From a historical perspective, epidemics have presented public health officials with the opportunity to shape and expand the public health enterprise. However, mere existence of an epidemic is insufficient. Its appearance must interact with a variety of ancillary factors: the climate of opinion about medical credibility and competence, the nature of the disease and its affected populations, the status of knowledge and belief about the epidemic, the standards and language of societal communication, and so on.4 The best example of this institutional opportunism can be seen in the New York City Board of Health's intervention in the tuberculosis crisis from roughly 1890 to 1920, during which time it established an epidemiological capability, extended its police powers, expanded its regulatory scope and resources, and solidified its public visibility and credibility.
The timing of the AIDS epidemic, however, probably could not have been worse for public health officials interested in a rapid and expansive response:
The individuals and institutions that comprise the health policy . . . were poorly prepared to take aggressive, confident action against a disease that was infectious, linked-in the majority of cases-to individual behavior, expensive to study and treat, and required a coordinated array of public and personal health services. . . . Everyone who worked in the health sector knew a crisis was occurring; so did attentive consumers of print and television news. Uncertainty about priorities, resources, and, most important, leadership pervaded the health policy. The AIDS epidemic was an additional element in an ongoing crisis.6
With the onset of the AIDS epidemic, controlling the spread of HIV infection became the dominant responsibility of many state public health officials and health commissioners in large urban areas. Before 1985 the technology of testing for antibody of HIV infection was not available, making it difficult to monitor the prevalence of infection in the population, much less to intervene to halt its spread. With the emergence of a somewhat reliable and relatively inexpensive test for HIV antibody (the ELISA test), enormous pressure began to mount on public health officials to act to stem the spread of the disease. Unfortunately, the availability of a testing mechanism for the presence of HIV antibody was a double-edged sword. It allowed (somewhat imprecise) identification of carriers of the virus, yet it suggested no compelling answers to the larger question of how to implement the test and what to do with the resulting information.
Thus, public health officials have been operating in a highly charged atmosphere of responsibility and consequence-in what Ronald Bayer calls a "matter of extraordinary social moment." Because it takes some time for HIV infection to convert into symptomatic AIDS, gains that are made today in controlling the spread of the infection will not be exhibited in reduced sickness and death until many years out into the future. Strong efforts to limit the spread of HIV infection are largely invisible today, but they have enormous consequences for reducing deaths and they help buy time to develop better medical interventions. Public health officials who act aggressively during the early stages of the epidemic will have the greatest impact on the ultimate course of the disease; however, many of these officials will no longer be in office if and when any improvement begins to be noted. For the foreseeable future, public health officials will have no good news to share. Because the infection is already widely distributed in the population and there is no effective therapy within view, the loss of life and social devastation will continue to mount.
Nonetheless, combating the epidemic requires public health officials to act on several fronts: (1) to affect individual behavior, especially among gay men and intravenous (IV) drug users; (2) to mold the climate of public opinion and the set of legislative choices that determine the range of public health interventions; and to develop administrative capacity and capture sufficient resources for managing AIDS policy over the long term. The job of the public health executive in controlling AIDS is unusual in its public management demands; it is primarily a task of external influence, not the management of internal agency functions and mission. The most important frontiers for the public health official are the framing of a legislative context that will allow the department to maintain accurate surveillance; the influencing of potential carriers; and the shaping of the larger milieu of public concern without triggering undue fear and backlash. These responsibilities place a premium on the political savvy and the public communications skills of the executive.
The only effective public health strategy for limiting or slowing the further spread of HTLV-in infection is one that will produce dramatic, perhaps unprecedented changes in the behavior of millions of men and women in this country. Such changes will demand alterations in behavior that are linked to deep biological and physiological drives and desires. They will demand acts of restraint and even deprivation for extended periods, if not for the Lifetimes of those infected and those most at risk of being infected.
The mobilization of groups is significant not only for the purposes of "self-restraint" but also for the purposes of exerting political influence on public health officials, state legislatures, and governors. The logic of collective action indicates that small groups, even those whose raison d'être may be peripheral to the development of AIDS policy, will dominate large, diffuse latent groups who are centrally concerned with or even defined by the AIDS epidemic. In addition to these factors, there are a number of other characteristics of the AIDS issue which further erode the public health officials' ability to respond. These features are weaker sources of impossibility.
