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."

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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.

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  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.

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  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.

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  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.

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99