THAT HEALTH CARE -- THAT IS, HOSPITALS AND
PHYSICIANS -- AND DISTINGUISHED AS WELL BY THE
ABSENCE OF SUCH NATURAL MARKETPLACE CONTROLS AS
COMPETITION IN REGARD TO PRICE, QUALITY, OR
SERVICE.WHAT IS THE EFFECT OF SUCH A SYSTEM
ANYWAY? |

17
ONE VERY SERIOUS EFFECT HAS BEEN THE EMERGENCE
OF A THREE-TIER FRAMEWORK OF HEALTH CARE.
WE'VE ALWAYS SAID WE NEVER WANTED EVEN A TWO-
TIER SYSTEM. |

I'M NOT HERE TO SUGGEST REMEDIES, BUT LET ME
JUST SAY IN PASSING THAT THERE ARE ONLY TWO
WAYS YOU CAN GO FROM HERE. BOTH REQUIRE MAJOR
CHANGES;AND A STOP TO BAND-AID THERAPY.

_ EITHER WE MAINTAIN THE DIVERSITY WE HAVE
IN THE AMERICAN SYSTEM, KEEP IT IN THE PRIVATE
SECTOR, DEMAND THE REWARDING OF EFFICIENCY AND
QUALITY WITH MORE PATIENTS RATHER THAN MORE
MONEY; OR WE GO TO A GOVERNMENT COST-
CONTROLLED SYSTEM AND LOSE FOREVER WHAT I
THINK IS THE POTENTIAL FOR THE BEST SYSTEM
POSSIBLE.

18
EXPERIENCE THE WORLD OVER HAS SHOWN THAT
WHEN GOVERNMENT ECONOMIC CONTROLS ARE
APPLIED TO HEALTH, THEY PROVE IN TIME, TO BE
DETRIMENTAL.

EVENTUALLY THERE IS EROSION OF QUALITY,
PRODUCTIVITY, INNOVATION, AND CREATIVITY.

THEN THERE IS LACK OF RESPONSIVENESS TO
PATIENTS, USUALLY BROUGHT ABOUT BY THE LOSS
OF CONTROL OF THE SYSTEM BY PHYSICIANS AND
THEIR REPLACEMENT BY NON-MEDICAL
BUREAUCRATS.

AND FINALLY, RATIONING AND WAIFING LINES

RECUR.
—

19
THERE HAVE ALSO BEEN CHANGES, NOW RATHER
SOLIDLY SET IN SOCIETY, IN REFERENCE TO THE
FAMILY IN AMERICA. I TALK ABOUT FAMILIES
BECAUSE HEALTH OF INDIVIDUALS IS INEXTRICABLY
TIED UP WITH THE HEALTH OF FAMILIES; AND
BECAUSE THE FAMILY IS THE BUILDING BLOCK OF THE
SOCIETY, WE WOULD LIKE TO SEE IMPROVE.

20
TODAY, FAMILIES ARE SMALLER. THERE HAS
BEEN AN INCREASE IN THE SINGLE PARENT FAMILY.
‘MOTHERS ARE OUT OF THE HOME; 6 OF 10 MOTHERS
WITH PRE-SCHOOL AGE CHILDREN ARE IN THE LABOR
FORCE. TWO-THIRDS OF THEM ARE IN THIS SITUATION
FOR ECONOMIC REASONS, |

INDIVIDUAL MEMBERS OF FAMILIES ARE OLDER |
THAN THEY WERE A GENERATION AGO. ALCOHOL AND
DRUGS ARE ABUSED BY MORE AND MORE FAMILY
MEMBERS. TEENAGERS HAVE BECOME MOTHERS. THE
VARIETY OF LIVING ARRANGEMENTS IS ALMOST
INFINITE. .

21
WHAT YOU AND I, THINK OF WHEN WE HEAR THE
WORD FAMILY, THE STEREOTYPE OF NOT SO LONG AGO,
IS NOW MET BY ONLY 10% OF FAMILIES. BY THIS
STEREOTYPE I MEAN THE FATHER IS AT WORK, THE
MOTHER IS AT HOME, AND SHE SPENDS HER LIFE
TAKING CARE OF 2.2 CHILDREN, *£€ 1 8440 TWO #ER (tom

BECAUSE FAMILIES ARE SMALLER, AND BECAUSE
THERE ARE MORE ELDERLY PEOPLE DEPENDENT UPON
FAMILIES, THE RESPONSIBILITY FOR SUCH CARE
FALLS ON FEWER CHILDREN FOR LONGER PERIODS OF

TIME.

IT IS MY FIRM BELIEF THAT ALL OF THE ABOVE
CONTRIBUTES IN SOME WAY TO VIOLENCE.

22
RISK FACTORS IN ABUSIVE FAMILIES VARY
CONSIDERABLY, AND I DO NOT MEAN TO SAY THAT
ost FAMILIES HAVE ALL OF THESE
CHARACTERISTICS OR EVEN MOST OF THEM.

NEVERTHELESS, THESE ABUSIVE FAMILIES TEND
TO BECOME ISOLATED, THE MEN ARE PRONE TO
ALCOHOLISM, THEY ARE ECONOMICALLY DEPRESSED,
FREQUENTLY ARE UNEMPLOYED /MEN DISCOURAGED
BECOME CONCERNED ABOUT POWER, THE
REAFFIRMATION OF LOST STATUS, AND FREQUENTLY

_THEIR ABUSIVE BEHAVIOR AT HOME IS CARRIED INTO

SOCIETY AT LARGE. |

23
TWO OTHER TRAGEDIES TOOK PLACE IN THE
MANAGEMENT OF THE PUBLIC'S HEALTH BEFORE I
CAME ON THE SCENE IN THE FEDERAL GOVERNMENT.

ONE WAS TO CLOSE OUR MENTAL INSTITUTIONS
WITH THE EXPECTATION THAT COMMUNITIES WOULD
ABSORB THE INMATES IN HALFWAY HOUSES AND
SHELTERED WORKSHOPS. THOSE INMATES HAVE NOT
BEEN SHELTERED AND PROTECTED AND THEY FORM A
LARGE SEGMENT OF THE HOMELESS IN AMERICA
TODAY.

IT'S A FUNNY THING ABOUT AMERICANS IN THIS
REGARD. THEY ARE GENEROUS TO A FAULT, BUT THEY
DO NOT LIKE HOMES FOR THE RETARDED, AIDS
HOSPICES, DRUG ABUSE TREATMENT CENTERS, OR
SHELTERS FOR THE MENTALLY ILL IN THEIR
NEIGHBORHOODS.

24
ANOTHER MISJUDGMENT WAS THE CLOSING OF
THE GREAT CITY HOSPITALS IN THIS COUNTRY--SO
DESPERATELY NEEDED NOW TO CARE FOR THE
INDIGENT, THE HOMELESS, AND NOW THE BURGEONING
NUMBER OF AIDS PATIENTS WHICH FREQUENTLY ALSO
CAN FIT EITHER THE CATEGORY OF INDIGENT OR
HOMELESS.

I SEE MY ROLE HERE TODAY AS AN ENUMERATOR
OF SOCIAL ISSUES, WHICH I HAVE ATTEMPTED TO DO
BUT CERTAINLY NOT EXHAUSTIVELY. I AM NOT HERE
TO OFFER SOLUTIONS. NEVERTHELESS, I WANT TO
POINT OUT THAT WHEN THE AMERICAN PEOPLE NEED
TO RISE TO AN OCCASION THEY CAN DO SO.

25
THE HEALTH CARE SYSTEM IN AMERICA TODAY IS
A TERRIBLE MORAL BURDEN FOR SOCIETY TO BEAR IN
THAT THE SYSTEM DOES NOT RESPOND AT ALL TO SOME
12 TO AS HIGH AS PERHAPS 15% OF OUR
POPULATION.

AND IT'S A TERRIBLE ECONOMIC BURDEN FOR
SOCIETY TO BEAR, IN THAT THE SYSTEM SATISFIES
ITS OWN UNCONTROLLED NEEDS AT THE EXPENSE OF
EVERY OTHER SECTOR OF AMERICAN SOCIETY. WE
NEED TO CHANGE THAT SYSTEM. WE NEED TO CHANGE
IT THOROUGHLY, AND WE NEED TO DO IT SOON,

26
BUT CAN WE DO IT? I'D LIKE TO THINK WE CAN...

BECAUSE WE HAVE TO... AND ESPECIALLY BECAUSE
WE'VE DONE IT BEFORE. |

27
SOME 50 YEARS AGO, FOR EXAMPLE, WE AMERICANS
KNEW THAT IT WAS MORALLY WRONG FOR OUR SOCIETY
TO ALLOW ITS OLD PEOPLE TO DRIFT INTO POVERTY AND
STARVATION/ WE KNEW THAT WE COULD NO LONGER
STAND BY HELPLESS IN THE FACE OF SUCH HUMAN
MISERY. AND SO WE ENACTED A SOCIAL SECURITY LAW
TO MAKE SURE THAT EVERY AMERICAN WOULD BE
ASSURED OF A MEASURE OF HUMAN DIGNITY AND
RESPECT IN HIS OR HER TWILIGHT YEARS/AT WAS AN ACT
OF FUNDAMENTAL DECENCY/ WE KNEW WE HAD TO DOIT. 7
AND WE DID IT.

WE MET A SIMILAR CHALLENGE MORE RECENTLY THAN
THAT.

28
BACK IN THE 1950'S AND EARLY 1960'S, THE PEOPLE
OF THIS COUNTRY BECAME PAINFULLY AWARE OF THE
TERRIBLE UNFAIRNESS OF "SEPARATE BUT EQUAL"
EDUCATION,/AND SO, THROUGH OUR COURTS AND OUR
LEGISLATURES, WE RELEASED AMERICA FROM THE

CRUSHING OFFICIAL, LEGAL BURDEN OF SEGREGATED

SCHOOLS.

THAT'S OVER. AND THANK GOODNESS IT IS.

29
DID WE GET RID OF THOSE BURDENS ONCE AND FOR
ALL?/ WELL, NOT EXACTLY: *WE HAVEN'T YET SOLVED

EVERY PROBLEM ASSOCIATED WITH "GROWING OLD IN
AMERICA."/ WE KNOW THAT.

* _ AND WE HAVEN'T YET PRODUCED THE PERFECT,

EGALITARIAN SCHOOL SYSTEM. WE KNOW THAT,
TOO.

30
BUT AT LEAST WE'VE LIFTED FROM THE SHOULDERS OF
OUR PEOPLE A LARGE MEASURE OF THE BURDEN OF SHAME
AND GUILT THAT CAME WITH DOING NOTHING. WE DID
WHAT WAS MORALLY RIGHT FOR THIS COUNTRY. ANDI
BELIEVE WE CAN -- AND MUST -- DO THAT AGAIN.

31
LET'S FINALLY SAY WHAT WE'VE HESITATED TO SAY
FOR TOO MANY YEARS, AND THAT IS ... OUR CURRENT |
SYSTEM OF HEALTH CARE IS NOT FAIR IT'S NOT JUST ...
AND, THEREFORE, IT IS NOT THE MORALLY STRONG SYSTEM
THAT OUR SOCIETY NEEDS --AND DESERVES.

WE ARE AT A CROSSROADS. WE CANNOT AFFORD TO
DO NOTHING, TO CONTINUE BUSINESS AS USUAL.

32
LET ME CLOSE WITH A FEW WORDS ABOUT THE:
CHURCH AND THE CHURCHES.

THERE WAS A TIME IN THE CHRISTIAN CHURCH,
AT LEAST, WHEN THOSE CONCERNED WITH THE
PROPAGATION OF THE GOSPEL WERE AFRAID THAT
CONCERN FOR THE WELFARE OF ONE'S FELLOW MAN
MIGHT BE CONSIDERED A SOCIAL GOSPEL AND NOT

THE REAL THING AIMED AT THE SALVATION OF THE
LOST. |

33
I THINK IN RECENT YEARS, THINKING PEOPLE
HAVE BEEN ABLE TO SEPARATE THEIR © CONCERN
ABOUT A SOCIAL GOSPEL ABLIATQ To
ese
ESPOUSE SOCIAL ACTION AS PART OF THE EFFECT
THAT THAT GOSPEL #aeED( ON THE LIVES OF MEN
is Suerte <d tfaAve
AND WOMEN.

SOME OF YOU REMEMBER THE CRITICISMS OF
SOCIAL PROGRAMS IN THE EARLY YEARS OF THE
FIRST REAGAN TERM AGP PRESIDENT HIMSELF
TALKED ABOUT THE SAFETY NET. IT WASN'T QUITE
CLEAR TO EVERYONE WHAT HE MEANT, OR WHAT THE
DIMENSIONS WERE OF THAT NET, OR HOW STRONG IT
MIGHT BE, AND ESPECIALLY HOW UNIVERSAL.

34
THOSE WERE DAYS WHEN I HAD A TITLE AND
VERY LITTLE TO DO WHILE I WAS WAITING FOR
CONFIRMATION, I GOT A CALL ONE DAY ASKING
IF THE CHURCHES WERE PART OF THE SAFETY NET.
WITHOUT EVEN THINKING, I SAID YES BECAUSE
THAT'S THE WAY I WAS RAISED.

MY CHURCH, MY FAMILY, CONSIDEROTHEMSELVES
TO BE THE SAFETY NET TO THOSE LESS FORTUNATE--
EITHER IN REFERENCE TO WORLDLY GOODS OR HEALTH
STATUS, ALTHOUGH OF COURSE WE DIDN'T CALL IT
THAT.

35
AND YET TODAY, MANY CHURCH PEOPLE ARE
DICHOTOMOUS AS THEY SEPARATE THEIR FAITH FROM
THEIR ACTION. THERE ARE TIMES WHEN FAITH CAN
BEST BE EXPRESSED BY WILLING HANDS AND FEET TO
ACCOMPLISH A TASK.

36
I RECALL A TIME WHEN OUR CHILDREN WERE
SMALL WHEN WE HAD A VERY DEVOUT CHRISTIAN
LADY WHO HELPED US OUT WITH HOUSEWORK AND
COOKING. ON ONE NIGHT OF TERRIBLE CRISIS WITH
CHILDREN SICK, EMERGENCY CALLS FOR ME FROM THE
HOSPITAL, AND SO ON, A HOUSE GUEST WENT INTO
LABOR AND DELIVERED,PRECIPITOUSLY, A
PREMATURE BABY JUST DOWN THE HALL FROM WHERE
OUR HOUSEKEEPER WAS SLEEPING.

SHE NEVER APPEARED ON THE SCENE. WHEN TEN
HOURS OR SO LATER, THINGS SEEMED TO HAVE
CALMED DOWN, MY WIFE ASKED HER WHERE SHE HAD >
BEEN AND WHY SHE HADN'T COME TO HELP. HER
REPLY WAS HONEST, STRAIGHTFORWARD, AND
SIMPLE. |

SHE SAID, "I KNEW YOU WERE HAVING MANY
PROBLEMS, SO I LAY IN BED AND PRAYED FOR YOU
AL a .

] F PRAYER [5S CommMuNtCAMow wtiTet
God i'm Jvaet SH & warn’? LINFIEM SOR ,

0

THE DIViwWe MESS HEE MVIF /f+AyY & Barw

Ci fw &~ "62? of wo Hée pt’

37
AT THE TIME,
I WAS REMINDED OF THE STORY MY
GRANDFATHER TOLD ME ABOUT ATTENDING A
MINISTERIAL CONVENTION.

GROUPS OF MINISTERS AREN'T VERY POPULAR IN
HOTELS BECAUSE ACTIVITY IN THE BAR DROPS OFF
AND SO DOES THE GENEROSITY OF TIPS AS A RULE.

ON THE OCCASION MY GRANDFATHER RECOUNTED,
THE MODERATOR OF ONE OF THE MEETINGS IN ¢ov€ R46
‘SOME HOUSEKEEPING MATTERS BEFORE
THE MEETING BEGAN, DELIVERED THIS MILD
ADMONITION AS HE CLOSED: "AND BY THE WAY,
FEWER 'GOD BLESS YOU'S' AND MORE TIPS WOULD BE
APPRECIATED BY THE HOTEL STAFF." .

/ RAVER} 14 om Mu VECAT COA
Go D/, fim/] syré ste wad |
Tite [Diviwe | mesiace _ [tim
eLstae. [“*Slez7 ofl wed ctréfe!

PRIM (WM ATIOW :

 

38
I'M NOT GOING TO TELL THIS GROUP ABOUT YOUR
OWN DISTINCTIVENESS. I DON'T THINKIHAVETO —
REMIND YOU THAT YOUR GIFTS ARE OF A SPIRITUAL
DIMENSION AND THEREFORE UNIQUE IN THEIR
ABILITY TO CONTRIBUTE TO IMPROVING THE HEALTH
OF INDIVIDUALS WHO B8REER-MAKE UP OUR NATION.

I DON'T THINK I HAVE TO TELL YOU THAT CHURCH
MEMBERS SHOULD BE POLITICALLY ACTIVE,
UNDERSTAND ISSUES, VOTE PROPERLY, AND MAKE

THEIR REPRESENTATIVES UNDERSTAND WHAT THEY
BecevE Am warns, Teer Wan? Fo SEF Attompesned

I CERTAINLY SHOULDN'T HAVE TO REMIND YOU
THAT YOU BELIEVE IN WHOLENESS, IN FAIRNESS, AND
_ IN JUSTICE AND THAT IF WE WERE TO EXERCISE ALL
OF THOSE VIRTUES, WE WOULDN'T BE HERE TALKING
ABOUT THIS SUBJECT TODAY.

39
I WILL, HOWEVER, DWELL ON SEVERAL THINGS»
THAT SEEM TO ME TO BE OBVIOUS GAPS IN THE |
OUTREACH OF THE CHURCH--AND I SPEAK OF COURSE
ABOUT THE CHRISTIAN CHURCH BECAUSE THAT'S THE

ONLY ONE Peer I HAVE HAD ANY EXPERIENCES
Ri ite’

40
I HAVE BEEN VERY CONCERNED OVER THE YEARS
ABOUT THREE ETHICAL ISSUES THAT ARE VERY MUCH
A PART OF THE SOCIAL RELIEF SYSTEM AND THE
POLITICAL ACTIVITY OF CHURCHES--ABORTION,

THE CARE AND FEEDING, IF I MIGHT SAY SO, OF

HANDICAPPED CHILDREN AS EXEMPLIFIED BY BABY

DOE, AND THE PLIGHT OF THE ELDERLY THAT LEADS

ALL TOO OFTEN TO A DISCUSSION OF EUTHANASIAe / 5 omE7ats
THM. AEBYITTHAT THAT TERM SHOULD BE DROPPED FROM

OUR VOCABULARY BECAUSE SO FEW PEOPLE

UNDERSTAND WHAT IT MEANS, OR MORE LIKELY

CONFUSE IT WITH ENTIRELY ETHICAL BEHAVIOR ON

THE PART OF REAXSONABEE PHYSICIANS.

RES CONS IBLE

41
I AM OPPOSED TO ABORTION BUT HAVE ALWAYS
ADMONISHED ANY CHURCH AUDIENCE I SPOKE TO
THAT IT'S NOT ENOUGH TO BE OPPOSED TO ABORTION
UNLESS YOU ARE WILLING TO EXTEND
UNDERSTANDING, SHELTER, NURTURE, AND ECONOMIC
AID TO A WOMAN WHO IS CARRYING AN UNWANTED
PREGNANCY AND SEEKING A WAY OUT.

42
_ ITIS NOT ENOUGH TO BE OPPOSED TO THE
WITHHOLDING OF FLUIDS AND NUTRITION OF
HANDICAPPED NEWBORNS UNLESS THE INDIVIDUAL
AND THE CHURCH ARE EQUALLY WILLING TO STAND
BY THE PARENTS OF THE HANDICAPPED CHILD.

MANY PARENTS SIMPLY LACK THE. RESOURCESBE
THEY MATERIAL, SOCIAL, OR ECONOMIC--OR
EMOTIONAL, MORAL, OR PSYCHOLOGICAL--TO CARE
FOR A DISABLED CHILD, EVEN IN THEIR OWN FAMILY.

43.
ALSO, MANY LAY ADVOCATES JUST DON'T HAVE
MUCH TO SAY ABOUT THE CHURCH'S ROLE OR THE
COMMUNITY'S ROLE IN HELPING PARENTS TAKE HOME
THEIR OWN BABY DOE. |

HAVING SPENT MY LIFE WITH BABY DOES, I CAN
ASSURE YOU THAT A GREAT MANY LOVING, CARING
PARENTS HAVE BEEN ENGULFED IN CONFUSION AND
DESPAIR. BUT I CAN ALSO ASSURE YOU THAT ¥FEext- (T
CAN BE ALLEVIATED BY THE TIMELY ASSISTANCE OF
_ A WHOLE RANGE OF PRIVATE COMMUNITY RESOURCES
THAT ARE FOUND IN THE CHURCHES.

44
THERE IS NO REASON WHY THE BURDEN OF
GETTING A HANDICAPPED CHILD TO A CLINIC A FOR
REHABILITATION VISIT CANNOT BE AIDED BY A
CHURCH THAT WOULD E& : ARE FOR
THE OTHER CHILDREN IN THE FAMILY DURING THE
PARENTS' ABSENCE.

 

OR, HOW MANY CHURCHES WORRY ABOUT THE
RESPITE DESPERATELY NEEDED BY PARENTS WHO
FACE THE PROBLEMS OF LIVING WITH A 0&4 “5 /vc
HANDICAPPED CHILD 24 HOURS A DAY. _

AND SPEAKING OF RESPITE, HOW ABOUT
PROVIDING THE SAME FOR THE FAMILY OR THE
INDIVIDUAL ALMOST OVERWHELMED WITH THE TOTAL
BURDEN OF AN INCAPACITATED ELDERLY
INDIVIDUAL.

45
WHEN I WAS PREPARING TO WRITE THE BOOK,
WHATEVER HAPPENED TO THE HUMAN RACE WITH
FRANCIS SCHAEFFER, I LEARNED A LOT ABOUT THE
ATTITUDES OF PEOPLE IN NURSING HOMES.

THEIR GREATEST FEAR WAS ABANDONMENT, 4p
INDEED , ABANDONMENT BY FAMILY AND FRIENDS HAS
BEEN SHOWN TO ACTUALLY INFLUENCE THE TYPE OF
‘CARE, AND THEREFORE, THE MORTALITY OF THESE
INDIVIDUALS IN NURSING HOMES. -

THINK fod THE ett+otldtES CIYO+7s
f

[te SHS Vorod.

“46
I COULDN'T CLOSE THESE REMARKS WITHOUT
SAYING A WORD ABOUT AIDS.

THERE ARE TWO PROBLEMS THAT ARE NOT
SPECIFICALLY SCIENTIFIC, ALTHOUGH THEY DO
IMPINGE UPON CARE.

47
UNTIL THIS POINT, WE'VE BEEN ABLE TO DEAL WITH
AIDS WITHIN THE FAMILIAR PUBLIC HEALTH MODEL OF
COMPASSION AND REDEMPTION: THE AMERICAN PEOPLE
FEEL BAD WHEN ANY OF THEIR NUMBER GET SICK AND
THEY TRULY WANT TO HELP. ' |

THEY ALSO FEEL THEY ARE SUFFICIENTLY REWARDED
BY THE RETURN OF THE ILL OR DISABLED PERSON TO HIS
OR HER FAMILY, COMMUNITY, SCHOOL OR WORKPLACE.
THAT'S REDEMPTION.

48
AIDS DRAWS UPON THE GREAT RESERVOIR OF
COMPASSION IN THIS COUNTRY. 29886 EXCEPT FOR THE
FINAL WEEKS OF A TERMINAL, AIDS-RELATED ILLNESS, A
PERSON WITH AIDS MAY CONTINUE VIRTUALLY ANY
NORMAL, ROUTINE WAY OF LIFE -- INCLUDING WORK,
EDUCATION, AND SO ON -- WITHOUT FURTHER
ENDANGERING HIMSELF OR HERSELF OR ANYONE ELSE, FOR
THAT MATTER. |

49
BUT REDEMPTION IS FAR FROM ASSURED. THE

ESSEN/7 1. Aq too VO
MORTALITY RATE FOR AIDS IS R

 

ALSO, AFTER HEARING AND SEEING SEVERAL YEARS'
WORTH OF INTENSIVE PUBLIC EDUCATION ON THE SUBJECT,

THE AMERICAN PEOPLE MAY NOT BE INCLINED TO BE
FORGIVING AND COMPASSIONATE WITH SOMEONE WHO --76 D&Y:
TODAY -- ENGAGES IN CASUAL, UNPROTECTED ANAL
INTERCOURSE OR WHO SHOOTS ILLEGAL DRUGS WITH A

USED, AIDS-INFECTED NEEDLE AND CATCHES AIDS.

30
I HAVE BEEN PREACHING AND TEACHING THAT WE
MUST FIGHT THE DISEASE OF AIDS ... NOT THE PEOPLE WHO
HAVE IT.

AND I STILL BELIEVE THAT HAS TO BE OUR ATTITUDE.

BUT I'M ALSO A REALIST AND I DON'T SEE THE
AMERICAN PEOPLE BEING ABLE TO KEEP THAT
DISTINCTION CLEAR IN THEIR MINDS FOR MUCH LONGER.

THE COST TO THE AMERICAN TREASURY IS ALREADY

BEGINNING TO MOUNT WELL BEYOND ANYTHING WE COULD
HAVE IMAGINED 2 OR 3 YEARS AGO.

51.
THE AVERAGE ANNUAL COST FOR THE CARE OF A
SINGLE PERSON WITH AIDS RANGES FROM $40,000 TO
OVER $100,000, DEPENDING ON WHAT YOU INCLUDE IN
THE COMPUTATION AND WHETHER YOU ARE ON THE WEST
COAST OR THE EAST COAST. IF YOU TAKE THE MEAN
COST, MULTIPLY IT BY THE CURRENT ANNUAL CASELOAD
OF 33,000 PATIENTS, YOU COME UP WITH A THEORETICAL
COST OF PATIENT CARE THIS YEAR THAT COULD EXCEED $2
BILLION. —

52
AND THIS IS TERMINAL CARE FOR SOME INDIVIDUALS
WHO, DESPITE PUBLIC ADVICE NOTICE TO THE CONTRARY,
CHOSE TO DO SOMETHING RISKY. THEY GAMBLED ... AND

LOST.

SO THE COST OF COMPASSION WITHOUT REDEMPTION
IS ALREADY VERY HIGH -- AND IT CAN ONLY GET HIGHER
UNTIL WE FIND A VACCINE. BUT, .
WE ARE STILL SEVERAL YEARS -- MAYBE
A DECADE -- AWAY FROM THE DEVELOPMENT AND |
RELEASE OF AN AIDS VACCINE.

33
I BELIEVE IT IS ABSOLUTELY ESSENTIAL THAT WE
LOOK AT THIS PROBLEM WITH CLEAR EYES ... AND THEN,
WITH THE SAME CLEAR EYES, PUT ASIDE OUR NATURAL
INSTINCTS TO BE VINDICTIVE OR HOLIER-THAN-THOU OR
TO SAY "I TOLD YOU SO" AND, INSTEAD, PURSUE THE
TRADITIONAL, NON-JUDGMENTAL AMERICAN COURSE OF
PUBLIC HEALTH CARE.

I BELIEVE THAT MAY TURN OUT TO BE THE AIDS

MESSAGE OF THE 90'S. AND I DON'T ENVY ANYONE WHO
HAS TO DELIVER IT.

54
THIS BURDEN UNFORTUNATELY, WILL FALL MOST
HEAVILY UPON THE LEADERSHIP OF THE BLACK
COMMUNITY, WHERE THE SHARPEST AND MOST ALARMING
INCREASES IN AIDS CASES ARE BEING REPORTEDSDIRECT
RESULTS -- I SHOULD ADD -- OF THE DRUG EPIDEMIC IN
THAT SAME COMMUNITY. 1 CAN ONLY HOPE AND PRAY
THAT AMERICAN BLACKS WILL HAVE LEARNED FROM THE
EARLY EXPERIENCE OF THE HOMOSEXUAL COMMUNITY AND
NOT POLITICIZE THE ISSUE. IN PUBLIC HEALTH MATTERS,
POLITICAL POSTURING COSTS LIVES ... IT DOES NOT SAVE
THEM. |

55
   

THE BATH-

 
  
   

THE POLITICAL CAMPAIGN TO KEEP O

CHICAGO THAT THE BLACK COMMUNITY WAS THREATENED
BY AIDS B USE JEWISH DOCTORS WERE INJECTING THE

TO BLACK CHILDREN.

THE GOOD SENSE AND GOOD HEART OF THE AMERICAN
PEOPLE -- OF ALL THE AMERICAN PEOPLE -- MUST BE
APPEALED TO AND MOBILIZED FOR THE REMAINING YEARS
THAT THIS AGGRESSIVE AND VICIOUS DISEASE
SURVIVES AMONG US.

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THANK YOU You THania oor UAdFER-~

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