Surgeon General Everett C. Koop Oral History 1993
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THE EARLY DAYS OF AIDS AS I REMEMBER THEM
Because some of you are historians, you might like to know that at Dartmouth there have been so many youngsters who have been concerned about health care and wondering about what they should know about it that we're going to have a course in the History Department on "The History of Health Care and Health Care Reform in this Country," so they'll at least know what's going on and when we have health care another generation down the line they'll be better prepared for it.
Early in 1981, when I was designated as Surgeon General, I had never heard of AIDS. No one had ever heard about AIDS. And, as a matter of fact, there were really only a handful of scientists who understood anything about immunodeficiency, and they didn't really have a name for it, much less know what it really was.
And AIDS entered the consciousness of the Public Health Service rather quietly, rather gradually, and with almost no fanfare at all. In June of 1981 it was reported at one of the senior staff meetings what was to become the AIDS epidemic, and it's a familiar story to all of you here. It was the story of those 5 well beforehand homosexual males who developed Pneumocystis carinii pneumonia, a disease I had handled in my cancer problems at the Children's Hospital of Philadelphia. Five cases isn't many, but that disease, only a handful sounds like an epidemic, and so it turned out to be. And soon the reports began to trickle in about other cases elsewhere, and a month later, at an agency heads meeting down in the Humphrey Building, we had the second report from CDC concerning 26 young homosexual men recently diagnosed as having Kaposi's sarcoma. 26 in one report, and in my lifetime I'd seen but two. So, there was something very uncommon going on. But from that very small beginning, those cases mushroomed into the AIDS epidemic of the late 1980s. And I remember the very first thought that I had after that second presentation, and that was about sodomy and enforced sodomy in prisons, and I remember mentioning at the time but didn't seem to have any people who were sympathetic. The Public Health Service had never had experience with a syndrome quite like AIDS before, and so they gave it a somewhat awkward title, which we still have, acquired immune deficiency syndrome. For a short time some people called it "GRID," Gay-Related immunodeficiency, but then there were new cases that came up that were in non-homosexuals and so it was called A.I.D.S. And then it was just called AIDS. And I've often thought what a great thing that was because we didn't have to put all those periods we would have to put in all these years. It could have stretched from here to the Sun and back.
By August of 1981 I and others were paying attention to the unusual news from CDC and learned that there were now just over 100 cases and almost half of those had died. So I knew--everyone knew--that we were in for big trouble, but there was not much that I could do about it. I was not the Surgeon General. And all through that awful summer of 1981 I was really preoccupied by my long struggle for confirmation as Surgeon General by the Senate. But I realized that if ever there were a disease made for a Surgeon General, it was AIDS. But for reasons of intra-Departmental politics, which I still do not understand to this day, I was cut off from the inner discussions about AIDS and from making any statements about AIDS for the next three and a half years. I was told that I would have my hands full and that AIDS would become someone else's responsibility.
And so, in those early days of my tenure as Surgeon General, I had to learn about AIDS on my own. I learned it from the newspapers, from internal documents of the Public Health Service which, of course, I had access to. I also read the MMWR and I did have discussion with colleagues.
Now, there were two reasons, I think, why it took awhile for public health authorities to get a handle on AIDS in the beginning. First was the relatively small number of trained clinicians and researchers who were familiar with these rare diseases which were turning up as opportunistic infections, and they were occurring in places like San Francisco, Los Angeles, Chicago, and New York. The second reason was that the first patients with those conditions were homosexual men, most of whom had patronized physicians and clinics that were more understanding of their so-called "gay lifestyle." And in making that choice for care, which was quite natural, these men effectively placed themselves outside of mainstream clinical medicine and therefore they were very difficult for us to know--to reach--and of course to help. And as a result, our first public health priority, that was to stop the further transmission of the AIDS virus, became needlessly mired in the homosexual politics of the early 1980s and we lost a great deal of precious time because of this and I suspect that we lost some lives as well. By July of 1985, CDC had reported just under 12,000 cases and just under 6,000 of those had died. And then just a week later I recall that the numbers for both the cases and the deaths had jumped by 100. So, the AIDS epidemic was really progressing and doing so at an accelerated rate. Then just about that time we were introduced to the death of Rock Hudson, who was the first national figure to die of AIDS, and that raised further public concern, of course, about the disease, but for the first time it captured the attention of the Reagan White House because the President, having been a former actor, was connected with the people who were now concerned and it touched the White House rather indirectly. It certainly didn't touch it nearly as severely as I wish that it might have. Also in 1985 we developed a test to identify the presence of antibodies. We hadn't seen the virus, but we knew it was there because we knew about the antibodies. There were lots of charges about foot-dragging in those days and they still continue in public television shows but, as Ruth said a few moments ago, we learned as much about AIDS in those first 6 years as we had learned about polio in the previous 40. And although we acknowledged that there was much that we did not know, and that we had made extraordinary progress in understanding what we did know, we had identified the virus, we named it, then we renamed it, we understood the epidemiology about homosexual men and about the transmission through the sharing of the works in in intravenous drug abuse. We learned of homosexual practices that were hitherto barely mentioned, and we understood, perhaps for the first time, the extent of homosexual promiscuity. As I said, we identified the antibodies to the virus and developed a screening test on the basis of that for the detection of these antibodies and this, in turn, made the blood supply relatively safe for transfusion, and we learned how to kill the virus in the blood products that were making clotting factors eventually safe for hemophiliacs.
But above all we were concerned about the disease was transmitted. And we learned that although the virus had been identified in several body fluids, it seemed to be transmitted only through blood and through semen and, nevertheless researchers were very cautious. I remember, for example, that Tony Fauci, later to direct the AIDS research here at NIH, insisted that we check out any study that didn't seem to rule out the spread of AIDS by casual contact. But gradually a convincing body of research led us to some very important conclusions. It was clear that, in spite of all kinds of unsubstantiated claims about mosquitoes and toilet seats and door knobs and that sort of thing, AIDS really could only be transmitted in four ways: through sexual contact, through blood contact associated with i.v. drug abuse, through pregnancy or delivery--contact between an AIDS-infected mother and her infant--and finally through transfused blood. But the most important thing, and perhaps the worst thing that we learned, and the deadliest, was the news that if you had AIDS your chances of surviving the next two or three years were not very good, and surviving much beyond that time were essentially nil. And then, as some presidential appointees began to prepare to leave Washington after the second Reagan election, I did have the opportunity to begin to talk about AIDS in 1984, and eventually my personal distance from the AIDS information and policy came to an end when President Reagan asked me to write a report to the American people on AIDS. And then, for the next two years, AIDS really took over my life. I had heard the rumors for a week or so and at the end of January, 1986, at a dinner hosted by then Secretary of the Treasury Jim Baker and his wife Susan, at least two members of the White House staff that were there came up to me and said, "You're going to be in the President's State of the Union Message." Well, they said that, but I wasn't too sure because White House gossip had told me that there were 1,500 items that had been presented to the President for inclusion in that speech and I thought that even if the President might, himself, be ready to eventually talk about AIDS, I was sure that his advisors were not ready.
I had previously talked to the Domestic Policy Council twice about the possibility of an AIDS report and they had raised the question with me, didn't I think that a Surgeon General's report would be appropriate. And I said, "Ever so much appropriate but, on the other hand, I hope you all know that there are down-sides to this politically for the President, because some of his constituents are not going to like the things that have to be said, and I'm not sure that you people are ready for the kind of straight talk that such a report would really have to include." Well, the night came for the President's speech and my wife and I sat there, in 1986, and over the tube came this rather upbeat, frothy kind of a speech, and halfway through we knew that the President was never going to mention AIDS. And he didn't. And that night, before I went to bed, I told Betty, I said, "Well, I guess I'm off the hook about writing that report." And then, just a few days later, the President made an unprecedented trip across town to the Humphrey Building and addressed, in the Great Hall, as many people as could crowd in there from the Department of Health and Human Services. And he said all the right things, you know, and thanked them all for their great and faithful work and, in the course of his remarks, he said that AIDS was a top priority for the Department and he looked forward to the day when there would be a vaccine. And then he announced that he was asking the Surgeon General to prepare a special report on AIDS. That was it. There was never a formal request. And I've often thought it's a good thing I went and it was a good thing I was paying attention. (Laughter.)
Now, I assumed that that report was meant to be simple and to be in language that could be understood by the average citizen; that it was really meant to allay the panic of those who were afraid they might get AIDS but really were never exposed to it; but also to warn those that were engaged in rather risky behavior what the inevitable outcome would be if they encountered the AIDS virus. But, you know, I knew that the Government clearance process could ruin any report that I would write and what I needed was the authority to write one on my own without having it cleared by anybody, and that's a very difficult thing to achieve in this Government. And what happened was the nice timing of the arrival of a new Secretary of Health, Otis Bowen. Now, Otis Bowen had been the Governor of Indiana, a very sharp Republican politician, and he was at HHS--people thought--to be a "caretaker" until the end of the term. But Dr. Bowen really served with distinction and actually served longer than anybody up to that time ever had in. (Side 1 ends mid-sentence).
(Side 2 begins mid-sentence) My work in Washington amounted to walking a tightrope because I needed to be in touch with all of the national groups that were really concerned, rightfully, about AIDS. I wanted to make sure that they knew what I was doing. I wanted to be sure that when we published the report they couldn't say that they had been kept in the dark or were blind-sided in any way. But equally important was that I needed all the help I could get and I really did value their input and advice. But, at the same time, I had to be sure that that report was independent and that it was objective and that it would be my report and not theirs, and to do that I really had to distance myself from those same groups who had provided me such encouragement and information.
A few of the meetings were especially helpful, that I think I should mention. The information provided by the National Hemophilia Foundation was absolutely critical. Their experience with hemophiliacs who had become infected with the virus allowed these tragic cases to be studied very carefully and it made a major contribution to our understanding of the disease. We also learned about the strength of young people who lived through their lives with two diseases as well as the fear of discrimination around every corner. The hemophilia experience nailed down the evidence that AIDS could not be spread by casual contact. 600 families were very carefully studied and their members, with a 2 year exposure to the virus, touched each other, used the same utensils for cooking, kissed each other, some shared razors, without passing the virus. Even the 7 percent who shared toothbrushes--and I must say that figure surprised me a lot--saw no transmission of the virus from infected patients to their toothbrush partners. Now, this was very important. This and a number of other studies meant that AIDS could not be passed by casual contact. Therefore, most Americans were not at risk if they did not engage in the high-risk behavior with sex or drugs. It also meant that persons with AIDS should not suffer discrimination and that the strident calls for quarantine or to deny them housing or insurance or employment or public schooling had to be repressed. Now, I had the help of two Public Health stalwarts in all of this effort, Mike Samuels and Jim McTiegh, and in August of 1986 I began to write the first draft of "The AIDS Report." I wrote and I rewrote, usually doing this in my residence at the Campus here, down in the basement, at a stand-up desk and, after the sixteenth draft I took it over to Tony Fauci, who eventually became the chief AIDS researcher here at NIH. He read it and made some excellent suggestions. But, other than that, and three women that I selected out of the wives of Public Health officials, nobody else really had a chance to look at that thing. The official American response to AIDS, as far as the Government was concerned, hinged on two Cabinet meetings. Remember this is a report now that I wrote, and the only Government person that really officially screened it was the Secretary of HHS and the next level was the Cabinet. Now, the first meeting was with that part of the Cabinet that only deals with domestic affairs and they, plus a lot of other people in the White House, are called the Domestic Policy Council. And the other one eventually would take place in May of 1987 and would involve the entire Cabinet and the President himself. Well, you can imagine that at each meeting I had to skate rather fast over thin ice to get by the political appointees who placed conservative ideology far above saving human lives. And knowing the way that Domestic Policy worked, I could see that a certain amount of nitpicking could take place and soon we would either have a report on AIDS written by political advisors to the President, or we would have no report at all. I also knew these people didn't like to spend money and so I decided to take a psychological gamble. It had been planned to print this report in a brochure that was four by nine inches, cheap paper, because we planned to print 2 million copies. So, I also ordered 1,000 copies printed on the best quality glossy stock I could find in the royal blue of the Public Health Service, with a seal in shining silver, and across the top the title, Surgeon General's Report on Acquired Immune Deficiency Syndrome. I figured if the Domestic Policy Council were to suggest changing anything in this report they would realize it was going to cost a fortune and they might back down. I think my first remark at that Cabinet meeting took them very much by surprise. I had nothing to lose and a lot to gain. And what I said was, "On what I read in the newspapers I've come to the conclusion that this room has a lot of leaks in it, and I would be very unhappy if this report were to reach the press before I released it, and therefore I am handing out numbered copies of this report and I hope you'll not be offended if I collect them at the door when you leave." I didn't have any comments, but I can tell you a lot of eyebrows did go up. I reviewed the report for them, page-by-page, but, I must say, in a rather superficial manner, and there was very little discussion. White House gossip informed me later on that the gentlemen present did not want to discuss condoms in the presence of the ladies who were present. So I knew that what I had said had not been absorbed in any depth by anyone. (Laughter.)
But at long last, on October 22, I did call a press conference, released the AIDS report and, of all the things that I said, only two words seemed to be remembered, "Sex education," and the next few days were spent fending off the press, questions about my ideas on when sex education should begin, and many of the larger issues in that AIDS report were eclipsed temporarily by this distraction. In the meantime, having failed to come to grips with the AIDS report when they first read it, the political meddlers in the White House tried to bottle up the whole effort and, in a very unusual move, two members of the Domestic Policy Council came across town to the Humphrey Building to interview me. Usually, when the White House calls, it's a demand appearance there and you go. And what they came to ask me was that they wondered if it wasn't time to update the report.
Well, the report was only two weeks old. AIDS was moving along fast, but not that fast. And the report didn't need any updating. In fact, that report doesn't need any updating today. And, of course, what they wanted me to do was to take out the word "condom," and this I refused to do. Meanwhile the presses were running and the mail trucks were running and the report went out and, at last, the people of the country did have something in hand that could tell them what was myth and what was fact about this epidemic and they knew it in plain English. But people really wanted to hear more and I found myself deluged by requests from all over the country to speak at various meetings, conventions, and even to combined sessions of state legislatures. America finally was getting mobilized for the first time against this epidemic. France and Australia requested permission to publish parts of that report. And a new and surprising band of opponents suddenly materialized against me. Suddenly I found myself praised by my formal liberal adversaries and condemned by my former conservative allies. Everybody, or at least those who didn't know me, said that I had changed. Conservatives said that I had changed and they were angry; liberals said I had changed and they were pleased. But I really hadn't changed at all. All the fuss surprised me somewhat. I just did what I had always done as a doctor. My whole career had been dedicated to prolonging lives, especially the lives of people who were weak and powerless--the disenfranchised--people who needed an advocate, newborns who needed surgery, handicapped children, unborn children, baby Does, and people with AIDS, and they were all the same to me. Some of my new opponents were more annoying than alarming, like Phyllis Schlafly. Why anybody paid attention to this lady is one of the mysteries of the 1980s. Maybe no one really did, but she sure buzzed around me like an angry hornet. Phyllis Schlafly would really rather have seen promiscuous young people contract and transmit AIDS than expose her own children to the knowledge that there were such things as condoms. Now, I didn't like having to talk about condoms, I must admit. It was really difficult for an old-timer, then 70 years of age, about to celebrate his 50th birthday, to be called "The Condom King." Sometimes talk about condoms in America in the wake of the AIDS report reminded me of 7th Grade children who finally found that they could go behind the barn and talk about naughty words. But I have to reiterate here what I've said so many times. I really never, in public, television, radio, lectures, I never talked about condoms as a preventive measure against AIDS without first stressing abstinence for young people and mutually faithful monogamy for older people. But the press never reported anything I thought about anything except that I was for condoms. But if the general public seemed to be making substantial progress in learning about AIDS, the White House still was not on board. And I quickly saw--or it wasn't quickly; I came to this decision rather slowly--that the Reagan White House, including the President himself, really reasoned usually in an anecdotal fashion instead of examining the evidence and acting upon those conclusions. In one of many examples, at another meeting of the Working Group of the Domestic Policy Council, one member, a nurse no less, said that there were many people in the country who really believed that AIDS was transmitted by cats, by mosquitoes, by door knobs and by typewriter keyboards and toilet seats and, she said, "Who was to know? Maybe they're right and the Government is wrong?" Now, these discussions about AIDS with a variety of Government officials of high level really depressed me about the lack of intelligence among some people in high places. The major problem really was that the President was reluctant to go out front offering the leadership that only he could provide. At least a dozen times I plead with my critics in the White House to let me have a meeting with the President so that he could hear from me my concerns about America and the AIDS epidemic and what his role should be in it. And for months I had been trying to cover the rather embarrassing silence of the Oval Office on the scourge of AIDS. I kept telling myself that the President would soon speak out. And finally he did, in April, 1987. And the occasion was interesting because it was back in my home town of Philadelphia.He went up there to celebrate with a speech the 250th anniversary of the oldest coterie of medical people in this country, the Philadelphia College of Physicians. And the day before he went, I got a call from one of his assistants, not from a speechwriter, who asked me, "Do you think he ought to mention AIDS?" And I said I thought that was the purpose of the whole meeting. And he did mention it, for the first time in public, touching upon the epidemic briefly and superficially in his speech. And that afternoon, when he went down to the Philadelphia Airport to get on Air Force One to come home he was crowded by reporters who kept asking him question after question to which he replied nothing at all until he got to the top step, just about to enter Air Force One, and he turned and said, "Just say no." And that night Tom Brokaw reported on his evening news hour that the President had never read The Surgeon General's Report on AIDS. So, by the spring of 1987, it had become obvious that one issue would shape official policy on AIDS in the United States, and that issue was testing for the antibodies to the virus. At first the suggestion was to test many people. With a killer disease on the loose, just test everybody and see who has it. But a little more thought on the issue fortunately revealed the shortcomings of that rather simplistic solution. First, what would you do with those who tested positive? Of course, I'd already heard from those Congressmen and others who wanted either to kill them or put them in concentration camps. And there was that little issue of the Constitution which really didn't allow you to round up people just because they were sick. And AIDS became an issue, therefore, not only of health, but also of civil rights. Widespread AIDS testing could result only in widespread discrimination against people who tested positive. And already the American people, at least those Americans who thought with justice and compassion, were horrified by stories such as that of Ryan White, the school boy who was driven by fear and hatred from his school and town in Indiana. Then there was the Ray family in Florida with three young hemophiliac boys infected with HIV through no decision that they ever made. They suffered not only humiliating discrimination but, eventually they saw their house burned down by arsonists, presumably fearful and hating neighbors. Above all, mandatory AIDS testing would drive underground and away from help and counseling the very AIDS infected people who needed help the most who, indeed, needed help not only with their own health, but needed help in reforming their behavior so that they would not infect others. And driven underground, these people would only continue to spread the disease.
Health officials, unlike some laymen, were adamant about the importance of AIDS testing but knew it would serve its purpose only if they were voluntary and absolutely confidential. Amidst this controversy about testing, at last, there would be a Cabinet meeting devoted primarily to AIDS. As far as I know, it was probably the only Cabinet meeting at which AIDS was discussed. At issue was whether the President was going to follow the advice given to him by the Public Health Service and the Secretary of HHS, or whether he would choose the plan of mandatory and widespread testing advocated by some of the political hacks in the White House.At the Cabinet meeting I was sitting in the second row and rather unobtrusively, I thought, I pushed my chair back about 6 inches so that I was sitting with Bob Windom on this side and Jim Mason on this side, but nobody in that room could see my face except the President, who was sitting right across the way. And whenever the President had a question that I wanted to answer, or whenever I wanted to reinforce or rebut something that I had just heard, I raised my right index finger to my nose and sort of nodded at the President. And he acknowledged me on every occasion without anyone really knowing that I had asked to speak because every time he acknowledged it he said something like, "I'd like to hear from Dr. Koop on that," or "Dr. Koop, would you care to comment on that?" The system worked eight times. There were no misses. And I like to think that it steered the President toward his decision to espouse the precepts of the Public Health Service on AIDS. "Testing," he said several days later, "would remain voluntary and would remain confidential." I was so pleased with the outcome that a couple of nights later when I attended an AMFAR function in a huge hot tent on the Potomac River here I barely noticed the pickets outside who were shouting obscenities as I entered and carrying placards that said, "Quarantine Manhattan and Burn Koop," and other encouraging messages like that. Our position against mandatory pre-marital testing was eventually vindicated by the states that adopted it, Illinois and Louisiana, because they later repealed their testing laws.
There is one anecdote that I don't think any of you have heard about, and that is that there was another state that was planning to have mandatory pre-marital testing, and that was the State of New Hampshire, and John Sununu was the Governor. And one day I got a telephone call from Bob Wilson. Well, I've met I don't know how many Bob Wilsons in my life, and when I finally straightened out on the phone that he was the Bob Wilson who had been my intern when I was the Chief Surgical Resident at the University of Pennsylvania and he was now practicing pediatrics in Concord, New Hampshire, he said, "I really don't understand your position on pre-marital testing. Would you give it to me?" I didn't know that in addition to being a pediatrician he was also a state legislator, nor did I know that Sununu had a bill before that legislature for mandatory pre-marital testing.When I finished talking to Bob Wilson he went across the street, rose on the floor and said, "I have just gotten off the telephone with the Surgeon General. This is what the facts are about pre-marital testing. I move we vote and defeat the bill." And they did. Well, two weeks later I went up to New Hampshire for my 50th Reunion at Dartmouth. By that time I had assumed kind of a quasi-celebrity status and so the college administration was showing me off to anybody they could, including the luncheon speaker, who was John Sununu. Well, as I was being brought up for the introduction, I could see the fire in this gentleman's eye, and so before he could say anything to me, I said, "Before you say a word, sir, let me explain the embarrassment that you endured at the floor of the legislature in reference to pre-marital testing." I explained what I just told you and then I said, "However, sir, the day will come when you will be extraordinarily grateful, because that was really terrible legislation." Well, the AIDS report had done its job. I think it had made accurate information available to the American people. But we knew from the start that making the information available did not mean that the people would really get it, and we in the Public Health Service had discussed several times the idea of mailing a copy of that report to everybody on the IRS mailing list, which is the largest such list anyplace in this country. And eventually it was taken out of our hands because Congress, feeling somewhat embarrassed, did eventually order that such a mailing be undertaken. And they did it in several ways. One, they appropriated the money, which was very essential. But then they rather insulted HHS by saying that the document need not be cleared at any level higher than the Director of the Centers for Disease Control. Well, that director actually bucked it up to the Secretary of HHS which was still Otis Bowen, and it was all set to go and was going to be the largest mailing in American history, 107 million copies. And then the question came up, who was going to sign the letter? And I can tell you more people came out of the woodwork that wanted to sign that letter than I thought were working at HHS. And Otis Bowen, again, handled that situation with his usual aplomb. He had the advertising agency do some studies with focus groups and then he called together all the would-be signers and said, "You know, when you ask for a consultation and you don't take the advice of the consultant you're a darned fool. And we asked for consultation. We had some focus groups. And the focus groups tell us that they'd like to see that letter signed by the Surgeon General, so Chick, you sign the letter." And so that's how the brochure finally went out. We made only one small mistake in that brochure. It had nothing to do with the message; it only was in the format. It was a part of the brochure that explained that you could not tell what a patient with AIDS looked like and the headline said, "This is What AIDS Patients Look Like." And we inadvertently put Tony Fauci's picture right next to it. (Laughter.)
Now, Ruth said earlier on--and Don mentioned--the fact that AIDS really occupied one's time. Bob Windom said there was AIDS, AIDS, and AIDS. I'd just like to read to you for a minute a couple of items out of a diary I kept at the time which was rather a staccato-like thing, but just to show you the kind of things that occupied my time and the kind of opportunities that provided themselves. And here's an excerpt that's about a page long.
"Spent a week in West and East Berlin on AIDS. Met with Hooks and NAACP on AIDS, then spoke briefly with Jesse Jackson. Made a public service announcement on AIDS with Ed Koch, Mayor of New York. Discussed the issue of providing clean needles to drug addicts but came up against the claim that often drug addicts want to share used needles as part of their camaraderie. Met with representatives of the AMA and the pharmaceutical industry and bounced off them my idea for incentive testing; that is, get tested and be listed by number to take priority advantage should the day come when a better drug than AZT was available. Spoke to the Evangelical Christian Publishers about hating the sin but loving the sinner. Spoke to 900 recruits and 650 instruction officers at the Army's Fort Leonard Wood in preparing a video to be seen by all recruits in the future to the United States Army. Learned that the Army personnel who speak to AIDS counselors at social functions are assumed to be seropositive, thus putting AIDS counselors in social isolation. Spoke in Cincinnati to the National Council of Juvenile and Family Court Judges and was concerned that the questions asked revealed how little was understood about AIDS even by these learned people. Discussed with teenagers how, when you have sex with someone, as far as disease was concerned, you're having sex with everyone they've had sex with and everyone those people had sex with. Taped the HBO show on "Everything You've Ever Wanted to Know About AIDS But Were Afraid to Ask." Met with labor groups about AIDS. Health attendants contact with splashed blood has become an issue. Went to NIH with President Reagan and new members of the AIDS Commission where the President and I, alone in an anteroom for security reasons, discussed AIDS briefly. That's the longest conversation I ever had with him, but long enough to have a good conversation. Participated in a bipartisan briefing on AIDS run by Senator Kennedy. Met with Bill Smith from the Academy of Health Education who has $118 million dollars from WHO to teach AIDS in the Third World. Visited with Margaret Hagarty and AIDS workers in Harlem Hospital. Visited clinics in Greenwich Village. Met with gay and lesbian groups." And on and on it went. My life was indeed consumed for those next two years by AIDS. Let me say in conclusion that the first phase of America and AIDS, that is from the first case in 1981 until the AIDS report of 1986, was marked by mystery and by fear, by a lot of suspicion and judgement and a lot of unknown nonsense. The second phase, that is the time when I made my contribution, I think, saw health officials really overcome considerable opposition, some misguided, some mean-spirited, to at last bring the facts of AIDS before the American people. And in the AIDS report, the AIDS mailer and the hundreds, and even thousands, of articles and television programs about AIDS, this was accomplished. And I've often said, and say it again now, that the press did a remarkable and commendable job of communicating the issues of AIDS. The American people learned that except for babies who got AIDS from their mothers, and except for innocent sexual partners of AIDS carriers who took no precautions, that in order to get AIDS you really had to engage in risky behavior and that, unfortunately, or fortunately, that kind of behavior many Americans today thought was either illegal, or immoral, or both, in addition to being very risky. And in that second phase of AIDS, Americans really sorted through the issues of testing, of discrimination, of civil rights, and in general I think they rejected the bad laws and approved of the good ones, and assuring people who did not practice high-risk behavior that they were protected from this disease, and also, in general, protecting the civil rights of those who were HIV-positive. But the disease, the epidemic, continued to grow in American society, claiming more and more victims each month. And so we entered the third phase of AIDS in America, and that is the phase we're in now, I think, when society, the health care system, and probably each American will eventually have to come to grips with AIDS because of friends and perhaps even relatives who die from this horrible disease. Thank you.
DR. LINDBERG: Chick, thank you so much for that wonderful presentation. I think we're sort of out of time, but I wouldn't feel right if we didn't take a question or two, if there could be a brief one.
QUESTION: You mentioned that the propensity of gay men to seek health care practitioners at clinics that were out of the establishment distanced them from services. Do you think that also--(inaudible)--health problems that they were bringing to these practitioners were perhaps more quickly visible in that setting?
DR. KOOP: I think it clustered them and had a beneficial effect only after we knew about AIDS. But I think in the beginning it isolated them from mainstream America and I think it isolated them from the things that we could have done initially to help them. There was quite a lag between the first few reports.
DR. LINDBERG: Dr. Helfand?
DR. HELFAND: How high up did the request come? inaudible)You delayed for three years.
DR. KOOP: It came from, I would say, PL-3, three down from the President. I was PL-4.
DR. LINDBERG: Ma'am?
QUESTION: Do you think that delay made a difference, and what sort of difference do you think it made?
DR. KOOP: Do I think what made a difference?
QUESTION: The delay in the leadership coming to--
DR. KOOP: Well, it's hard to say "what if," or "if only," but I have a feeling that there would have been a certain sense of comfort, a certain sense of direction, if the President had come forward and acknowledged what AIDS was and said that he understood it and was for its, you know, progressive management, just the way I think that if this President hadn't undertaken to champion health care reform we'd still be floundering around talking about it. I think it does require leadership and I think there are certain things in this country of such unbelievable importance that only the President can be the coach.
DR. LINDBERG: The last one please?
QUESTION: Yes. I was just wondering if you would comment on the current policy of testing immigrants and refugees to the United States and what your view is on that?
DR. KOOP: Well, I was always opposed to testing refugees. Either you're going to take refugees or you're not going to take them. Immigrants, I think, could be considered different if they have no visible means of support and it means by taking them on an immigration visa into this country to be extraordinarily burdensome to us financially and socially that there could be an argument. But certainly there is no argument about the person who is here on a visitor's or a tourist visa.
DR. LINDBERG: Thank you very much.