Fourth Annual Ash Lecture 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 Armed Forces Medical Museum
June 1, 1988
It had been four days since I had last address a public audience on the AIDS epidemic.
One of the things I enjoyed most during the eight years of my two terms as Surgeon General was the opportunity I had to mingle
with the medical personnel of the Army, the Navy, and the Air Force. In particular being a member of the National Defense
Health Council was a privilege because not only did I meet my counterparts in the three armed forces, but also the highest
ranking medical folks in the Uniformed Services University of Health Sciences and the Veterans Administration, but in addition
non-medical people from the Joint Chiefs of Staff and the offices of the Secretary of the Army, the Navy, and the Air Force.
I wanted this occasion to be an opportunity when I could acknowledge the Public Health Service achievement, as well as the
excellent cooperation and assistance we received from the Armed Forces as we moved forward toward our goal.
It was appropriate that the Army Medical Museum had just opened a new exhibit on AIDS, for which I thanked the director and
his staff and made the suggestion that if anyone was the least bit unclear about AIDS, a study of the new exhibit at the Armed
Forces Medical Museum would do the trick.
I acknowledged that we had very strong and well conceived efforts to keep the general public, as well as the medical and health
professions, informed of all the developments in the unfolding tragic chapter in human history. The "we" I referred
to was the United States Public Health Service, but I acknowledged that we couldn't have done it without the popular press,
and our own professional journals.
I laid out my focus as being not the details of the disease and its history, but instead the focus on three main aspects of
the epidemic and how they were affecting the way Americans thought about the disease, about each other, and about responsibility;
professional, social, and personal responsibility.
I began with analogy of AIDS attacking the central nervous system, but also I pointed out how it had disturbed the peace of
mind of our citizens and was a constant challenge to our social cohesion and national purpose.
I went through my usual litany of AIDS being a mystery, a virtually one hundred per cent fatal disease, and one that is spread
by behaviors that most people do not practice and do not approve of others practicing. I reminded the audience that we had
been working on AIDS only for half a dozen years and that our critics, who might be well meaning, as well as highly critical
and impatient with government, really had an extraordinarily lack of understanding of the processes of scientific inquiry.
I also said that we in the biomedical world had to look at our own "culture" and be truly interdisciplinary and point
to an example that had taken place that past February under the co-sponsorship of the Armed Forces Institute of Pathology
and brought together for the first time in one meeting clinicians and pathologists to share their views on AIDS. I thanked
Dr. Abe Macher of the A.F.I.P and Dr. Harold Ginzberg of the National Institutes of Health.
The desired clear-cut answers the public demanded were not available and that was hard for a generation that had grown up
confident of the conquest of biomedical science - not its defeats - and a generation that had been successfully inoculated
against polio, measles, and half-a-dozen strains of flu. I took a poke at the enthusiasm for anti-baldness remedies and suggested
that the same generation might be the first not to go bald. Even if science could conquer baldness, it didn't mean that
an AIDS cure was just around the comer.
To this largely medical audience I was frank and clear about the methods of transmission, but did not have to be as specific
as I might have been to a lay audience, and of course, I added a list of the things that were part of the transmission process.
It was the first occasion on which I added vaginal secretions to blood and semen as body fluids containing the highest concentration
Speaking to government people, I felt it should be mentioned again how tolerant the American people had been of those who
got sick because they did something they very likely knew was not a smart thing to do. Hence, we have relied on tax revenues
to support V.D. clinics, alcoholism and drug treatment centers, as well as to do diet nutrition counseling, family planning,
and emergency medical services for highway trauma. Yet, AIDS had driven the first serious wedge into our remarkable public
health compact. The reason was simple enough. With all the things that happened between the time of the entrance of the virus
into the human body none of them so far plays a role in preventing the person from dying. So, after a prodigious investment
of public funds there was no rescue, no reformation of character, no one is saved or redeemed and returned to society. I added
that one symptom of this unrest was that the upcoming election in California in that year may have a referendum stimulated
by a half-million signatories to a petition that would require physicians to report the names of people who did not yet have
AIDS, but were HIV positive. Fortunately, California also had a strong confidentiality statute that applied to HIV records
and AIDS as well. I was concerned that sero-positivity information could escape that control, and inasmuch as our reticence
to have mandatory testing or mandatory reporting was based on our fear of discrimination we had to acknowledge that California
had no anti-discrimination law.
These questions were first raised in the 1970s when herpes, reportable under federal and state laws was reaching epidemic
proportions and I reminded the audience that herpes, while not fatal, was a lifelong condition with no cure. Unfortunately,
before society could agree on an equitable way to handle the herpes problem, we were confronted by the AIDS problem. And that's
where we are now, still trying to sort out the issues, the people, the science, the economics, and do so within the framework
of our better than 200 year-old democracy and its commitment to protecting the individual citizen. In 1987, President Reagan
at an Awards Dinner put on by the American Foundation for AIDS research, stated that we had to fight this disease with everything
we had at our command, but he said this: "It's also important that America not reject those who have the disease,
but care for them with dignity and kindness. This is a battle against disease, not against our fellow Americans."
As I remember those words and the occasion on which the President said them, I have to remember that was also the night that
I, in full uniform was burned in effigy on a street in Georgetown, because my statement that we were fighting a disease and
not the people who had it, was interpreted by some to be coddling the homosexual community. So, our challenge is always to
show the world how compassion and justice . . . in addition to first class science . . . can triumph over this mysterious,
Achievements of Public Health Services in AIDS
AIDS and America's social cohesion and national purpose
AIDS contrasted with other social programs
AIDS exhibit at the Armed Forces Medical Museum
AIDS and the central nervous system
American tolerance of behavior that produces illness
Californian petition for AIDS referendum
Confidentiality in AIDS and HIV records
Critics' lack of understanding of scientific inquiry
Culture of biomedical science
Expectations of the public from science
Fatality of AIDS
Fight the disease of AIDS and not the people who have it
Goal of the Public Health Service in AIDS
Herpes in the 1970s and AIDS now
Lack of an AIDS vaccine
Lack of clear-cut answers on AIDS
Mandatory reporting of people with AIDS or HIV
Mystery of AIDS
Need for first-class science
Popular press in health education
Relationship of AIDS mortality to lack of optimism
Responsibility: professional, social, and personal
Sights of highest concentration of the AIDS virus
Tax revenues to support social programs
Transmission of AIDS
Use of compassion and justice
What doesn't transmit AIDS
Working relationship between the United States Public Health Service and its sister, Uniformed Services