Presented at the Opening Plenary Session of the 69th Annual Meeting of the American College of Physicians
New York, New York
March 3, 1988
It was only 2 days since I had last spoken about AIDS publicly and on this same day I had already addressed the American College
of Physicians on another huge health problem in America, -- smoking.
The American College of Physicians is one of this country's most prestigious medical organizations and their traditions
mean something to them and everyone else. I noted that they had changed their practice that morning and that the plenary session
that I was addressing was a real departure from tradition and that I was honored to be the chosen speaker. I expressed the
desire to take advantage of the opportunity and their hospitality to explore a couple of questions that troubled many of our
colleagues in medicine and a great many of our fellow Americans as well. These questions had to do with the AIDS epidemic
-- chiefly whom it was affecting and how we were responding. I issued a disclaimer at this point saying that I would not dwell
on the particulars of the disease because the daily press and the professional journals, which they read so avidly, had done
a very good job of that. Indeed, the American College of Physicians itself had done an excellent job of informing the medical
profession of the medical, scientific, and the social aspects of the epidemic.
I extended a word of appreciation to the college for its "position papers," approved and released the previous month,
which recounted not only the facts about AIDS, but also dealt with the ethical and financial issues that had evolved over
the 6-year history of this dreadful disease. These papers echoed the request made by many others that the federal government
come forward with a clearer and more precise statement of national policy regarding AIDS.
This gave me the opportunity to say that I placed as much or possibly even more faith in the policy positions taken by the
college, by the American Medical Association, by the American Nurses Association, and by many other groups representing health
professionals. If all of them say that as concerned professionals something should be done, the chances are very good they
will be - certainly much better if I should do the same thing.
I expressed a conviction that the overwhelming majority of the American health professionals were living up to the highest
ideals of their calling. Virtually all patients who developed AIDS were being cared for and the American people ought to be
aware of that and comforted by it.
Then, came the hard part to express properly the fact that many Americans -- possibly as many as 35 millions -- were outside
the traditional system of health care delivery in this country. They were not our familiar patients, they did not have a family
physician, they were not covered by health insurance, but fortunately, most of them did not engage in high-risk behavior and
therefore, would not contract AIDS. If the opposite were true, we would certainly have known about it by the time I was making
Although we didn't know what percentage of the uninsured and culturally isolated might be carrying the virus, we do know
that the people who were infected plus the people at most at risk were becoming infected would include drug abusers who shared
the works of I.V. drug abuse. They comprised a fourth of all AIDS victims at the time of this lecture. They had never been
within easy reach of the health care system and even the AIDS epidemic had convinced only a few to come forward and shake
The high-risk population was also homosexuals or bisexual males who were not monogamous and who still engaged in rough and
unprotected anal intercourse with multiple partners. This group accounted for two-thirds of all AIDS cases thus far. We did
have evidence that public education programs had greatly reduced the numbers of men engaging in high-risk sexual behavior.
(All of this was a true statement. The initial response of the homosexual community was to inform their own about the dangers
of HIV, but they had done that, they rested on their laurels not realizing that every day young men come to the realization
that they are homosexual and therefore, the task of education never stops. Statistics prove what I had just said.)
The at-risk population also includes a number of women, mainly, but not exclusively, prostitutes. Many are drug abusers themselves
or are sexual partners of such. These folks are not on the patient rolls of most physicians.
Next, there are the children, really infants. Seven hundred had already been given AIDS along with the gift of life by their
virus-infected mothers. Finally, I recalled that a number of disproportionate number of persons with AIDS are Black or Hispanic
and live in urban areas where health care systems were already stretched to the limit.
I stepped over the social line and added that the overwhelming majority of Black and Hispanic Americans were not at risk for
AIDS, just as the overwhelming majority of Whites are not at risk either. However, the Black community -- already grappling
with housing, employment, and education was beginning to feel overwhelmed by the addition of the AIDS issue as well. They
needed the understanding and assistance of the majority White community in this country and were obliged to respond.
For the most part, all of these Americans still linger on the perimeter of -- or clearly outside -- our system of health care
delivery. They desperately need to get in. My personal contact with these folks has indicated that they accuse all of government
and society of being, at the very least, callous and indifferent, or at the very worst, racist and vengeful. I don't agree,
I think we're in a terrible bind -- one that persists despite the best efforts by people of good will and all backgrounds.
Yet, on the other hand, I'd spoken to colleagues that you know well in medicine and social services who dismiss the plight
of people with AIDS as something they "brought upon themselves." I don't agree with them either. It's not
all that clear to what extent an American man or woman, born in -- and dying in -- an urban American ghetto, has the emotional,
cultural, educational, or economic wherewithal to truly control his or her own personal behavior.
These folks are fearful and so am I, but for other reasons, I sense the effects of the AIDS virus on the social compact that
has held American society together through periods of profound turmoil as well as tranquility. I also sense its effect upon
the health system of our country that reflects an historic national temperament of charity and tolerance, of responsiveness
I also feel the affect of the AIDS virus upon the people who make the system work . . . the physicians and nurses, the dentists
and technicians, the social workers, and the administrators. Our calling, which you know so well, is based upon the most valued
ethic in human history . . . an ethic that is integral to our professional oath, which says, in effect, "Do what you can
to help . . . but in any case, do no harm."
In your position papers there is strength in this point of view.
I closed this talk to a very prestigious audience by some simple words of advice how they could actually help right where
they were and doing what we needed. I did say that we were being tested and that the epidemic of AIDS was providing one of
the most serious tests of social and political will that our society had ever undergone. I believe that we will come through
a test with our ideals and our institutions intact. I say that because I believe the professional men and women in this country
will, in the long run, roll up their sleeves and do what has to be done despite an environment of overwhelming tragedy, both
personal and national.
AIDS and our social compact
AIDS and prostitution
AIDS and the Hippocratic oath
AIDS as a generator of fear
AIDS as a testing ground for the future of health care
AIDS -- how are we responding?
AIDS in infancy
AIDS -- who is affected?
American College of Physicians' special plans for this meeting
Barriers to access to health care
Challenges to the medical profession
Disproportionate incidence in Black and Hispanics
Effect of AIDS on the health care system
Health care and the socially isolated high-risk behaviors in AIDS
Health care and the uninsured
Paraphrasing the Hippocratic oath for the AIDS epidemic
Patients on the margins of health care
Patients without physicians
Perimeter of health care
Position papers of the American College of Physicians