AIDS lecture December 1, 1988
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          Address
          BY
    C. Everett Koop, MD, ScD
      Surgeon General
           Of the
     U.S. Public Health Service
U.S. Department of Health and Human Services

Presented to the Harvard AIDS Institute
   Boston, Massachusetts
    December 1,1988

It had been sixteen days since I had last spoken to public audience on the epidemic of AIDS.

This was a tough assignment. The requested subject of my remarks was "Setting Priorities and
Developing Policies for the Next Decade". I was part of a very full schedule, a joint meeting,
which included the American Foundation for AIDS research, the American Society of Law and
Medicine, the American Public health Association, the Harvard School of Public Health and the
AIDS Institute, the American Hospital Association, and many, many others.

This may be one of the more important lectures I ever gave - considering the audience - because
it stated the primacy of public health and fit AIDS into the public health picture, not making it
law unto itself.

I started off with a disclaimer of not being especially knowledgeable in public health financing,
or in virology, or in modalities in patient care for people with AIDS. Even though I would be
prudent and leave those kinds of issues to the outstanding speakers and panelists to follow that
day and the next, I still was somewhat awed by the enormity of the implications of the title of my
talk.

Even though one might think that the substance of my title might best be presented by a
consensus statement at the end of such a meeting, I chose to deal with a more general approach
to the matter, speaking as the Surgeon General from the very special perspective of that office.
A perspective that may be particularly important this time, in the brief, but catastrophic history
of the AIDS epidemic.

I wanted to focus on the position of the AIDS epidemic relative to the many other public health
matters on our national agenda - not easy to do, because the health and well being of so many
millions of people was at stake -- right across the board.

Also, to my mind, at least, while the American people were quite aware of AIDS, they had not
given a clear signal to indicate what they wanted to do about it. That meant that those of us in
public health tended to fall back on our own predispositions for ultimate guidance. The question
becomes: "How do I feel about the AIDS epidemic and what do I think ought to be done about


it?" I recognized that this was not the most stable situation for "setting priorities" after
"developing policies" for the handling of this epidemic.

If there is no clear signal from the public about the AIDS epidemic, that doesn't mean we were
operating in a kind of social and medical limbo. Strictly speaking, the goal of the Public Health
Service is to help, in concert with the private sector, to protect and improve the health of the
nation. The Public Health Service does this with the private sector, by developing policies,
setting priorities, and guiding implementation, in order to assure the delivery of reasonable care
at reasonable cost to prevent illness and disease. The public health community also sees the role
of the Public Health Service in that way, although in earlier times they may have taken a much
broader view.

Let's look at priorities. The first national priority in public health is to protect and improve the
health status of all pregnant women, nursing mothers, and infants through their first year of life.
This has been true for decades. We ought to be so concerned, because child bearing and delivery
is a phenomenon that occurs close to 4 million times a year in our society. Next, we have to be
concerned about the long-term problems of hundreds of thousands of our people who live their
lives under great and irreversible stress, both physical and mental. So, it is an appropriate
national commitment.

For example, if we honor our debts to maternal and child health, we are prepared to care for the
pregnant woman with AIDS and her child, who has a good chance of being infected also. We are
doing that. My concern is can we make sure we will do it in the future? What I was trying to
say, was that we could best try to maintain or improve our level of effort in regard to maternal
and pediatric AIDS by maintaining or improving our overall national commitment to maternal
and child health. They are inseparable. That meant we would do the job in both human and
fiscal terms.

At times some people have raised arguments against providing such care. Baby Doe is an
example. But their arguments were defeated. As a civilized, post-industrial society we will care
for mothers and babies with AIDS. We do so not because they have AIDS or any other disease,
but because they are mothers and children.

Our second national priority, on which there is universal agreement, is to provide for our elderly
citizens whatever health and medical care they require. Although there is much debate about this
priority, please note that at least for the moment, the American people aren't debating whether
they should or should not provide such care. The current debate revolves almost exclusively
around how to pay for such care without in any way compromising our commitment to provide
it.

Our commitment to the elderly means it is a commitment even if they have one, two or more
chronic conditions, whether they are disabled or not, whether or not the elderly person is a
member of a minority group or a majority group. This commitment requires that we care for the
older person who is terminally ill.


Such a consensus, we seem to be saying, is further evidence of our compassion and generosity as
an advanced civilization. I believe the American people have agreed on an overall commitment
to ease the burden of terminal illness for the individual and for his or her family. That means the
over-arching commitment will provide care for terminally ill persons with AIDS. The key to
both of the above major priorities is research. And I think we are generally committed to a
strong and innovative biomedical research program.

I decided to stop right there, not thinking I had to go through the whole gamut of health and
medical issues to make my central point, which was this: we can best strengthen all our AIDS
research and patient care, if we recognize the relationship of those efforts to what we are already
committed to in health and medical care. In other words, we must not isolate our efforts in AIDS
Corn the mainstream of public health and medicine, despite the many temptations to do so. It is
important. We hold all we do about AIDS to the same ethical standards we apply to public
health and social relationships in general. It's important that we not plead that AIDS somehow
belongs outside the accepted universe of major national public health concerns. It's important
that we deal with this epidemic within a strengthened framework of overall public health
policymaking and priority setting

I was pleased at what I said at this lecture and pleased with the response of the audience. I was
pleased because I was saying what I thought a Surgeon General should say and I thought the
public was responding to the public health commitment that the Surgeon General represented for
the Public Health Service of the United States. Much of the debate I had was with myself and
was philosophical and for that reason there will be no index.

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