"AIDS and the Social Order" 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 a Forum for Kalamazoo County
February 16, 1988
It had been fourteen days since I had last spoken publicly about AIDS.
Kalamazoo Michigan, at the time this speech was given, was home of the Upjohn
Pharmaceutical Company and the home of the Stryker Corporation. The latter dealt in the manufacture of orthopedic frames and
appliances. Both were industrial giants, both wielded extraordinary influence in Kalamazoo, and its surrounding areas and
both, indirectly, were eventually responsible for a crisis, not in the paucity of heath care, but in too much health care
and too much money being spent for it. (Many years later, I exposed this anomaly, when I was doing five one-hour primetime
specials on health care reform for NBC, which they entitled "C. Everett Koop, M.D.")
Ted Cooper was the president of the board of Upjohn and the reason I had been asked to speak. He had been at one time the
director of the National Heart, Lung and Blood Institute at the National Institutes of Health, had been the dean of the Cornell
University Medical College, from which I graduated -- although in a different era -- and then had been the Assistant Secretary
for Health in the Department of Health and Human Services. After he left that post, he eventually wound up as CEO at Upjohn.
He was, for a period of time, I believe, the most powerful, influential medical personage in the United States, if not the
world. He took a liking to me when I became Surgeon General and was available for advice anytime I needed it, but also offered
advise he thought I needed whether I asked for it or not. On several occasions when he was flying from Kalamazoo elsewhere
in the United States he would arrange to pick me up in Washington so that we could fly together and have a chance to talk
about governmental problems in health. I found him to be a valuable friend and an interesting companion. After I left government
and became a director of Biopure Corporation in Cambridge, Massachusetts, he arranged for the initial financial partnership
between Upjohn and Biopure. When Upjohn merged with Pharmacia our relationship did not continue. For Ted Cooper and Kalamazoo
this would be a new lecture and not a repeat and after thanking Ted Cooper and bringing him the greetings of his former devoted
colleagues, I committed myself to sharing my perception of what effect the
epidemic of AIDS is having upon the way Americans think about disease, health and responsibility.
The Michigan statistics were for those days not very impressive with 530 people reported as having AIDS; not much of the national
total of 53000. But looking at numbers alone would lead to missing the real story of the disease, which had burrowed its way
into the fabric of American life. It was my impression that if we didn't recognize that damage it could do there, it would
cost more and lose more than human lives. I told the audience that the nation's social cohesion and national purpose were
threatened and that included enough so that our job as citizens and community leaders was to save individual lives and to
save our country.
I then went on to say things I have said many times before about the fact that AIDS is a mystery, is fatal, and is transmitted
by behaviors that most people don't engage in or approve of other people doing either. Therefore, we had reason to be
cautious and not paralyzed by the discrimination shock resulted from such attitudes.
By way of practical suggestion I talked of the Public Health Service guidelines, and reported for the first time a different
number of health care workers out the force of nearly 7 million who had infected on the job by the AIDS virus- fewer than
a dozen. In each of these cases the risk had been avoidable. Yet, in spite of this remarkable record, there were still professionals
who would not treat AIDS patients. But the response of many private organizations had been most encouraging. The American
Management Association had developed briefing materials, The National Education Association had done the same for its members,
individual businesses such as AT&T, Westinghouse, San Francisco based Wells Fargo, and Bank America are among the first
of many to do something positive about AIDS education for their own companies. That however leaves a great deal that local,
community leaders -- such as those in Kalamazoo -- could do to maintain a rational, compassionate approach to the problem
and that does not mean one has to compromise, in anyway, just how one feels about the kinds of behavior that makes AIDS possible.
We have to keep our priorities straight: first, fight the disease and not the people who have it; second, educate everyone
about the disease so it would not spread. I then turned to economics quoting an annual expenditure now of about 1.6 billion
dollars to which the American taxpayer contributes about 1 dollar of every 4. However, over the next four years the annual
AIDS caseload will more than double and annual costs will more than triple.
There is a difference with past experience with government programs in that, unlike maternal and child health programs, alcohol
programs, drug abuse programs, and hypertension screening and so on where the patient and the community benefit, AIDS is fatal
and the annual cost is now running between 20 and 50 thousand dollars per patient depending upon the city and the type of
AIDS-related condition the person has. I then raised the question about whether our traditional altruism was being threatened.
Most Americans are generous to a fault but I certainly was in a position to hear echoes of other irrational and hateful responses
to people with AIDS.
I had to mention that AIDS was becoming particularly a scourge of people who were young, Black, or Hispanic; among persons
with AIDS under 30, 25% are Black and 14% are Hispanic. This is twice the rates at which these groups appear in the population
as a whole and it's worse among females than among males. I closed with a plea for leadership and hoped that we were secure
enough to strive to extend our very best medical care to every citizen who needs it.
AIDS and the threat to altruism
AIDS and the way Americans think about disease
AIDS and the young, the Black, and the Hispanic
AIDS as a threat to the nation's social cohesion and national purpose
AIDS compared to the response of Americans to other health problems affecting the public
American Management Association briefing materials
American tradition of non-abandonment of patients
Characteristics of AIDS
Fairness and social change
Irrational and discriminatory response to AIDS
Low incidence of AIDS infection among health care workers
Michigan statistics on AIDS
National Education Association's by lines
Need for caution as oppose to paralysis
Need for community leadership
Predictions of costs and caseload over the next four years
Priorities in AIDS management
Public Health Service Guidelines for AIDS
Rational compassionate approach to AIDS
Refusal to treat patients with AIDS
Statistics on cost
The cost of AIDS
The threat of AIDS to the fabric of American life
The management of AIDS as opposed to other US public health programs