Arrayed against the seeming intractability of the problem of controlling AIDS are the enormous stakes involved as the virus spreads and its consequences begin to be felt. Coping with this situation at a personal level requires a strategic map, a benchmark against which executive choices and expenditures of time, political capital, energy, and intellect can be judged.
The job of managing AIDS policy also requires the heavy use of symbols to convey messages that have political and educational content. Officials who exploit symbols utilize one of the few resources that are available to influence individual behavior. When a chef in a prestigious Sacramento restaurant died of AIDS, California Health Director Ken Kizer took the opportunity to eat a much-publicized meal there. * 'The Bon Appétit thing was a good example where I think we did more in a couple of hours to dispel some myths, to help some education, than you could have probably done with hundreds of hours of lectures. It was a symbolic thing, but if their business is any reflection, I think it turned a lot of people around."
Perhaps there is no better example of the power and utility of symbols and political leadership than Dr. C. Everett Koop, the highest public health officer in the nation. Koop was an unlikely candidate for implementing an aggressive national AIDS prevention campaign. He was brought into the administration in part for his strong pro-life views and was believed to be primarily a champion of its conservative social agenda. Instead, Surgeon General Koop fashioned a frank and controversial personal campaign that pushed his standing and support in the administration to the limit. Most important for the purposes of this study, Koop maximized his use of symbols in the personal performance of his job. Whenever he testified as surgeon general, he wore the striking military garb of his office and used the language of a general going to war. Partly as a result of this orchestrated effort to win the hearts and minds of people at risk, C. Everett Koop has become a household name. He inculcated an esprit de corps in his service that was very impressive.
Certainly at the state and municipal level the opportunities for public exposure and influence are less dramatic than those available to the surgeon general. Nonetheless, the opportunities for a public presence in this issue must be exploited. The proper imagery is probably less that of a general launching a war than of a guerrilla fighter seeking to make small inroads into the difficult and persistent problems of behaviors not in the individual's or society's interest.
Much of the debate about AIDS policy has been dictated by old and questionable public health approaches. Although new methods will be difficult to develop, market, and implement, this task should occupy a large share of the executive's effort. Techniques of using the mass media offer the best prospects for public health innovation. In New York an ambitious and frank campaign has been mounted through a collaborative effort of public health officials and advertising agencies working pro bono. As Dr. Joseph suggests, the aggressive use of the media asserts the tradition of vigorous public health intervention without the downside of highly coercive, liberty-depriving measures. "I hope when the controversy erupts, that our purpose is not to assault taste. . . . But the Department of Health is not the guardian of public morality. We are the guardian of public health." In Washington, D.C., Commissioner of Health Reed Tuckson has recruited rock musicians to develop an unusual media strategy for AIDS prevention.
Political leadership requires careful navigation around the shoals of executive authority, the will of the legislature, the sometimes ferocious pressures of special-interest groups, and the tolerances of public opinion. The engineering of a workable legislative and legal context requires the acknowledgment that AIDS is first and foremost a political problem; it then requires careful attention to the applied problems of agenda formation that accompany this issue.34 Public health executives who most energetically respond to the epidemic perceive the importance of political management. It has been said that Mervyn Silverman believed that "all public health policy was basically political; as someone who relished public approbation, he was a good politician. It was his strength as a public official." Stephen Joseph also observed that "politicization is a good thing, because it brings all that leverage and attention to the issue."
Simply defining AIDS as a political problem and managing it as such does little to limit the impossibility of the task. For Silverman, conceiving the management of the epidemic as a problem of brokering political interests in San Francisco overshadowed the traditional public health concern of fighting contagion. Without a narrow focus on the demands of public health, the public health executive could become paralyzed by the ambiguity of the task. AIDS carries too many civil-libertarian, ethical, special-interest, cultural, and political implications for the public health executive to be attentive to all concerns. Those who have been personally most successful in waging war against the epidemic-with Koop standing as the most visible example-have dared to confront political resistance, instead of searching for accommodation and consensus.
Further, approaching the management of AIDS as essentially a political problem will be foreign and antithetical to the skills and personalities of many who have selected this profession. As Martin Rein has pointed out, there are fundamental differences in the games of science and politics.
The games of science seek to establish patterns of experience that all may share. They are value neutral in the sense that they are deliberately designed to filter out the values of the participants so as to arrive at unbiased "truth." The proper posture for a gamesman of science must be one of restraint, dispassion, conservatism, the willingness to suspend belief pending more evidence. The games of politics are quite different. They are designed to find one purpose or course of action acceptable to individuals who have begun the play by espousing diverse purposes, values, and actions. . . . The proper posture for a gamesman of politics is one of boldness, persistence, opportunism; the good gamesman is able to mobilize and sustain belief and commitment.
The conflicts between these two games have been most apparent in Bernard Tumock's confrontations with the state legislature in Illinois. As Senator DeAngelis observed Turnock's approach to AIDS and the legislature: "Health officials want to be clinically correct. The General Assembly wants to be a bit more reactive. I think that sometimes it's extremely difficult for a professional in a field to adjust to the political world as well. . . because they tend to be purists." Despite the demands for scientific integrity in the various aspects of public health work, including the surveillance and reporting of AIDS, the importance of political acumen to this policy area cannot be understated.
With the emergence of AIDS in the early 1980s, the job of many state and municipal public health officials shifted from one that was largely ''possible" to the stewardship of controlling an epidemic. The major source of impossibility that AIDS introduces into the job is the intractability of sexual and drug-taking behavior that underlies transmission of HIV infection. This transmission has basic properties of collective behavior that make prevention and risk reduction an especially problematic public health undertaking in the early years of the epidemic. Moreover, the logic of collective action suggests that the political dynamics will be stacked against executives who seek an expedited response. Groups centrally concerned with the prevention of HIV infection have been relatively slow to emerge and highly fractured; they have confronted highly articulated special interests who engaged AIDS policies as a by-product of their primary agenda. To make matters more difficult, AIDS presents problems of uncertainty, law, public health strategy, and public opinion that severely constrain the possibilities for control. Although managing this epidemic calls for both political and technical competence, neither of these skills is sufficient by itself. The public health management of the AIDS epidemic necessarily brings the conflict between these "games of politics" and "games of science" into sharp relief.
Because the prevalence of HIV infection is largely invisible and its progression-conversion to symptoms, sickness, and death-occurs sometime in the future, the efforts of public health executives to affect the transmission of infection will go virtually unrewarded. Indeed, as the steady, inevitable progression of AIDS mortality and morbidity is broadcast monthly, the thesis that public health officials "failed" in their management and control of the AIDS epidemic will be continually reinforced.
