PUBLIC HEALTH AND PRIVATE LIVES BY c. EvEREl[T KOOP, MD A RESPONSE ON RECEIVING THE COSMOS CLUB AWARD 1989 COSMOS CLUB WASHINGTONDC OCTOBER 19, 1989 I WANf'TOTHANKYOUFORTHEHONOR OFRECEMNGTHE COSMOS CLUB AWARD. AS YOU MAY KNOW BY NOW, I AM PRECISELY ON THE 19TH DAY OF MY LIFE IN THE PWATE SECTOR,....WHEEtEIPLAN?Y)CONTINUEMYCONCEEtNSASA PUBLIC SERVO, PUBLIC SERVICE, FOR SOME OF US, IS A / REWARD IN ITSELF. BUT FOR ME, PUBLIC SERVICE, WITH THE APPRECIATION AND GRATITUDE I HAVERECEIVED FROM THE PUBLIC, IS ALSO SOURCE OF HUMILITY AND DEEP PERSONAL SATISFACTION. TONIGHT, THEN, I'D LIKE TO TALK ABOUT THE EXPERIENCES OF CITIZEN C. EVERETT KOOP, AS HE PARTICIPATED INONECO- OFTHEAMERrCANNATIoNALGO- OVER THE PAST 8 YEARS. - BUTLEI'MEWARNYOUTHATTHISWILLNOTBEANEVENING OF "KISS-AND-TELL." I DON'T FIND THAT BEHAVIOR TO MY TASTE AT ALL. ALSO, AS A PRACTICING SURGEON FOR NEARLY 40 YEARS, I STILL CARRY THE INGRAINED HABIT OF NOT VIOLATING THE CONFIDENCES OF A PATIENT. NOT THAT EVERYONE IN WASHINGTONREQUIRES SPECIAL CARE . . . WELL, CERTAINLY NOT EVERYONE BUT L;ET ME BEGIN. FIRST, I MUST TELL YOU THAT THE PRMLEGEOFBEINGSURGEONGENERAL HAS BEEN THE MOST DEMANDING AND MOST EXCITING POSITION I HAVE EVER HELD. I AM STILL GRATEFUL TO PRESIDENT REAGAN FOR HAVING NOMINATED ME IN 1981 AND FOR HIS UNOMXNATION OF ME IN 1985. YOUMAY REMEMB ER, I'M SURE, THAT MY NOMINATION WAS NOT WITHOUT SOME CONTROVERSY, WHICH IS PUTrING IT AS DELICATELY AS I CAN. /6 PRIVATE LIFE I HAD BEEN AN CiUTSPOKEN PERSON WITH VERY STRONG OPINIONS ON IMPORTANT ISSUES. AND THESE OPINIONS -- A&D MY AGE, 65 -- WERE USED AS ARGUMENTS AGAINST MY BEING THE COUNTRY'S SURGEONGENERAL. THECONGRESSANDMANYPEOPLE . . ACROSS THE COUNTRY DEBATED THESE MATTERS FOR ABOUT 8 MONTHS. BUT_IDID, TOO. I ASKED MYSELF IF I SHOULD -- OR COULD -- VOW TO BE A CHANGED PERSONINORDERTO GAINTHE SENATE'S APPROVAL. SHOULD I, FOR EXAMPLE, DEPOSIT MY RELIGIOUS BELIEFS JN ABLIND TRUST? SHOULD I DONATE MY MORAL VALUES TO SOME WORTHY CHARITY? BEFORE MOVING To WASHINGTON, SHOULD I PACK AWAY MYETHICSINANATI'ICTRUNK? AND I SAID, "NO . . . NONE OF THE ABOVE." I TRULY BELIEVED THEN -- AND I BELIEVE NOW -- THAT THE BEST APPROACH YOU CAN MAKE TO PUBLIC SERVICE IS TO PROMISE TO GIVE IT EVERYTHING YOU HAVE . . . OF WHATEVER IT IS YOU Do HAVE . . . TO DRAWTOTHEFULIJ3ST IZTENT FROM YOUR OWN STOREHOUSE OF KNowL;EDGEAND PERSONALLFEEXPERIENCE . . . AND TO SQUEEZE OUTEVERYOUNCEOFGOOD JUDGMENT OF DEEP FELLOW FEELING, AND OF LxlvE OF COUNTRY. AS I SAY, THAT WAS MY APPROACH AND I THINK IT WAS AND IS THERIGHT ONE. BUT. IT DOESN'T MAKE THE ASSIGNMENT ANYEAS ""/ ON THE CONTRARY, THIS APPROACh MERELY MADE MEMORE~TOTHENEWINFORMATIONTHATIWOULDBE /wmtBING IN THIS POSITION. LKEMANYOTHERSWHOAREC~TOWASHING'ION,I TOOFELTGREATPRlDE~BE~GABLETOS~~MYCOUNTRY... AND I TOO HAVE BEEN FOR- TO DISCOVER THINGS ABOUT MYSELF~~~~YTHATIDIDNOT~YUNDERSTAND UNTIL THIS EXPERIENCE. AND THA?*S PROBABLY THE PREMISE OF MY REMARKS TONIGHT: THATGOVERNMENT SEEtVICEFORCESYOUTOKNOW MORETHANYOU~KNOW-EVENMORE'THANYOUMAY CARE m KNOW - A.BOU'l- THE WAY OUR DEMOCRACY WORKS . . . ABOUT THE MOTIVES, GOOD AND BAD, OF YOUR FELLOW CITIZENS - INCLUDING COLLEAGUES AND CLOSEFRIENDS . . . i&D ABOUT YOURSELF. 8 I DO NOT BELIEVE YOU CAN TRULY PREPARE YOURSELF FOR THE EXPERIENCE, BECAUSE ID0 NOT BELIEVE YOU CANREALLY PREDICT HOW YOU WILL ACT IN A SITUATION AFFECTING THE LIVES OF A FEW -- OR A FEW MILLION -- TOTAL STRANGERS. ANDINTHEHEADYEXm OFBEINGCALLEDBYTHE PRESIDENT ..m OF BEING FOLLOWED AROUND BY THE PRESS . . . OF LATE-NIGHT CONVERSATIONS WITH POWEKFUL SENATORS AND CONGRESSMEN . . . WHEN ALL THIS IS HAPPENING, YOU CANNOT -- AT THE SAME TIME -- TRULY UNDERSTAND WHAT YOUR JOB IS YOU SA!fPLY DONT KNOW. AND YOU DON'T DARE ASK. IN IHADNOTBEEN P VERNMENT VERY LONG -- LESS THAN 6 MONTHS-~IHADTOCONFRONTTHESEDIFFICULTTRUTHS FOR THE FIRST TIME. THE INCIDENT WAS TRIGGERED NOT BY ANY EXTRAORDINARY EVENT IN WASHINGTON BUT BY A WHAT COUID HAVE BEEN AN QBSCURE EVENT IN BLOOMINGTON, INDIANA. 10 ON APRIL 8,1982, IN BLOOMINGTON HOSPITAL A LITTLE BOY WAS BORN WlTH MULTIPLE CONGENITAL DEFECTS, INCLUDING AN ESOPHAGEAL OBSTRUCI`ION AND DOWN SYNDROME. HE WAS GIVENTHEANONYMOUS AND TEMPORARY NAME OF "BABY DOE" . . . THE NAME, IRONICALLY, BY WHICH HE WILL BE KNOWN FOREVER IN THE MEDICAL AND SOCIAL HISTORY OFTHE UNlTED STATES b OBSTETRICIAN TOLD "BABY DOE'S" PARENTS THAT THE CHILD HAD ABOUT A 50-50 CHANCE OF SURVIVING AN OPERATIONTO CLEAR UP THE OBSTRUCTION. HE FURTHERINFORMEDTHEPARENTSTHATIFHEDIDSURVIVE, `BABY DOE" WOULD PROBABLY GRO$Up S EvEEwLYrnARDED ANDENDUR.EAPOOR"QUALITYOFIJFE." THEPRE%RECORDED THATHEREFERREDTOBABYDOEASA"BLOB". 11 ON THE BASIS OF THAT KIND OF INFORMATION, THE PARENTS OF "BABY DOE" ASKED THAT NO FURTHER MEDICAL ASSISTANCE ORNOURISHMENTOFANYKINDBEGIVENTOTHEIRCHJLD. INTHENEXTFEW DAYS, LOCAL DOCTORS AND SOCIAL SERVICE WORKERS MADEHASTYAPPEALS TOTHECOURTS ON BEHALF OF "BABY DOE" AND THE CASE CAUGHT THEZ ATTENTION OF THENATION- BUT ON APRIL 15, ONE WEEK Ah-`ER HIS BIRTH AND JUST HOURS BEFORE U.S. SUPREME COURT JUSTICE JOHN PAUL STEVENS WAS TO HAVE STEPPED INTO THE CASE, "BABY DOE'DIED. AND HIS CASE BECAME MOOT. 12 ITWASASTUNNIN G EXPERIENCE FOR ME FOR SEVERAL REASONS. DURING MY CAREER AS A SURGEON, I HAD PERFORMED 475 OPERATIONS TO CORRECT ESOPHAGEAL ATRESIA AND I HAD A FAR HIGHER SUCCESS RATE THAN 50-50. DURING THE LAST 8 YEARS THAT I WAS AN ACTIVE SURGEON I NEVER LOST A FULL-TERM BABY WITH THIS DIAGNOSIS AFI'ER SURGERY, AND MY SUCCESS RATEWITHPRFMATUREBABlES WAS 88 PER CENT. OTHEXR PEDJXTRIC SURGEONS, HERJ3 AND THERE,wEREEQumY SUCCESSFUL. YET, AS "SURGEON GENERAL," NO LESS, I WAS NOT ABLE TO DO FOR "BABY DOE" WHAT I HAD DONE FOR HUNDliEDS OF OTHER BABIES WITHTHESAMECOND~ON. 13 ALSO, NO PHYSICIAN -- PEDIATRICIAN OR OTHERWISE -- CANEXAMlNEANlNFANTwITHDOWNSYNDROMEANDPREDICT ~ANYDEGREEOF~T~,WHATSOE~~OWRETARDED THAT CHILD WILLBECOMEOR WHAT IT'S "QUALITY OFLIFE" WILL BE. BEFORE COMING TO WASHINGTON, I HAD MUCH TO SAY -- AND PUBLKIaY -- ABOUT PARENTS WHO GAVE UP ON HANDIC~F'ED CHEDEN. HENCE, I WAS SORELY TEMPIEDTO SPEAK OUT ON BEHALZ OF "BABY DOE" RIGHT IN BLOOMINGTON HOSPITAL, IF NEED BE. 14 BUTI'I'SOONBECAMECLEARTOMETHATITWASPERFECI'LY ALL RIGHT FOR TO BE A PRO-ACTIVE SURGEON GENERAL SPEAKING OUT ON BEHALF OF THE "BABY DOES" OF THIS WORLD . . . BUT WASN'T I ALSO THE SURGEON GENERAL OFTHEIRPARENTS AS WELL? _ AND -- LIKE IT OR NOT --I REMAINED THE COLLEAGUE AND SURGEONGENERAL OFTHEPHYSICIANS INVOLVED, Too, WHETHERORNOTIAGREEDWITHTHEKINDOFADVICESOMEOF THEM WERE GIVING TO THOSE PARENTS. 15 ASITRIEDTOTHINKTHROUGHMYNEWROLElNTHlSVERY SENSITIVE AND HIGHLY EMOTIONAL ISSUE, I KNOW I SURPRISED AND -- I SUSPECT -- DEEPLY DISAPPOINTED MY MANY FRIENDS 3N THE PRO-LIFE MOVEMENT AND IN THE SEVERAL ASSOCIATIONS THAT ARE ADVOCATES FOR HANDICAPPED CHILDREN. TO THEM, I WAS TEMPORIZING AND EVEN ABANDONING THE POSlTIONS I HAD TAKEN FOR MANY YEARS. THEIR CRITICISMS WERE SHARP, BUT UNFAIR. MY PERSONAL FEELINGS HAD NOT CHANGED ONE IOTA. THEY ARE I ESSENTIALLY UNCHANGED TODAY. BUT MY PIJBLIC POSITIC?N DID REQUIRESOMEADDlTIONALTHOUGHT. 16 ODDIX ENOUGH, I WAS NCYJJ RESPONSIBLE FOR THE DRAFI'ING OF THE 0-S FIRST TWO SETS OF "BABY DOE" REGULATIONS, ALTHOUGH I HAD PROBABLY HAD MORE ACTUAL "HANDS-ON' ExpERIENcEwITHsucH~RENANDTHEIR FAMILIESTHANANYONEINAMERICA. 17 I~~TRYTOEXCUSETHOSEWHOKEPTMEOUTBY REMINDING YOU THAT I WAS STILL THE NEWEST "KID ON THE BLOCK," SO TO SPEAK, AND HENCE NOT AUTQMATICArrY BROUGHT INTO MANY OF THESE DISCUSSIONS. THEPUBLICSEEZMEZDToKNOWMORETHANTHEGOvERNMENT. THEY JUST PLAIN ASSUMED THAT WITH MY BACKGROUND, I WAS THE AUTHOR OF THE REGULATIONS. 18 ITHEREFOREBF0lMETHEIJGHTNINGRODFORTHOSEWHO DISAPPROVED OF THE GO -S LIGHTNINGROD IS CONSIDERED TO BE A BADGE OF HONOR ON SOME OCCASIONS, BUT IT WAS PARTICULARLY ONEROUS TO BE BLAMED~RSOMEIHINGOVERWHICHIHADNOCONTROL IRECEIVEDABARRAGEOFCRITICISMFROMTHEMEDICAL PROFESSION, MANY OF WHOM WERE MY COLLEAGUES IN EARLIER BATI'LESINADVOCACYFORCHILDREN. 19 IN ANY CASE, THE DEPARTMENT S INITIAL REGULATIONS WERECHALLENGEDINTHECOURTSANDWERESTRUCKDOwN. A THIRDSETHADTOBEWRITIEN. MARGARET HECKLER WAS THEN THE HH.S. SECREI'ARY. AT ABOuTTHETlMETHECOuRTRuLINGSwEREPuBLISHED, SFCRETARY HECKLER AND I WERE ON AN INSPECTION TRIP OF U.S.-SUPPORTED HEALTH PROJECTS IN THE MIDDLE EAST. DURING A FLIGHT FROM CAIRO TO ATHENS I CON-VINCED HER TO GIVEME THE TASK OF WRITING THE THIRD SEX OF "BABY DOE" REGULATIONS. 20 ~S~TOMETHATWEHADTOSOMEHOWGFTBEYOND THE IMMEDIATE "BABY DOE" EVENT -- AS TRAGIC AND EMOTIONAL AS IT WAS -- AND TRY TO FASHION A GOVERNMENTALRESPONSE, LEGAL AS WELL AS MEDICAL, THAT 21 THE NEWREGULATIONS Sl3OULD LEAD TO THE SAVING OF CHILDREN'S LIVES . . . THEY SHOULD BE UNDERSTOOD AND ACCEPT'ED BY PARENTS . . . AND THEY SHOULD BE CARRIED OUT IN GOOD FAITH BY PHYSICIANS AND NURSES WITH A MINIMUM OF GOVERNMENT OVERSIGHT . . . OR MAYBE NO OVIXSIGHT AT ALL. `lWT'HATEND,IENTERED INTONEGOTIATIONS WITHALL THESE INTERESTED PARTIES . . . ADVOCATES FOR THE HANDICAPPED, PEDWIRICIANS, AND THE PRO-LIFE FORCES. 22 AND FIUNKLY I WAS DISAPPOINTED BY SOME OF THEM WHO CAMEToTHENEGOTlATINGTABLE~L~MORETHANTHEIR OWN CLEAR AND CONSISTENT. IDEOLOGIES IpPUBLIC HEALTH MATTERS, IDEOLOGY MAY BE HELPFUL . . . BUT IT'S NOT ENOUGH. 23 HOWEVER, AS WE HAMMERED AWAY AT THE PROBLEM TOGETHER, THEIR MUTUAL HOSTILITY AND SUSPICION GAVE WAY TO COOPERATION AND TRUST. IN FACT, AT ONE POINT, THEY JOINTLYWROIlMNDSIGNEDONEOFTHEFINESTDOCUMENTSI HAVEEvER%EN,RELATIVETOTHERIGHTS OFHANDICAPPED CHILDREN. IN THAT KIND OF SPIRIT, THEN, I WAS ABLE TO WRITE THE THIRD SEI' OF REGULATIONS. AND, FOR THE TIME THEY WEREONTHEBOOKS,THEYWORKED. 24 I THINK ONE REASONTHEY WORKED WAS THE FACT I USED THE LANGUAGE THAT HAD BEEN HAMMEREDOUI'INPREPARING THEHANDIcAPPEDDOcmmNT BY A GROUP OF PEOPLE -- ALL COMING TO THE ISSUE FROM QUITE DIFFERENT POINTS OF VIEW -- BUT A&LNE~THELESS WILLINGTO PUT ASIDE THEIR SPECIAL PLEADINGINORDEEUODOSOhammG TOGETHER ON BEEIALF OF HANDICAl?PED cHILDRENANDTHEIRFAMILIES. 25 THIS WAS A VERY IMPORTANT DEVELOPMENT, SINCE MANY PARENTS OFA "BABY DOE"NEEDHELP IKNEWTHATFROMMY / OWN 35 YEARS IN PEDIATRIC SURGERY. MANY PARENTS SIMPLY LACK THE RESOURCES -- BE THEY MATERIAL, SOCIAL, OR ECONOMIC .:a OR EMOTIONAL, MORAL, OR PSYCHOLOGICAL-To CARE FOR A DISABLED CHILD IN THEIR OWN FAMILY. 26 ALSO,MANYLAYADVOCATESJUSTDONTHAVEMUCHTO SAYABOU'I'THECO~ S ROLEINHEXPINGPARENTS WHO TAKE HOME THEIR OWN "BABY DOE." AND THAT ALWAYS BOTHERED ME, TOO, BECAUSE I KNEW - AGAIN, FROM MY YEARS AT .CHILDRJZN'S HOSPITAL OF PHILADELPHIA -- THAT A GREAT MANYLOVING,CARINGPARENTSWOUL;DHAVEBEEN~G~ IN CONFUSION AND DESPAIR, HAD IT NOT BEEN FOR THE TIMELY ASSISTANCE OF A WHOLE RANGE OF PUBLIC AND PRIVATE COMMUNITYRESOURCES. 27 AND, TO BE QUITE CANDID, I WAS ALSO SHORT-TEMPERED WITH SOME OF MY COLLEAGUES IN MEDICINE, WHO -- AS A RESULT OF THE SUPREME COURT DECISION IN ROE V. WADE -- HAD TAKEN. TO CALLING A NEWBORN `BABY DOE" A "FETUS EX UIERQ," OF ALL THINGS. IN OTHER WORDS, SOMEPHYSICIANS THOUGHT THEY COULD SAFELYDENYANEWBORNC~HISORHERPERSONHOODAM> CONSmONAL PROTECTIONS SIMPLY BY CHANGING SOME LABELS . . . CALLING A DISABLED "cHIL;D" NOT A "CHILD" BUT A NINE-MO?I'I=~~FEmS THAT SOMEHOWLEFT ITS MOTHER'S uTERUS~~s~PERFEcTCO~~ONAND,~O~, DESERVED TO BEPUNISHED. BYDEATH. 28 THE YEAR OR SO FOLLOWING THE DEATH OF "BABY DOE" WAS A VERY DIFFICULT PERIOD, WITH MUCH WRANGLING BOTH INSIDE ANDOuTs~~THEGOVERNMEW...LEGALCHALLENG~ . ..AND MY SGT OFREGULATIONS. 29 ALSO, HAD THEY NOT DONE SO, I KNOW MY REGULATIONS WOULD HAVE WORKED. I SAY THIS BECAUSE THE PEDIATRICIANS, WHO HAD BEEN THE FIRST TO SUE OVER THE TWO EARLIER SETS OF REGULATIONS, REFUSED TO JOIN OTHER MEDICAL GROUPS, SUCH AS THE AMERICAN MEDICAL ASSOCIATION AND THJ3 AMERICAN HOSPITAL ASSOCIATION, WHO HAD MUCHLESS AT STAKE. 30 HOWEVER,THEFINALOUTCOMJ3 OCCURREDINTHECONGRESS IN A NEW LAW THAT DOES PROTECT THE "BABY DOES' OFTHIS SOCIETY. CONGRESS EXPANDED THE DEFINITION OF AN "ABUSED ANDNEGLECI'ED CHILD"TOINCLUDEADISABLEDINFANTLIKE "BABY DOE." AND THATS WHEXE THE MATI'ER STANDS TODAY. BUT THE PASSAGE OF A LAW AND THE WRITING OF NEW REGULATIONS ARE NOT THEEND OF ANYTHING. THEYWEEETHE BEGINNING. 31 FOLLOWING THE YEAR-LONG "BABY DOE" DIALOGUE, I CONVENED A SERIES OF "SURGEON G ENERAL'S WORKSHOPS" THAT FOCUSED ON THE NEEDS OF THE HANDICAPPED CHILD AND HIS OR . HER FAMILY. I INVITED PHYSICIANS, NURSES, SOCIAL WORKERS, HOSPITAL PEEUONNEL, COMMUNITY ACI'IVISTS, CHILD ADVOCATESJNDOTHERS. GRADUAL;LY,WITHTHE~POF~~W~WANDTHESE WORKSHOPS,THECOUNTRYHASBEENAB~NOTONLYTODEFEND THE LIVES OF ITS NEWBORN CITIZENS, BUT ALSO TO DEAL MORE DIREcTLYANDMOREHELPFUI&YWlTHTHEPROBLEMSTHAT ARISE-AS A RESULT OF THE SAVING OF THOSE LIkES. 32 WHAT HAS EVOLVED IS "FAMILY-CENTERED, COMMUNITY- BASED, COMPREHENSIVE CARE FOR CHILDREN WITH SPECIAL NEEDS." IT'S A NEW CONCEPT. IT WORKS. AND IT'S BEING ADOl?TEDMOREANDMOREALLACROSSTHECOUNTRY. AND I MUST CONFESS THAT, WHlLE I RECEIVE MUCH PUBLIC PRAISE FOR MY INVOLVEMENT WITH SUCH HIGH VISIBILITY ISSUES AS SMOKING AND AIDS, I COUNT AS ONE OF My MAJOR ACHIEVEMENTS OF THESE PAST 8 YEARS THIS EVOLUTION OF A MORE WIDESPREAD, MORE EJ?~%CTIVE, AND MORE COMPASSIONATE APPROACH TO CHlLDREN WHO ARE BORN WITH A NON-FATAL HANDICAF'. 33 IT HAS BEEN A LONG PROCESS, BUT THEN MUCH OF DAY-TO- DAY GOD IS EXACTLY THAT: THE WORKING THROUGHOF LONG AND COMPLEX PROCESSES. I STILL CAN'T BELIEVE I HAD THE PATIENCE TO STICK WITH IT . . . I WOULD NEVEEt HAVEPREDICI'ED THAT KIND OF BEHAVIOR FORMYSELF. BUT I'M CERTAINLY GLAD IDID. IN SoME ~PECTS, THE "BABY DOE" ISSUE WAS COMPARAT'I-VELYEASY. OURFOCUS OF ATTENTION WAS ClElILDREN, AND YOU CAN ALWAYS FIND ALLIES FOR CHILDREN. 34 ANDTHEN,WEWERETALKlNGABOUTACOMPARATIVELY FEW CHILDREN . . . AT MOST MAYBE 100,000 OR SO EACH YEAR . . . WHO MIGHT BE BORN WITH A HANDICAP OF SOME KIND. AND EVEN OF THESE, ONLY A SMALL FEbKTION WOULD ACI'UALLY BE IN JEOPARDY, AS "BABY DOE" WAS IN &OOM.INGTON, INDIANA. AND FINAILY, WITH DISABLED YOUNGSTERS, THERE WAS ALWAYS THE EXPECI'ATION THAT THE CHILD YOU SAVED WOULD IN FACT GROW UP IN A PEACEFUL, LOVING ENVIRONMENT AND MIGHTEVENOVERCOMEHISORHERHANDICAPTOB~O~A CREATIVE, PRODUCTIVE MEMBER OF SOCIETY. 35 THATS ALLQUlTEDIFFElERENT FROMTWO OTHER ISSUES THAT WERE GERMINATING AT ABOUT THIS SAME TIME, EARLY IN MYFIRSTTERMAS SURGEONGENERAL THE FIRST ISSUE WAS FAMILY VIOLENCE AND THE SECOND WAS AIDS. LErMESPEND A MOMENT OR TWO ON EACH AND BEGIN WITH THE ISSUE OF FAMILY VIOLENCE. 36 FOUR OR FIVE YEARS AGO, I BECAME CONVINCED THAT THE ROL;EOFPUBLICHEALTHCOULDBECENTRPiLTOSOCIEITS ABILJTY TO SAVE THE LIVES OF POTENTIAL VICTIMS . . . MAINLY Wo=, mm, AM> OLDPEOPLE . . . AND EVENPREVENT VIOLENCEFROMHAPIjENlNG. HOWE-VEEt,TODOTHATMIGHTREQUIRETHEINTERVENTION INTO FAMILY LIFE BY PUBLIC HEALTH PERSONNEL, TO A NEW AND GREATEREXTENT THANEVERBEFORE. ANDI'VEBEENHAUNTED BYTHATTRADE-OFFEVERSINCE. 37 OF COURSE, SUCH NECESSARY AND LAWFUL INTERVENTION WAS ALREADY EXERCISED BY OUR SOCIAL SERVICE AND cRIMINAL JUSTICE SYSTEMS INREGARD TO DOMESTIC VIOLENCE. BUT NOW IT WAS GOINGTO BEOURTURN. MY INTEREST IN THIS ISSUE BEGAN IN A CURIOUS WAY. 38 IN 1984, I WAS ASKED TO ADDRESS A MEETING ON T.V. VIOLEN~THEGOVERNMENT HADBEENFUNDINGRESEARCHIN T.V. VIOLENCE FOR THE PAST 20 YEARS AND SPEECHES ON THE SUBJECT BY THE SURGEON GENERAL wERERATHERROUTJNE... HENCE, THE INVITATION. BUTDESPITEXHEYEARS OFRESEARCHANDREPORTS AND CONGRESSIONAL HEARINGS, WE STILL HAD NO CLEAR ROLE FOR GOVERNMENT -- EXCEPT THAT OF SUPPORTING THIS MINT- INDUSTRY BY FUNDINGMORERESEARCH. 39 A~ALLY,THEREAREMANYSUCHFEDERALLY-SUPPORTED MINI-INDUSTRIESINOURS~~~I~G~YOUCO~. MAKE A CASE FOR THEIR SOCIAL UTILITY. NEVERTHELESS, I BEGANTO WONDER IF SOMEHOW OUR PREocCUPATI0NWITHT.V. VIOLENCE WASN'T ACTUALLY PREVENTINGUS FROM SEEING A LARGER AND MUCH MORE SERIOUS PROBLEM OF VIOLENCE IN OUR Soam'YG~Y. 40 AND INDEED THERE WAS -- AND IS -- SUCH A PROBLEM. I LEARNEDFROMOURSTAFFTHATEACHYEARANESTIMATED4 - MILLION OR SO CHILDREN ARE VICI'IMS OF ABUSE AND NEGLECT . . . OVER A MILLION WOMEN ARE ASSAULTED AND PHYSICALLY ABUSED EACH YEAR . . . AND NEARLY A MILLION ELDERLY PERSONS -- MOST OF THEM WOMEN ALSO -- ARE ABUSED OR NEGLECTED AS 41 WE DON-7 HAVE GOOD STATISTICS IN THIS DIFFICULT AREA. BUT, JF ANYTHING, THESE NUMBERS ARE MUCH TOO LOW. WE ESTIMATE, FOR EXAMPLE, THAT FOR EVERY ADULT VICTIM OF VIOLENCE COUNTED BY THE POLICE AND THE F.B.I., AS MANY AS THREE ADDFrIONAL ADULT VICTIMS PASS THROUGH HOSPITAL EMERGENCY ROOMS OR COMMmm'y CLINICS AND AREMISSED BY THEPollKEALToG~ 42 CLEARLY, THEN, VIOLENCE IS HAVING AN OVERWHELMING IMPACI' UPON THl3 NATION'S HEALTH CARE SYSTEM. I TESTED OUT THIS ISSUE IN A SPEECH BEFORE THE AMERICAN ACADEMY OF PEDIATRICS AND AGAIN IN A PRESENTATION AT THE WESTERN PSYCHIAmC INSTITUTE AT THE UNIVERSITY OF PITTSBURGH, THERESPONSE%iS VERY GOODBOTHTIMES. THEREFORE, IN 1984, I CONCLUDED THAT WE OUGHT TO MOVE AHEAD AND ADDRESS THE LARGER ISSUE OF DOMESTIC VIOLENCE AS A PUBLIC HEALTH ISSUE AND PUT ASIDE FOR A WHILE THE NARROWER, SUB-SET OF T.V. VIOLENCE. 43 WITH NO "B-Y DOE" To TRIGGER FEDERAL INTEREST, WE FELTABLEToPROCEEDWITHMOREDELIBEEtATION. HENCE,WE BROUGHT TOGETHER SOME 170 EXPERTS FOR THREE DAYS IN LEESBURG, VIRGINIA, ANDASKEDTHEMTOSUGGESTWHATTHE NATION OUGHT To DO NEXT. THAT 1985 "SURGEON GENERAL'S WORKSHOP ONVIOLENCE AND PUBLIC HEALTH" WAS A BENCHMARK EVENT AND ITS REPORT -- CONTAINING 153 RECOMMENDATIONS --HAS BEEN WIDELY READ AND CONSULTED. 44 BUT IT WAS A PROFOUNDLY DISTURBING EVENT FOR ME. MUCH OF THE DISCUSSION REVEALED HOWAMBIVALENT AMERICANS STILL WERE ABOUT SEX, VIOLENCE, AND POWER. I HEARD, FOR EXAMPLE, THAT, WHlIZ RAPE IS A FELONY CRIME, FEWER THAN 30 STATES RECOGNIZED MARITAL RAPE AS A CRIMEATALL. 45 INREGARD TO ABUSED CHILDREN, THE SITUATION WAS A LI'ITLE Dm . . . BUT NOT ANY MORE ENCOURAGING. IT WAS TRUETHATTHECOUNI'RYHASSTRONGFEDERALANDSTATE LAWS MANDATING PERSONS TO REPORT ACTUAL OR SUSPECTED CASES OF CHILD ABUSE. BUT, AS THE EXPERTS AT THE WORKSHOP WERE QUICK TO POINT OUT, CHILD ABUSE WAS -- AND IS - ONE OF THE MOST UNDER-REPORTED CRIMES IN OUR SOCEIY. AU THIS WAS VERY DISTURBING JNFORMATION, SINCE IT INDICATED THAT, FOR MANY OF OUR MOST vULmRABLE cLTIzENS,THE~N~OFFAMlLYANDTHEHO~DIDNoT REPRESEN'I'SAFEI"yANDNURTURE... ITSTOODFORVIOLENCEAND VICTIMIZATION. 46 I SAY IT WAS "DISTURBING INFORMATION" BECAUSE, FOR THEBEITERPARTOFTWOCENTURM, ouRcouNTRYHAD TRADITIONALLY NOT QUESTIONEDTHE BEHAVIOR OFITS FAMILIES, EXCEPT IN VERY RARE AND NARROW INSTANCES. AND ALMOST ALL THOSE INSTANCES HAD A PUBLIC HEALTH IWI'IONALE: HOW FAMILIES BURIED THEIR DEAD, FOR EXAME'LE . . . HOWTHEYh!bkINT~A~ LEVEL OF SANITATION . . . AND, INTHE CELEBRATED VACCINATION CASES, HOW FAMILIES PARTXCIPATED IN SOCIETY'S EFFORTS AGAINST `I333 CONTAGIOUS DISEASES OF CHILDHOOD. 47 BUT A SHIFT IS OBVIOUSLY TAKING PLACE AND SOCIETY IS DEMANDING CERTAIN KINDS OF BEHAVIOR FROM ITS FAMILIES . . . ORll3VILLINTEEtVENEAND EFFEcTlvELY ENDTHOSEFAMILY UNITS. WE WILL PLACE AN ABUSED CHILD IN PROTECTIVE CUSTODY AND ARREST THE ABUSING PARENT, &D WE WILL PROVIDE SHELTER FOR AN ABUSED WOMAN -- AND HER CHILDRJXN, IF NECESSARY -- AND PREVENT HER SPOUSE FROM FINDING HER ANDBRING~GHERBACKTOREPEATTJ3EOFFENSE. 48 AS SURGEONGENERALISLm?oRmTHESHELTER MOVEMENT BECAUSE IT IS CLEARLY'PART OF THE TOTAL INTEGRATED SOCIAL SERVICE AND PUBLIC HEALTH SYSTEM THATSNEEDEDTOPREVENT DoMEsTIcvIoLENcEwHERE POSSIBLE . ..-OR CARE FOR ITS VICTIMS, WHERf3 PREVENTION IS NOTPOSSIBLE. FRANKLY, IT WAS NOT AN EASY POSITION FOR ME TO TAKE, SINCE I HAVE BEEN -- AND I STILL AM -- ARDENTLY "PRO- FAMILY." AND'1 KNOW THAT MANY PERSONS IN THE "PRO- FAMILY" MOVEMENT SEETHESESHELTERS AS DEVICES THAT ACCELERA~~BREAKDO WN OFFAMILIES. 49 BUT MY DEEPLY PERSONAL CONVICTIONS IN THIS MA'ITER DID NOT SATISFY THE NEED FOR ME -- IN MY PUBLIC ROLE AS SURGEON GENERAL -- TO FIND WAYS TO HELP SOME OF MY FELLoWAMERIcANSwHENTHEYAREINTRouBL+EORATRISK INDEED, PART OF MY CONCERN HAS BEEN To DIAGNOSE AND REMEDYTHEPROB~PRESENTEDBYTHEP~~TORAS~ AS THAT PRESENTED BY THE VICTIM. AND, IN SITUATIONS LIKE THAT, YOU HAVETO'GO BNOND IDEOLOGY FOR ANSWERS THAT WORK. 50 I HAVE SINCE PUBLISHED A "SURGEON GENERAL'S LETI'ER ON CHILD SEXUAL ABUSE," MY OFFICE PRODUCED AND WIDELY DISTRIBU'IED A PUBLIC SERVICE T.V. ANNOUNCEMENT ON SPOUSE ABUSE, AND WE'VE URGED THE MEDICAL PROFESSION TO DEAL MORE CANDIDLY AND DIRECTLY WITH THIS ISSUE OF DOMESTIC VIOLENCE WITH OUR ENCOURAGEMENT, FOR EXAMPIE, THE AMERICAN COLLEGE OFOBSTI3IRICIANS AND GYNECOLOGISTS HAS COME FciRWARDWlTH~EXCELLENT INFORMATION AND EDUCATION PROGRAh8 FOR ITS OWN MEMBERS. AND THAT IS AN APPROPRIATE PLACE TO START, WITH PHYSICIAIb WHOSE PATIENTS ARE ALWAYS WOMEN. 51 THEN, THIS MONTHTHE AMERICANMEDICAL ASSOCIATION SPONSORED A MEETING TO INlTlATE A "NATIONAL PHYSICIAN RFiSOURCECENTERFORTHEP REVENTIONOF FAMILY VIOLENCE AND VICTIMIZATION", AND I GAVE THE KEYNOTE ADDRESS. WHENILEFTGOWRNMENT JUST A FElW DAYS AGO, ITRULY FELT A REAL SENSE OF ACCOMPLISHMENI' FOR WHAT I WAS ABLE TODOFOR HANDICAPPED CHILDREN AS ARESULT OFTHE "BABY DOE" SITUATION. 52 I BELIEVE THEPRINCIPLE IS NOW FIRMLY ESTABLISHED IN THE MINDS OF HEALTH PROFESSIONALS EVERYWHERE THAT A NEWBORN CHILD IS A CITIZEN DESERVING OF EVERY CONSTTI'UTIONAL PROTECTION, AND ANYONE -- INCLUDING A PARENT OR AN ATTENDING PHYSICIAN -- WHO DENIES A CHILD SUCH PROTECTION IS CO MMITTING A SERIOUS VIOLATION OF MORALS, JQ'HKS, AND THE LAW. SIMILARLY, I ALSO FEEL SATISFIED THAT THE AMERICAN PEOPLE -AND THOSE CONCERNED FORTHEIRHEALTEf-ARE COMJNGTOACCEPTTHEIDEATHATNOHUMAN BEINGHAS THE RIGHT TO ABUSE ANOTHER HUMAN BEING, AND `l!HAT NO INSs1TIzTTION - INCLUDING "THE HOME" AND "THE FAMILY" -- CAN BEALLOWEDTOSHIELDSUCHCRIMINALBEHAVIOR. 53 FOR THE PUBLIC HEALTH COMMUNITY, ASWELLASFORTEIE NATIONINGENERAL, THESEDEVELOPMENTSWERENECESSARY ANDTHEYARERIGHT.BUTIAMDEEPLYPAINEDTHATTHEYARE, INFACT, NEEDEDBY OURSOCIEIY. - DURINGTHEMONTHSANDYEARSTHATTHE"BABYDOE" ISSUE AND DOMESTIC VIOLENCE WEEtE QWTURING MY ATTENTION, ANOTHER RATHER MYSTERIOUS HEALTH PROBLEM CAMETOLIG~ANDGREWNEXORABLYINTOA-Y FAR MORE MENACING PUBLIC HEALTH PROBLEM THAN ANY I'VE DISCUSSED SO FAR. 54 I'M SPEAKING, OF COURSE, ABOUT AIDS. THES~JEC'I'OFAIDS HAS BEENCOVERED SOEXTENSIVELY AND IN SUCH DFiE'TH THAT I WILL SPEAK TONIGHT ABOUT JUST A COUPLE OF-PERSONAL PEEtCliW-`IONS I HAVE HAD ABOUT THE ISSUE. 55 FIRST, YOU MAY RECALL THAT, ON JUNE 5,1981, THE U.S. PUBLIC HEALTH SERVICE PUBLISHED THE FIRST REPORTS OF WHAT WAS TOBECOMETHEAIDS EPIDEMIC. THEY CONCEEtNED 5 "PREVIOUSLY HEALTHY" HOMOSEXUALS WHO WEEXE ADMITI'ED TO LOS ANGELES HOSPITALS WITH PNEUMOCYSTIS CARINII PNEUMONIA, AVERY RAREFORM OFPNEUMONIA. THE~ALSOPRESENTEDEVIDENCEOF~MEGALOVIRUS AND CANDIDAINFECTONS. BY THETIMETHEREPORTHAD BEEN PUBLISHED, 2 OF THEMENHAD DIED. THE OI'HER 3 DIED SHORTLY 56 ONEMONTHLATER,THECfa'mtS FoRDISEASECONTFtOL REPORTED THAT 26 HOMOSEXUALS -- 20 IN NEW YORK CITY AND 6 IN CALIFORNIA --HAD BEEN DIAGNOSED AS HAVING KAPOSI'S SARCOMA, A HIGHLY UNCOMMON FORM OF CANCER, USUALLY FOUNDINOLDMEN. EIGHTWEREALREADYDEAD. ASMALLNUME3ER AMONG = 26 ALSO HAD PNEUMOCYSTIS CARINII PNEUMONIA. PATHOGENIC VIRAL OR YEAST IIWECIION . . . C.M.V., HERPES SMPLEX, CRYlr]rOCOCCALMINNGrrI& ANDSOON 57 THECASELOAD CONTINUED TOMOUNT - CONTINUES MOUNTING TO THIS DAY -- WITH MEN S UFFERINGFROMCOMPLEX, RARE, ANDl?OOR.LY UNDERSTOODDISEASES. THELlTER.ATUREOF THIS EPIDEMIC ABOUNDS NOT ONLY WITH KAPOSJS SARCOMA AND ~~UM~cys~~ CARINII, BUT ALSO WITH DIFFUSE, UND-TED NON-HODGKINS LYMPHOMA, SPLENOMEGALY, Gs LYMPHADENQPATHY, TOXOPLASMOSIS, DISSEMINATED MYCOBACIERIUM AVIUM-INTRACELLULARE, ANDSO ON. HENCE,FROMTHEVERYBEGINNlNGOFTHIS EPIDEMIC,WEWEREDEALINGWlTHMYSTERIESCO~~~BY MYSIERIES. ~NATIONDIDNOTHAVEMANYTRAINED CLINICIANS ANDRESEARCHERS WHO WEREFAMiLIAR WITHTHE RARE DISEASES THAT WERE BEING PRESENTED. AND IN ANY CASE,WEHADNOCURESFORTHEM., 58 IN ADDITION, THE HOMOSEXUAL COMMUNITY, WITHINWHICH THE AIDS SYMPTOMS WERE BEING PRESENTED, WAS AT ODDS WITHTRADITIONALCLINICALMEDICINE. INCREASINGLY DURING THE 1960s AND 197OS, HOMOSEXUAL MEN HAD CHOSEN TO PATRONIZE PHYSICIANS AND CLINICS WHOWEREMOREUNDERSTANDINGOFTHE SO-C- "GAY LIFESNLE." -THIS HAD BEENNECESSARY OR WISE IS A SEPARATE QUESTION. THE EFFECT, HOWEVER, WAS QUITE CLEARz IT PLACED HOMOSEXUALS OUTSIDEMAINSTREAM MEDI0NE~,THEREFORE,MOREDXFFlCULTFORTHE GOvERNMENTTOKNOWANDTOREACH...ANDTO%ELP. 59 THrsALsooccuRRED -- NOT COINCIDENTALLY -- AT THE TIME OF THJ3 "GAY REVOLUTION," WHEN HOMOSIZUAL AND BISEXUALMENWEJ3E"COMlNG0UT0FTHECLOSEI"'AND ASSERTING THEIR CIVIL RIGHTS. UNFORTUNATELY, THE GAY ACI'IVISTS COMBINED THE SEhiRATE HEALTH AND POLITICAL ISSUES INTO A SINGLE PACKAGE OF GRIEVANCES, FOR WHICH THEY SOUGHT PUBLIC REDRESS. 60 THIS STRATEGY AROUSED AS MUCH PUBLIC CONFUSION AND ANGER AS IT DID PUBLIC SYMPATHY. AS A RESULT, OUR FIRST PUBLIC HEALTH PRIORITY -- THAT IS, TO STOP FURTHER TRANSMISSION OF THE AIDS VIRUS -- BECAME HOPELESSLY AND NEEDLESSLY ENSNARED INTHE SEXUALPOLITICS OFTHEEARLY 1980s. SOME PRECIOUS TIME WAS LOST BETWEEN 1981 AND 1983, DURING'WHICH'IHEHOMOSEXUALCOMMUNITY WASDMDED BEIWEEN THERHEI'ORIC OF "GAY RIGHTS" AND THE REALITY OF AIDS DEATHS. 61 IT WAS NOT A PRFi'ITY TIME. AND yEI: DESPITETHE CONFUSION AND'FRUSTRATION, THE ANGER AND THE IGNORANCE, THETERRORANDTHEDEATH, SCIENCEDIDMOVEFORWARDVERY QUICKLY ANDABLOODTEST WAS DEVISEDANDMADE AVAILABLE IN THE FALL OF 1985. 62 NOT MAJSIY CRITICISMS MiKE MY BLOOD BOIL ANY MORE. BUTTHEREISONETHATSTILLDOES. ISTILLHEARPEOPLE COMPLAINTHAT "THE GOVERNMENT DRAGGEDITSFEEI'AND WOULDN'T RELEASE A BLOOD SCREENING TEST UNTIL 1985. THEFACI'OFTHEMATIERISTHAT,INCOMINGUPWITHA BLOOD SCREENING TEST BY OCTOBER 1985, THE GOVERNMENT AND ITS SCIENTISTS HAD PERFORMED A RESEARCH MIRACLE. THEY HAD DISCOVEEtED A WAY TO SUCCESSFULLY SCREEN BLOOD FOR THE "FOOTPRINTS," YOU MIGHT SAY, OF A VIRUS THEY COULD NEl!EDB IDENTIFY NOR FIND. 63 IWOuLDLovEToTAKE~~FORTHEEARLY~~SHIp SHOWN BY THE GO VERNMENT -- BUT I CAN'T. I WAS NOT INVOLVED AT ALL IN THE EARLY DAYS OF THE AIDS EPIDEMIC. ANDTHERl3ASONHASNOTHINGTODOWlTHMYWELLr ADVERTISED RELIGIOUS BELIEFS. NO ONEEVER BROUGHT THAT UP. THE REASON IS MUCH MORE MUNDANE. IN CASE YOU ARE UNAWARE OF IT, THE POSlTION OF SURGEON GENERAL IS SUPPORTED BY A HALF-DOZEN STAFF AND ASMALLAL,LO?n?ENTOFFUNDSFROMTHEMUCHLARGEROFFICE OF THFi ASSISTANT SECRETARY FOR HEALTH, TlZiE OFFICE WITHIN G WHICH THE SURGEON ENERCS OFFICEISLOCA'iED. 64 THE AIDs RESEARCH WAS BEING CARRIED OUT AT THE NATIONAL INSTITUTES .OF HEALTH, THE CENTERS FOR DISEASE CONTROL, AND THE FOOD AND DRUG ADMINISTRATION. THE SURGEONGENlX4L RUNS NONE OF THESE. THE CASEREPORTING HAS BEEN CARRIED OUTMAINLY BY EPIDEMIOLOGISTS IN OUR STATE AND MUNICIPAL PUBLIC HEALTH AGENCIES, AND THEY HAVEBEENEXI'RAORDINARY. IDIDN'TRUN 65 THE CONGRESSIONAL INTERESTHASBEENSHARPAND UNRmG, W'I' THElR QUESTIONS USUALLY CONCERN HOW MUCH MONEY IS BEING SPENT . . . WHERE ITS BEING SPENT . . . AND HOW MUCH MORE COULD BE - OR OUGHT TO BE -- SPENT. I HAD NO OFFICIAL ANSWERS FOR THEM, SINCE THE AIDS PURSE WAS NOT THEN UNDER MY CONTROL, NOR HAS IT BEEN AT ANYTIME SINCE. 66 BUT SOMETHING WAS GOING ON IN 1985 AND EARLY 1986 THAT BROUGHT ME INTO THE AIDS ISSUE. THE PUBLIC WAS GETTING A GREAT MANY MIXED AND CONFUSING MESSAGES ABOUT THIS DISEASE. HENCEJJ=TMEHADCOMEFORTHEGOvE3RNMENTTo INVEST ITS CREDIBILITY IN ONE PERSON WHOSE TASK IT WOULD BE~OTEUTHEAMERICANPEOPLEWH.ATWEKNEWTOBETRUE ABOUTTHE~SEPIDEMIC...WHATWEKNEWTOBEFALSE ABOUTTHEEPIDEMIC... ANDWHATWESTILLDIDNOTKNOW ABOUTTHEAIDS EPIDEMIC. 67 IN FEBRUARY 1986, PRESIDENT REAGAN DIRECTED THAT I BE THAT PERSON AND PREPARE A REPORT TO THE AMERICAN PEOPLEONhDS. THEREPORTHADTOGlVETHEFACTSABOUT AJDS AND HOW TO PREVENT lT. THE REPORT ALSO HAD TO EXPOSE TJ3EFALSEhfY'THOLOGIESTHATHADBEGUNTOAPPEAR CONCERNNGAIDS, MYTHOLOGIES PERPETUATED BY MIUN- lWRITED PEOPLE WITH A MACABRE VIEW OF THE HUMAN CONDITION. 68 I~ONEDTHATTHEHOMOSl3CUALCOMMUNlTYHAD HOPELESSLY AND NEEDLESSLY POLITICIZED THE AIDS ISSUE IN THEBEGINNING. INALLFAIRNBS,IMUSTRECALLTHATTHE ISSUE WAS FURTHER POLITICIZED --AGAIN, NEEDLESSLY AND CALLOUSLY -- BY EXTREME CONSERVATIVES, PEOPLE FOR WHOM IDEOLOGY WkiXVEEtYTHING. THEY CHEEREDTHEPRFtSIDENTS DFCISIONANDMISTAKEl%Y PREDICIXD THAT I WOUID PRODUCE THE `RIGHT" KIND OF REPORT. 69 AFl?ER 8 MONTHS OF LISTENING TO ALL SHADES OF OPINION - - LEFT, RIGHT, AND CENTEIt -- FROM A BROAD CROSS-SECTION OF AMEJZICAN PUBLIC LIFE, I RELEASED MY Rl3'ORT DIRECTLY TO THE PUBLIC IN AN OCTOBER 1986 PRESS CONFERENCE. I KNEW WELL IN ADVANCE THAT MY FRIENDS IN CONSERVATIVE PROTESTANT GROUPS AND IN THE CATHOLIC CHURCH -- FRIENDS AND ALLIES IN MANY PAST BATTLES AGAINST ABORTION -- I KNEW THAT THEYWEREN'TGoINGTOUKEMYRE.FORT. 70 THEY VIEWED ANAL INTERCOURSE -- OR SODOMY -- AS A VIOLATION OF LAWS BOTH SPIRITUAL AND TEMPORAL. SODOL BUT ,mT WAS HARDLY THE ISSUE IN 1986. THE ISSUE THEN WAS THAT ANAL INTERCOURSE WAS THE PRIME MEI'HOD OF TRANSMISSION OF THE VIRUS -- WHETHER WE LIJBD IT OR NOT -- ANDWEHADToCONVINCEMENTOSTOPDOlNGT.f3AT. 71 CONCLUSION THAT FURTHER IRRITATED MANy OF My OLD FRrENDSANDALLlES. IF HOMOSEXUALS AND BISEXUAL MEN PERSISTED IN ENGAGING IN ANAL INTERCOURSE, ESPECIALLY WITH ANONYMOUS OR CASUAL SEX PARTNERS, THEN THEY OUGHT TO PRtYIECI'THEMSELVESWITHSOMEKINDOFWERMEABLE TRANSMISSION BARRIER. 72 SUCHBARRlERSARECOMMONLYKNOWNASCONDOMS. THAT WAS THE "C-WORD" OF 1986 AND `87. AND THERE ARE SOMEOFMYFoRMERWASHJNGTONFFilENDSWHODON'TSPEAKTO ME TODAY BECAUSE I USED THE WORD. 73 BUT THAT WAS HARDLY THE END OF IT. FROM THE DATA GIVEN TO ME BY THE CENTERS FOR DISEASE CONTROL, IT APPEARED THAT THE MEDIAN AGE OF AIDS VICTIMS WAS QUITE LOW, IN THE EARLY 20s. HOWEVER, BY 1986 WE ALSO HAD A FAIRLY GOOD IDEA THAT THE INCUBATION PERIOD FOR THE AIDS VIRUS COULD LAST AS LONG AS 7 YEARS --NOW WE KNOW IT CANBEEVENLONGER- BEFORETHE INFECIED PERSON SHOWED SIGNS OF AN OPPORTUNISTIC INFECTION . . . KAPOSI'S SARCOMA, PNEUMOCYSTIC CARINII PNEUMONIA, AND SO ON. 74 THAT LONG AN INCUBATION PERIOD, IN TURN, MEANT THAT THE TRANSMISSION OF THE AIDS VIRUS WAS OBVIOUSLY TAKING PLACE AMONG A SIZEABLE NUMBER OF YOUNG MEN UNDERTHEAGEOF19. ANDTHATMEANT.TEIATTHEWHOLE AIDS ISSUE-- COMPLETE WITH EDUCATION IN SEXUALITY AND DISCUSSIONS ABOUT CONDOMS -- WOULD HAVE TO MOVE INTO ouRscHooLs. 75 INTHEABSENCEOFAN -ANDGENERALLY AVAILABLE VACCINE -- SOMETHING THAT WAS AND IS STILL YEARS AWAY -- IT BECAME QUITE CLEAR THAT OUR SINGLE WEAPON AGAINST AIDS FOR MANY YEARS TO COME WOULD BE EDUCATION . . . EDUCATION . . . AND MOREEDUCATION. I WAS PROMPTLY AND WITLESSLY ACCUSED OF ADVOCATINGTHE TEACHING OF SODOMY TO THIRD-GRADEEtS AND IT WAS REPORTED THAT I HAD PASSED OUT CONDOMS TO 8- YJZAR-OLDS. CAN YOU BELIEVETHAT? 76 AND FOR ALMOST A YEAR ALL SORTS OF LIBELOUS THINGS WERESAID~OUTME. MYSTAFFCOUNSELEDMETOBE MAINTAIN MY SCIENTIFIC AND DIS INTERESTEDPOSTURE. ANDIT WAS EASY FOR THEM TO SAY. BUT NOT EASY FOR ME TO DO. 77 MD IN ANY CASE, MY PERSONAL REPUTATION WAS NOT WHAT WAS REALLY AT STAKE. TO UNDERSTAND THE SERIOUSNESS OF THESE CRITICiSMS, YOU HAVE TO GO BACK TO THE ORIGIN OF THE ASSIGNMENT, WHICH WAS TO ESTABLISH A CREDIBLEPUBLIC SPOKESPERSON WHO WOULD KEEP THE PUBLIC UP TO DATE WITHTHE FACTS ABOUT AIDS. 78 INTURN,THEPUBLICHADTOBEWlLLINGTOFiEADAND LISTEN TO THE FACTS AS I RELAYED THEM . . . AND TO BELIEVE THESE NONSENSICAL CRITICISMS COULD HAVE HAD THE EFFECT OF SERIOUSLY DAMAGINGMY CREDIBILJl'Y AND, HENCE, DENYINGTHE PUBLIC A SINGLE, RELIABLE, CREDIBLE SOURCE OF INFORMATION. 79 AFTER ALL, MYPREDECESSORS AS SURGEONGENERALHAD SO~~U~THEMsEr~THATTHEOFmcEOFSuRGEoN GENEELXLWASTHEMOSTCREDIBLEANDRELIABLEINTHE GOVERNMENT . . . THE ENVY OF PRESIDENTS, I MIGHT ADD. NOW IT WAS MY JOB TO DO AND SAY WHAT WAS NECESSARY -- BUT NEVERTHELESS MAINTAIN THE CREDIBILITY OF THIS OFFICE FOR MY SUCCESSORS AND FOR THE NATION. I TRULY BELlEVE THAT I SHOULD DO THAT. 80 ANDIBELIEVEIHAVE. I'DLIKETOTAKEFULLCREDITFOR THE RESULTS. BUT IN ALL FAIRNESS I HAVE TO ADMIT THAT MY SUCCESS IS ALSO AN EXAMPLE OF THE POWER OF THE GOVERNMENT IN GAINING ACCESS TO THE MEDIA AND TO PUBLIC PLATFORMS, IF IT WANT3 TO. AS A RESULT, I'VE BEEN ON EVERY TELEVISION NEIWORK NEWS SHOW . . . I'VE BEEN FEATURED INALLTHENEwSMAGAzINEs...ANDTHEwIRESERvIcEsAND INDIVIDUALCORRES~~~SHAVEQUOTEDMEAG~AND AGAIN IN NEWSPAPERS AND MAGAZINES SERVING EVERY TOWN AN-DEVERYMANNER OFREADERSHIP. 81 INADDITION,WEMAILEDOUTA"SURGEONGENERAL'S REPORT" OF SORTS TO 107 MJLLION AMERICAN HOUSEHOLDS, AN HISTORIC ACHIEVEMENT THAT'S A STORY IN ITSELF. PUBLIC EDUCATION HAS BEEN MY S`OB FOR THE PAST 3 YEARS. I'DGUESSTHATTHEONLY PEOPLEWHOGAVEMORE SPEECHES THAN I OVER THE PAST COUPLE OF YEARS WERE ALL THE CANDIDATES FOR PUBLIC OFFICE . . . . . . COMBINED. 82 AT LEAST, IT FEELS THAT WAY. IN ANY CASE, THE EDUCATIONAL EFFORT APPEARS TO HAVE HAD AN EFFECT. EVERY PUBLIC OPINION POLL OF THE PAST YEAR HAS SHOWN THAT PUBLIC KNOWLEDGE ABOUT ADS IS EXTENSIVE AND REASONABLY ACCURATE. HOWEVER, OUR JOB IS FAR FROM OvHt 83 IN FACT, THERE IS A NEW AND MORE COMPLICATED AIDS MESSAGE FOR THE PEOPLE OF AMERICA. I'VE ALREADY BEGUNTO DEAL WITH IT, BUT MY SUCCESSOR WILL BE THE ONE TO CARRY OUT THIS PARTICULAR INFORMATIONAL ASSIGNMENT FOR THE NEXT FEW YEARS. BRIEFLY, THIS IS THE NEW, EVOLVING ISSUE TOBEADDRESSED. 84 UNTILTHIS POINT, WEVEBEENABLETODEALWITHAIDS WITHIN THE FAMILIAR PUBLIC HEALTH MODEL OF COMPASSION ANDREDEME?llON9'HEAME3RICANPEOPLEFEELBADWHENANY OFTHEIRNuMBERG~SIcKANDTHEyTRuLYWANTToHELp. THEYALSOFEELTmYARESuFFICIENTLYREWARDEDBYTHE ltETURN OFTHE ILL OR DISABLED PERSON TO HIS OR HER FAMILY, COMhNNlTY, SCHOOL OR WORKPLACE. THAT3 RED-ON. 85 AIDS DRAWS UPON THE GREATRESERVOIR OF COMPASSION IN THIS COUNTRY. ALSO, EXCEIT 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 ENDANGERINGHIMSELFORHERSELFORANYONEELSE,FORTHAT tim 86 BUT REDEMPTIONIS FAR FROM ASSURED. THEMORTALITY RATE FOR AIDS IS STATISTICALLY BETTER THAN 90 PERCENT . . . WHICH, FOR ALL INTENTS AND PURPOSES, IS TO SAY IT'S 100 PERCENT. HENCE, AIDS IS NOT LIKE HYPERTENSION, SYPHILIS, T.B., OR THE FLU. WE CAN BEAT THOSE DISEASES. BUT AIDS IS STILL BEATING us. ALSO, AFI'ER HEARING AND SEEING SEVERAL YEARS' WORTH OF INTENSIVE PUBLIC EDUCATION ON THE SUBm, THE AMERICAN PEOPLE MAY NOT BE INCLINED TO BE FORGIVING AND COMPASSIONATE WITH SOMEONE WHO -- TODAY -- ENGAGES IN CASUAL, UNPROTECII`ED ANAL INTERCOURSE OR WHO SHOOTS ILLEGAL DRUGS WITH A USED, AIDS-INFECTED NEEDLE AND CATCHES AIDS. 87 IHAVEBEENPREACHINGANDTEACHING~TWEMUST 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 PEopIlEBE~GABLlEToKEEpTHATDISTINcTION~INTHEIR MlNDSFORMUCHLONGER. THE COST TO THE AMERICAN TREASURY Is ALREADY BEGINNINGTOMOUNTWEUBEYOND ANYTHINGWECOULDHAVE IMAGINED 2 OR 3 YEARS AGO. 88 THE AVERAGE ANNUAL COST FOR THE CARE OF A SINGLE PERSON WITH AIDS RANGES FROM $40,000 TO OVER $100,000, D~~~GONwHATYOUINcLuDEINTHECOMpuTATIONAND - YOU ARE ON THE WEST COAST OR THE EAST COAST. IF YOU `IIKE THE MEAN COST, MULTIPLY IT BY THE CURRENT ANNUAL CASELOAD OF 33,000 PATIENTS, YOU COME Up WITH A THEORliZI'ICAL COST OF PATIENT CARE THIS YEAR THAT COULD EXCEED $2 BILLION. 89 AND THIS IS TERMINAL CARE FOR SOME INDIVIDUALS WHO, DESP~PUB]UCADVICENOTICETOTHECONTRARYY,CHOSETODO SOIvm'HING RISKY. THEY GAMBLED . . . AND LOST. SO THE COST OF COMPASSION WITHOUT REDEMPTION IS ALREADY VERY HIGH--AND~TCANONLY GETHIGHERUNTILWE FIND A VACCINE. BUT, AS I SAID A FEW MOMENTS AGO, WE AFtmE STILL SEVERAL YEARS -- MAYBE A DECADE -- AWAY FROM THE DEVELOlWENT AND RELEASE OF AN AIDS VACCINE. 90 I BELIEVE IT IS ABSOLUTELY ESSENTIAL THAT WE LOOK AT .THIsPROBLEM~cLEAREyEs...ANDTHEN,~~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. IBELIEVETHATMAYTURNOUTTOBETHEAIDSMESSAGEOF THE 90s. AND I DON'T ENVY ANYONE WHO HAS TO DELIVER IT. 91 THIS BURDEN UNFORTUNATELY, WILL FALL MOST HEAVILY UPONTHELEADERSHlPOFTHEBLAC!KCOMMUNITY,WHERETHE SHARPEST AND MOST ALARMING INCREASES IN AIDS CASES ARE BEING REPORTED, DIRECT RESULTS -- I SHOULD ADD -- OF THE , DRUG EPIDEMIC IN THAT SAME COMMUNRY. I CAN ONLY HOPE ANDPRAYTHATAMERICANBLACKSWILLHAVELEARNEDFlROM THEEARLYEXP~CEOFTHEHOMOSExuALCOMMUNITYAND NOT POLITICIZE THE ISSUE. JN PUBLIC HEALTH MATTERS, POLITICAL POSTURING COSTS LIVES . . . IT DOES NOT SAVE THEM. 92 THE POLITICAL CAMPAIGN TO KEEP OPEN THE BATH-HOUSES OF SAN FRANCISCO WAS STUPID AND DANGEROUS. AND EQUALLY STUPID AND DANGEROUS WAS THE ASSERTION BY AN ASSISTANT TO THE MAYOR OF CHICAGO THAT THE BLACK COMMUNTITY WAS THREATENED BY AIDS BECAUSE JEWISH DOCI'ORSWEEtEINJECTlNGTHEVIRUSINTOBLACKCHILDREN. THEGOODSENSEANDGOODHEARTOFTiJEAMERICANPEOPLE -- OF ALL THE AMERICAN PEOPLE -- MUST BE APPEALED TO AND MOBILIZED FOR THE REMAININGYEARS THATTHIS AGGRESSIVE AND VICIOUS DISEASE SURVIVES AMONG US. 93 AND THATS A JOB FOR PEOPLE ON BOTH SIDES OFTHE BRASS BUTIDNS I USED TO WEAR. NOW, YOU'VE BEEN FXTREMKY PATIENT, SO I WILL CLOSE WITHAFEWBRIEF,FINA.LREMARKS. 94 WHEN I ASSUMED THE! OFFICE OF SURGEON GENERAL, THE BIG TOPIC ON MY OFFICIAL AGENDA WAS SMOKING. AND I WAS D~TODOWHATEVERICOULDTOREDUCESMOKlT\TGIN THIS COUNTRY. IT WAS -- AND STILL IS -- THE LEADING CAUSE OF DEATH AND DISABILITY IN THIS COUNTRY. IN 1984 I DECIDED TO BITE THE BULLET, SO TO SPEAK, NO LONGER WAGE A PIECE-MEAL CAMPAIGN AGAINST SMOKING BUTTOGOALGOUT.ANDSOISENTOUTA"CALL"TOMAKETHIS A "SMOKE-FREE SOCIETY BY THE YEAR 2000." 95 THAT "CALL" -- PLUS THE RE LENTLESSANNUAL PUBLICATION OF DATA ON THE DANGERS OF SMOKING -- HAVE HAD AN EFFECT. PER CAPITA CIGARETTE CONSUMPTION IS D-Y GOINGDOWNINTHIS COUNTRY. UNFONIJNKELY, IN ONE OFTHE MOST DISGRACEFUL EXAMPLES OF PRIVATE ENTERPRISE GONE AMOK, THE CIGARETTE INDUSTRY IS FOCUSING ITS HIGH-POWERED -G A'ITENTIONONTHEUNPROTECI'ED ClTEENS OFTHIRD-WORLD NATIONS IN ASIA, AFRICA, AND SOUTH AMERICA. 96 AS A RESULT, THOSE NATIONS ARE NOW BEGINNING TO FXPERIENCE THE SAME RISE IN SMOKING-RELATED DISEASES THAT WE EXPERIENCED A GENERATION AGO . . . HEART DISEASE, STROKE, AND CANCER OF THE LUNG, MOUTH, ESOPHAGUS, AND SToMAm~ AS SURGEON GENERAL I WAS -- AND AS A PRIVATE CITIZEN, I AM-- APPALLED BY THIS BEHAVIOR OF AMERICAN COMPAN?J3SANi),FUR'lXER,IAMSHOCKEDBYTHEOUROWN GO-S SUPPORT OF SUCH BEHAVIOR. 97 WE WIU JUSTLY EARN `I!HE `ITILE OF "THE UGLY AMERICAN", AS WE CONTINUE TO EXPORT DISEASE, DISABILITY, AND DEATH TOTHETHIRDWORLDWHICHWILLNEVEJXBEABLETOPAYTHE HEALTHBILLDOWNTHEROAD. IDONOTBELIEVETEIE UNITED STATES WILL EVER AGAIN BE A GOOD MARKFT FOR TOBACCO PRODUCTS. THE CURVE IS GOING DOWNANDACCELERiTING. ANDIFEELQUITEGOODABOUTTHEROLEIBELIEVEIP~~ INBRINGINGABOUTTHIS MARKETCHANGE. DURINGMYTENURE, SMOKING IN THE UNITED STATES DROPPED FROM33 PER CENT TO 26 PER CENT. 98 MYONEREGRETISTHATIAMLEAVINGOFlFICEJUSTAS~ ~G~ISB~~GTOR11>THERESTOFTHEWORLDOFTHE SCOURGE OF TOBACCO AS WELL. IT'S A SHAME, BECAUSE I REALLYFEELUPTOlT. BUT I MUST LEAVE THAT CAMPAIGN TO MY SUCCESSOR. AND LASTLY, I LEAVE TO MY SUCCESSOR -- AND ALL SUCCESSORS B -THESUREKNOWIEDGETHATYOU CAN MAKE A DIFFERENCE THROUGH PUBLIC SERVICE . . . AND THAT THE DIFFERENCE MAY BE IN YOURSELF, AS WELL AS IN YOUR NATION. ANDBOTHARED- Y WORTHTHETROUEXE. THANK YOU. ##### 99