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 from 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
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.