An emerging interpretation of the Acquired Immune Deficiency Syndrome (AIDS) epidemic holds that public health officials failed in their jobs and that the spread of the disease could have been limited during the early 1980s if these officials had acted more vigorously and with greater competence. Despite the enormous stakes involved and the apparent clarity of the task, the public health establishment has taken several years to gear up for the epidemic; many observers of the early history of response to AIDS argue that public health officials missed the only opportunity to control the spread of the virus.
To say that the public health officials have failed implies that success and failure are definable and measurable with respect to this disease and that public health officials are accountable for what has resulted to date. Although a verdict of failure may ultimately be warranted, it is important to place the actions of public health officials in a political and institutional context. Further, before holding individual public health executives responsible for the spread of AIDS, it is necessary to articulate their professional role regarding this disease.
No one seems to be happy with the performance of state and municipal public health officials on the front lines during the early period of this epidemic. This article explores the idea that controlling the spread of AIDS during this phase was an impossible task for state and municipal public health officials. The argument is multidimensional: (1) Relative to the larger cycles of reform in public health, the "time" was not right for public health officials to act with the requisite authority, resources, and dispatch; (2) the spread of the epidemic had collective-action characteristics that precluded group mobilization for either prevention or political advocacy in the brief period of time available; and (3) both the epidemic and the job of the public official were so muddied and complicated that an immediate, unilateral, and effective public health response may have been an unrealistic expectation. This article examines the experiences of three officials who confronted the archetypical issues of AIDS policymaking: closing bathhouses, dispensing free needles, and requiring antibody testing. Finally, some ideas for positive coping in the face of an impossible task are explored.
If the meaning and accuracy of the tests are troublesome, then the accumulation of test results in a registry compounds these problems. The list itself could be inaccurate, and opportunities would arise for breaches of confidentiality. Many fear that mandatory reporting combined with the existence of registries may discourage high-risk people from seeking out the test-in effect, driving high-risk behavior further underground. Colorado, for example, has required that all positive antibody tests be reported to state and local health departments on the grounds that these agencies need to know who is infectious. Carriers can then be counseled about their own status and the possibilities of transmission for epidemiological purposes as well as notified if and when an antiviral agent was developed. Colorado has apparently managed to protect the confidentiality of these reports, but elsewhere there have been isolated incidents of disclosure that have fueled fears that invasion of privacy and discrimination may accompany registration of cases.
Contact tracing, a technique for identifying and counseling the partners of a known case, has been used to prevent the spread of sexually transmitted diseases since the early part of the century. A person identified as infectious is asked to provide names and addresses of sexual or drug-using partners, who are subsequently contacted and advised of the potential of infection. These techniques require a substantial invasion of privacy and cooperative effort. When a person becomes known to authorities as someone who continues to put others at risk, many have suggested the use of quarantine to isolate the infected man or woman and prevent further spread of the virus. Public health authorities in Florida and Texas have resorted to quarantine for brief periods, though the compulsory isolation of people pushes the boundaries of public health law and seriously infringes on individual liberties.
In sum, the traditional arsenal of public health approaches leaves public health officials with a very weak and troublesome set of alternatives for combating AIDS. Identifying who is infectious, the foundation of any preventive effort, is problematic because of weaknesses in the test itself. Methods such as registration and contact tracing that build upon the identification of HIV-positive people perpetuate the weakness of the test and introduce new problems of confidentially, civil liberties, and ultimately effectiveness. One of the major challenges facing the public health executive is an intellectual one: how to develop, out of whole cloth, a new arsenal of public health strategies for dealing with this problem.
Constraints Imposed by the External Environment: Public Opinion. The climate of public opinion and fear is one of the most subtle instrumentalities of the public health executive's job. At a certain level of intensity and in certain forms, public attention is the greatest resource available to the public health executive. The only way to generate widespread behavioral change is by exposing the risks of transmission, yet it is exactly this exposure that can generate hostility, discrimination, stigmatization, and backlash toward affected groups. Interacting with public opinion surrounding AIDS is a subtle problem of rhetoric, where the choice of language has significant implications for the willingness of people to come forward and be tested and ultimately for the societal treatment of those with AIDS.
At the state and city level, the major catalyst of public attention has been the emergent political debate about testing, reporting requirements, and quarantine. The vast publicity that has attended these debates, however, is a mixed blessing in the effort to control AIDS. Although the public health official wants to do everything possible to raise the consciousness of the populace about AIDS, there is a fine line where consciousness turns to hysteria. The regrettable treatment of children with AIDS who have attempted to register for school in Kokomo, Indiana; Arcadia, Florida; and New York City has demonstrated that a very subtle game of public education and public relations needs to be played in this area. The management of public opinion stands out as the most important and most difficult task of public health executives. Without raising sufficient concern, people will not change their behavior. When concern tips over into hysteria, however, both the political options and educational mission of the executive become extremely closely limited.
Resources. Although resource constraints are almost automatically on any list of what makes a public sector job difficult or impossible, the problem of resource constraints in policymaking for AIDS is somewhat unique. Many health agencies have experienced large infusions of funds to respond to AIDS but have had difficulty developing their organizational capability quickly enough to spend these resources intelligently and in a cost-effective manner. Between fiscal years 1984 and 1988, state-only funding for AIDS programs increased fifteen fold, from $9.3 million to $156 million. These funding levels do not include state and local use of federal funds, Medicaid, or municipal expenditures. The city of San Francisco, for example, reported spending $17.5 million of its own funds in fiscal year 1988.
Further, although resources are increasing rapidly, the even more rapid increase in the numbers of infected and symptomatic people constantly outstrips the public effort. The New York City experience is instructive: In 1988, the city and state plan to spend about $15 million for prevention and education efforts. This effort is large relative to previous outlays but pales when one considers that there may be half a million people who are carriers of the virus. An expenditure of $15 million for prevention and education represents 6 percent of public spending on AIDS (including healthcare) and about .1 percent of all spending.
Despite the significant increases in resources that have been captured by many public health departments, the successes and failures of public health officials in this epidemic have been largely defined by their performance in several test issues. In the public eye, the most significant questions during the early period of the epidemic have been the regulation of bathhouses, the dispensing of free needles to IV drug users, and the implementation of mandatory premarital screening for HIV antibody. These issues reveal the predicament faced by public health officials in three venues and illustrate the sharply divisive political responses that compound the already-difficult task of reacting quickly and forthrightly to the emerging epidemic.
