ORIGINAL

ADDRESS

BY

C, EVERETT KOOP, MD, ScD
  SURGEON GENERAL

       OF THE

    U, S, PUBLIC HEALTH SERVICE
UI S, DEPARTMENT OF HEALTH AND HUMAN SERVICES

PRESENTED TO THE ANERICAN SOCIETY OF HOSPITAL PHARMACISTS
           ATLANTA, GEORGIA
          DECEMBER, 7, 1987


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(GREETINGS TO HOSTS, FRIENDS, COLLEAGUES, ETC,)

  I'M DELIGHTED TO JOIN YOU AT YOUR MIDYEAR CLINICAL MEETING,

YOURS IS A VITAL PROFESSION WITHIN THE CONTEXT OF CONTEMPORARY

HEALTH CARE IN AMERICA, I REALIZE THAT I HAVE NOT HAD MANY

OPPORTUNITIES TO SPEAK WITH PHARMACISTS DURING THE TIME I'VE BEEN

YOUR SURGEON GENERAL,

  SO THIS IS A SPECIAL OCCASION AND A SPECIAL OPPORTUNITY FOR

ME-AND, I HOPE, FOR US BOTH,

  BUT I'M A LITTLE UNCOMFORTABLE ABOUT BEING SURROUNDED BY SO

MANY PHARMACISTS  I AM REMINDED OVER AND OVER AGAIN HOW MUCH THE

PEOPLE OF THIS COUNTRY TRUST YOU,


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YOU'RE RIGHT UP THERE NEXT TO THE CLERGY,

  AND I SUSPECT THAT IN THE MINDS OF SOME PEOPLE OF LATE, YOU

MIGHT COME OUT EVEN BETTER THAN THE CLERGY,

AS A FORMER PRACTICING SURGEON, I DON'T KNOW WHERE I AND MY

COLLEAGUES IN MEDICINE COME IN THOSE PUBLIC OPINION POLLS,

  BUT IF ANY OF YOU u KNOW, J'D CONSIDER IT A GREAT KINDNESS IF

YOU JUST DIDN'T TELL ME,

  I SUSPECT ONE REASON PEOPLE ARE FOND OF PHARMACISTS IS THAT

THEY REALLY KNOW YOU,
     YOU TALK TO THEMmYOU ANSWER THEIR QUESTIONS

,,,YOU MAKE EYE CONTACT AND "SMILE CONTACT,"


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AND ALL THAT IS PROBABLY AS IMPORTANT A PART OF MODERN-DAY

HEALTH CARE AS ANTIBIOTICS AND HEART TRANSPLANTS,

MAYBE EVEN MORE IMPORTANT,

AT ANY RATE, I LOOK UPON THE PHARMACIST'S CONTRIBUTION AS BEING

CRUCIAL TO THE ACHIEVEMENT OF QUALITY HOSPITAL-BASED HEALTH CARE IN

THE UNITED STATES,

  THAT SYSTEM OF HEALTH CARE HAS MET A MULTITUDE OF CHALLENGES IN

THE PAST,  IT HAS WEATHERED THEM ALL, THANKS TO PHARMACISTS AND YOUR

COLLEAGUES WHO PROVIDE QUALITY PATIENT CARE DAY-BY-DAY, YEAR AFTER

YEAR,


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BUT LET'S NOT GET SMUG ABOUT IT BECAUSE ONE OF THE MOST

DIFFICULT CHALLENGES WE'VE EVER FACEDmIS FACING US RIGHT NOW,

AND THAT CHALLENGE IS THE CHALLENGE OF AIDS,

  I'M SURE YOU'VE ALREADY HEARD A GREAT DEAL ABOUT THE EPIDEMIC

OF AIDS -- ESPECIALLY THE BIOMEDICAL INFORMATION -- SO I'VE CHOSEN
TO SPEND THE NEXT FEW MOMENTS SHARING WITH YOU A NUMBER OF OTHER,
JjQ&MEDICAL CONCERNS THAT HAVE BEEN BROUGHT TO MY ATTENTION, AS I
HAVE TRAVELED ABOUT THIS COUNTRY AND ALSO OVERSEAS,


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  THEY MAY BE NON-MEDICAL, BUT I THINK YOU WILL AGREE THAT THEY

STRIKE AT THE VERY HEART OF THE AMERICAN SYSTEM OF HEALTH CARE

DELIVERY,

  AND, TO MY WAY OF THINKING, THE SCIENTIFIC ISSUES TEND TO PALE,

WHEN COMPARED TO THE HIGHLY SENSITIVE ISSUES OF LAW, ETHICS,

ECONOMICS, MORALITY, AND SOCIAL COHESION THAT ARE BEGINNING TO

SURFACE,

AND TO TELL THE TRUTH, WE MAY ALREADY BE AT A VERY SENSITIVE

STAGE IN REGARD TO THE ETHICAL FOUNDATION OF HEALTH CARE ITSELF,


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  FOR EXAMPLE, DESPITE THE SENSIBLE AND RATHER ELEMENTARY
GUIDELINES FROM THE CENTERS FOR DISEASE CONTROL, WE STILL HEAR --

EVERY DAY -- OF PHYSICIANS, DENTISTS, NURSES, AND OTHER HEALTH
PERSONNEL WHO REFUSE TO TREAT PERSONS WITH AIDS OR EVEN PERSONS WHOM

THEY SUSPECT OF HAVING AIDS,

  THEY SAY THEY ARE AFRAID OF CATCHING THE DISEASE THEMSELVES
WELL, THAT'S CERTAINLY UNDERSTANDABLE, BUT EQUALLY UNDERSTANDABLE
IS THE FACT THAT IT IS VERY UNLIKELY THAT A HEALTH WORKER WILL CATCH

THE DISEASE AT ALL,


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  THUS FAR, OF THE NEARLY 7 MILLION PERSONS IN SOME KIND OF

HEALTH WORK IN THIS COUNTRY, ONLY 8 HAVE CONTRACTED AIDS ON THE

JOB, AND IN ALMOST EVERY CASE, THE INDIVIDUAL SIMPLY DID NOT FOLLOW

THE ROUTINE INSTRUCTIONS FOR SELF-PROTECTION THAT C,D,C, PUBLISHED

OVER A YEAR AGO,

  LET ME QUICKLY ADD THAT THIS REJECTION OF AIDS PATIENTS IS NOT

CHARACTERISTIC OF HEALTH PROFESSIONALS BY ANY MEANS, ON THE

CONTRARY, THE OVERWHELMING MAJORITY OF OUR COLLEAGUES HAVE PROVIDED

-- AND CONTINUE TO PROVIDE -- QUALITY, COMPASSIONATE CARE TO PERSONS

WITH EVERY KIND OF ILLNESS,,,INCLUDING AIDS,


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  AND I WANT TO TAKE SPECIAL NOTE OF THE RECENT POLICY STATEMENT
BY THE AMERICAN MEDICAL ASSOCIATION ON THIS VERY ISSUE, THE A,M,A,

STATED IN UNEQUIVOCAL LANGUAGE THAT IT EXPECTED THE MEMBERS OF THE

MEDICAL PROFESSION TO LIVE UP TO THEIR OATH AND PROVIDE CARE TO

THOSE WHO REQUIRE IT, PERIOD,

  BUT THE GOOD CONDUCT OF THE MAJORITY DOES NOT IN ANY WAY

RELEASE US FROM FACING THE UN-PROFESSIONAL CONDUCT OF A FEARFUL AND

IRRATIONAL MINORITY,

  WHAT SHOULD WE DO ABOUT IT? THAT'S AN IMPORTANT QUESTION,

BECAUSE HEALTH CARE IN THIS COUNTRY HAS ALWAYS BEEN PREDICATED ON

THE ASSUMPTION THAT -- SOMEHOW -- EVERYONE WILL BE CARED FOR AND m

ONE WILL BE TURNED AWAY,


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  AS A PHYSICIAN AND AS AN AMERICAN, I'M PROUD TO BE PART OF A

TRADITION OF CARE THAT WILL NOT ABANDON THE SICK AND THE DISABLED..,

WHOEVER THEY ARE,

  HENCE, I REGARD AS VERY SERIOUS INDEED THOSE REPORTS OF A FEW

PHYSICIANS, DENTISTS, AND EVEN HOSPITALS WITHHOLDING CARE FROM

PERSONS WITH AIDS, SUCH CONDUCT THREATENS THE VERY FABRIC OF HEALTH

CARE IN THIS COUNTRY,

BUT THIS ISSUE HAS YET ANOTHER WRINKLE TO IT,

  SOME HOSPITALS WELL-KNOWN FOR TAKING IN AND CARING FOR AIDS

PATIENTS ARE NOW BEING AVOIDED BY MANY MEDICAL AND NURSING STUDENTS

LOOKING FOR RESIDENCIES, INTERNSHIPS, OR OTHER WAYS TO COMPLETE

THEIR PROFESSIONAL TRAINING,


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  IN ADDITION, MANY U-AIDS PATIENTS -- ESPECIALLY THOSE WITH

GOOD INSURANCE COVERAGE -- ARE ASKING THEIR PHYSICIANS TO CHECK THEM

INTO HOSPITALS THAT DO NOT HAVE MANY -- OR ANY -- AIDS PATIENTS,

   THIS IS A SERIOUS MATTER BECAUSE THE ACTUAL, DIRECT IMPACT OF

AIDS THUS FAR ON OUR HOSPITAL SYSTEM HAS BEEN QUITE SMALL, ,,BUT THE

INDIRECT IMPACT CAN BE HUGE,n,DISPROPORTIONATELY SO,

IT IS THE KIND OF IMPACT THAT COULD WELL LEAD TO THE DEVELOP-

MENT OF DE FACTO "MEDICAL GHETTOS" FOR AIDS PATIENTS,

HOW CAN WE PREVENT THAT FROM HAPPENING? WE ALL NEED TO WORK ON

SOME ANSWERS TO THAT QUESTION BEFORE THIS DEADLY AIDS VIRUS FURTHER

WEAKENS THE ETHICS OF MEDICAL PRACTICE IN THE UNITED STATES,


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  NATURALLY, WE ALL HOPE THAT THIS KIND'OF PROBLEM CAN BE BROUGHT

UNDER CONTROL BY THE HEALTH PROFESSIONS THEMSELVES, BUT THAT ISN'T

HAPPENING, SOME PROFESSIONAL ASSOCIATIONS ARE PROVIDING GUIDANCE

FOR THEIR MEMBERSwBUT MOST ARE NOT,

  THEREFORE, THE DEPARTMENTS OF LABOR AND OF HEALTH AND HUMAN

SERVICES HAVE JOINTLY ISSUED SAFETY GUIDELINES THAT SHOULD BE

FOLLOWED BY HEALTH WORKERS AND BY HEALTH FACILITIES, IN ORDER TO

REDUCE THE POSSIBLITY OF ON-THE-JOB INFECTIONS FROM EITHER AIDS OR

HEPATITIS Bm

THE FULL NOTICE WAS IN THE OCTOBER 30 ISSUE OF THE THE FEDERAL

REGISTER, IN CASE ANY OF YOU MISSED IT,


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WE HOPE FOR TWO OUTCOMES FROM THIS JOINT PROGRAM:

FIRST, OF COURSE, IS TO PROTECT HEALTH-CARE PERSONNEL FROM

ACCIDENTAL INFECTION,

SECOND, WE HOPE TO CONVINCE HEALTH WORKERS THAT THEIR FEARS OF

BEING AT "HIGH-RISK" ARE SIMPLY UNFOUNDED AND, THEREFORE, THEY

HAVE NO BASIS FOR SHUNNING AIDS PATIENTS,


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  AS YOU KNOW, THIS ADMINISTRATION HAS TENDED NOT TO RELY ON

REGULATIONS AND ENFORCEMENT ACTIVITIES, UNLESS THE SITUATION HAS

CLEARLY WARRANTED IT,

  AS FAR AS AIDS IS CONCERNED -- AND IN PARTICULAR THE ROLE OF

HEALTH CARE WORKERS IN THE TREATMENT OF AIDS PATIENTS -- THAT TYPE

OF SITUATION HAS ALREADY ARRIVED, THAT'S WHY WE'VE HAD TO MOVE IN

THIS MANNER,

  THE FEDERAL REGISTER NOTICE, BY THE WAY, ALSO CONTAINS A GREAT

DEAL OF VALUABLE, UP-TO-DATE BACKGROUND DATA ON THE AIDS EPIDEMIC,

SO, FOR A VARIETY OF REASONS, I URGE EACH ONE OF YOU TO GET A COPY

AND READ IT ALL THE \iAY THROUGH,


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  BUT WE'VE HAD REGULATIONS BEFORE TO DEAL WITH OTHER DIFFICULT

ISSUES IN HEALTH CARE, AND WE KNOW THAT, BY THEMSELVES, REGULATIONS

DON'T GET THE JOB DONE, THE ONLY THING THAT WILL REALLY WORK IN

THIS CURRENT SITUATION IS FOR EVERY HFALTH PROFESSIONAL TO BECOME

RE-COMMITTED TO THE PRINCIPLE OF "QUALITY CARE FOR EVERYONE/'

IF WE CAN'T DO THATwWE'RE GOING TO BE IN WORSE TROUBLE THAN

WE ALREADY ARE,

A RELATED ISSUE IS THE COST OF CAREwAND IT'S AN ISSUE THAT I

KNOW IS WORRYING MOST OF YOU RIGHT NOW,


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  I'M TOLD THAT THE TOTAL COST OF CARING FOR AIDS PATIENTS IS NOW

RUNNING AT A RATE OF ABOUT $2 BILLION A YEAR, THE JOURNAL OF THE

AMERICAN MEDICAL ASSOCIATION JUST PUBLISHED A STUDY INDICATING THAT

THE AVERAGE IN-PATIENT COST PER AIDS PATIENT PER YEAR IS $20,320,

  BY 1991, WE ANTICIPATE THE ANNUAL BILL TO CARE FOR AIDS

PATIENTS WILL RANGE ANYWHERE FROM A LOW OF $8 BILLION TO A HIGH OF

$16 BILLION,

WHO SHOULD PAY THAT BILL?

RIGHT NOW, THE AMERICAN TAXPAYER IS COVERING ABOUT 25 PERCENT

OF THAT COST, POSSIBLY MORE, IS THAT FAIR?


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  WE BELIEVE IT IS, BASED UPON OUR PAST NATIONAL EXPERIENCE, THE

AMERICAN TAXPAYER, AFTER ALL, HAS SUPPORTED HEALTH PROGRAMS FOR

ALCOHOLICS, DRUG ADDICTS, SYPHILITICS, AND OTHERS WHO HAVE BEHAVIOR-

BASED ILLNESSES.

  BUT THOSE PROGRAMS HABEN'T VERY EXPENSIVE,, ,THEY CERTAINLY

DON'T ADD UP TO $8 BILLION, IN ANY CASE, BUT, IN ADDITION, SUCH

PUBLIC HEALTH PROGRAMS ARE GEARED TO BRING -- OR TO BRING BACK --

MEN, WOMEN, AND CHILDREN TO A STATE OF GOOD HEALTH,

BUT AIDS IS A DIFFERENT STORY, HEALTH AND MEDICAL CARE FOR

AIDS PATIENTS IS VERY EXPENSIVE,


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  AND WHAT'S THE OUTCOME? AFTER CONSUMING ONE, T\FJO, OR THREE

YEARS' WORTH OF COSTLY MEDICAL CARE AND SOCIAL SERVICESwTHE AIDS

PATIENT DIES,

  NOW, LET'S LOOK AHEAD, AS THE AIDS CASE-LOAD CLIMBS AND THE

COSTS RISE, WILL THE AMERICAN PEOPLE CONTINUE TO PUT UP THE MONEY

FOR PATIENT CARE? OR WILL THEY ASK FOR RELIEF?

WILL THEY STILL EXPECT THE BEST POSSIBLE CARE FOR EVERYONE? OR

WILL THEY SUPPORT ONLY SECOND-CLASS CARE FOR AIDS PATIENTS?

  THESE ARE VERY TROUBLING QUESTIONS, THIS IS "THINKING THE

UNTHINKABLE" AND "SPEAKING THE UNSPEAKABLE,"


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BUT, FOR THE SAKE OF THE FUTURE OF AMERICAN HEALTH CARE, THAT'S

WHAT WE'VE GOT TO BEGIN DOING,,,AND RIGHT AWAY,

  ANOTHER ISSUE THAT HAS COME UP FAST OVER THE PAST YEAR OR SO IS

THE ISSUE OF INDIVIDUAL PRIVACY VERSUS THE NEED TO PROTECT THE

COMMUNI'TY FROM DANGER,

NEITHER SIDE OF THIS EQUATION REQUIRES AN ABSOLUTE RESPONSE,

LIFE ISN'T A BLACK-OR-WHITE GAME ANYWAY,

BUT, AS A FREE YET RESPONSIBLE PEOPLE, HOW MUCH LEEWAY DO WE

REALLY HAVE?


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  ANOTHER WAY OF PUTTING THAT IS TO ASK, "HOW MUCH RISK CAN THE

COMMUNITY TOLERATE IN ORDER TO PRESERVE THE RIGHTS OF INDIVIDUALS?"

THIS, OF COURSE, IS THE HEART OF THE DEBATE OVER CONFIDENTI-

ALITY IN RECORDS,

  AS YOU ALL KNOW, THE PROMISE OF CONFIDENTIALITY HAS BEEN A

LONG-STANDING PRACTICE IN PUBLIC HEALTH WORK, IT HELPS US GET A

GREAT DEAL OF SENSITIVE, HEALTH-RELATED INFORMATION FROM THE

INDIVIDUAL,

  WITHOUT THIS SYSTEM OF CONFIDENTIALITY THIS COUNTRY WOULD NEVER

HAVE SUCCEEDED IN CONTAINING MOST INFECTIOUS DISEASES, AS WE HAVE

DONE,


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  IT'S CERTAINLY NOT A NEW CONCEPT EITHER, SOME 2,400 YEARS AGO,

THE GREEK PHYSICIAN, HIPPOCRATES, WROTE THE FIRST OATH FOR

PHYSICIANS, IN WHICH HE SAID,,,

"WHATEVER, IN CONNECTION WITH MY-PROFESSIONAL PRACTICE, OR NOT

IN CONNECTION WITH IT, I SEE OR HEAR, IN THE LIFE OF MEN, WHICH

OUGHT NOT TO BE SPOKEN OF ABROAD, I WILL NOT DIVULGE, AS

BELIEVING THAT ALL SUCH SHOULD BE KEPT SECRETmu"

  HIPPOCRATES MAY NOT HAVE KNOW ABOUT AIDS, BUT THEY HAD PLENTY

OF OTHER DISEASES IN ANCIENT GREECE THAT HAD THE SAME

CHARACTERISTICS AS AIDS,  THEY ALSO WERE MYSTERIOUS, FATAL, AND
RESISTANT TO THE CRUDE THERAPY AND PREVENTION REGIMENS OF THE DAY,


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  PUBLIC HEALTH PERSONNEL BELIEVE THAT THE ASSURANCE OF TOTAL

CONFIDENTIALITY IS THE KEY TO HAVING POTENTIAL AND ACTUAL CARRIERS

OF THE AIDS VIRUS PRESENT THEMSELVES FOR VOLUNTARY TESTING AND

COUNSELING,

  HOWEVER, IN RESPONSE TO STRONG APPEALS BY THEIR OWN STAFFS, A

NUMBER OF HOSPITALS ARE ALREADY ROUTINELY TESTING PATIENT BLOOD FOR

THE PRESENCE OF THE AIDS ANTI-BODIES, THAT'S OKAY,, aAND THERE IS

LEGAL PRECEDENT FOR DOING THIS,

   BUT NOT ALL HOSPITALS THAT ARE TESTING HAVE ALSO INDICATED THAT

THEY CAN SCRUPULOUSLY HONOR THE NEED FOR CONFIDENTIALITY OF THE

BLOOD TEST RECORDS, AND THAT WOULD APPEAR TO BE A SERIOUS BREACH OF

TRUST WITH THE PUBLIC,


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  WE MUST INDICATE TO THE PUBLIC THAT WE ARE CONCERNED ENOUGH

ABOUT ALL OUR CITIZENS TO WANT TO TAKE BLOOD TESTSwBUT WE'RE ALSO

CONCERNED ENOUGH ABOUT FACH ONE OF OUR CITIZENS TO MAKE THE RESULTS

OF THOSE TESTS ABSOLUTELY SECURE, AVAILABLE ONLY ON A VERY NEED-TO-

KNOW BASIS,

  THE PRESIDENT AND HIS ADMINISTRATION DO NOT SUPPORT A FEDERAL

LAW ON CONFIDENTIALITY, WE BELIEVE THIS IS ESSENTIALLY A STATE

RESPONSIBILITY, AND I SUSPECT THAT MOST OF YOU WOULD AGREE, AFTER

ALL, YOU ARE LICENSED BY YOUR STATES AND YOUR CODE OF PROFESSIONAL

CONDUCT IS ENFORCED BY YOUR STATES,


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BUT NOT ALL STATES HAVE DONE ANYTHING ABOUT IT YET, uAND OF

THOSE THAT HAVE, THE LAWS ARE FAR FROM UNIFORM,

  SO THIS IS A LEARNING PERIOD FOR ALL OF US, THAT'S HARDLY A

GOOD ANSWER FOR SOMEONE WHO TESTS SEROPOSITIVE AND THEN IS FIRED

FROM A iJOB, SENT HOME FROM SCHOOL, EVICTED FROM HOUSING, OR LOSES

INSURANCE BECAUSE THE TEST RESULTS WERE LEAKED,

  SO WE'VE GOT SOME SERIOUS THINKING TO DO ON THIS MATTER AS

WELL, AND WE HAVE TO GET ON WITH IT, BECAUSE SOME OF OUR CITIZENS

ARE NOT WAITING,


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  AS MANY OF YOU KNOW, A HALF-MILLION CALIFORNIANS HAVE SIGNED A

PETITION AND NOW HAVE A PLACE ON THE BALLOT NEXT NOVEMBER FOR A

REFERENDUM THAT, IF PASSED, WILL REQUIRE PHYSICIANS AND OTHER HEALTH

PERSONNEL TO REPORT TO THE STATE THE NAMES OF PEOPLE WHO ARE

SEROPOSITIVE,

  IF SUCH A REFERENDUM SHOULD GAIN A MAJORITY OF THE VOTES CAST,

WE WILL SEE A VERY DIFFERENT KIND OF PUBLIC HEALTH PRACTICE IN

CALIFORNIA FROM WHAT WE'VE SEEN SO FAR,

  I HOPE AND PRAY THAT THE PEOPLE OF CALIFORNIA AND ELSEWHERE

WILL DEAL WITH THE AIDS ISSUES IN A MORE RATIONAL WAY,,,ONE THAT IS

MORE CONSISTENT WITH AMERICAN TRADITIONS AND VALUES,


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  BUT HOPES AND PRAYERS MAY NOT BE ENOUGH, WE WILL NEED

COURAGEOUS LEADERSHIP AT ALL LEVELS OF GOVERNMENT AND THROUGHOUT OUR

SOCIAL, POLITICAL, AND PROFESSIONAL INSTITUTIONS TO REINFORCE THOSE

HOPES AND PRAYERS,

HOW CAN YOU,,,AND I-AND EVERY AMERICAN INSURE THAT THIS BE

DONE?

  PRESIDENT REAGAN HAS SAID THAT WE MUST COME TOGETHER TO FIGHT

THIS DISEASE WITH EVERYTHING AT OUR COMMAND,  BUT WE MUST NOT FIGHT

THE PEOPLE WHO HAVE IT,


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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,

  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, 200-YEAR-OLD SOCIETY WE PROFESS TO BE,

  IF WE DO, WE MAY GIVE THE WORLD SOMETHING EVERY BIT AS PRECIOUS

AS THE MUCH-DESIRED AIDS VACCINE:

WE WILL SHOW THE WORLD HOW COMPASSION AND JUSTICEmIN ADDITION

TO FIRST-CLASS SCIENCEmCAN TRIUMPH OVER THIS MYSTERIOUS, FATAL

DISEASE,

ONCE AGAIN a, ,THANK YOU,, ,AND BEST WISHES FOR THIS MEETING,

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