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The social effects of the aids virus in the 20th century

State governments have the primary responsibility for public health: The authorities and responsibilities of the state and territorial health officers vary, but all share a common mission of protecting the public against various types of infectious or communicable diseases. A number of states have strong traditions of providing primary health care services to low-income populations through county and city health facilities.

Department of Health and Human Services has responsibility for monitoring communicable diseases, many chronic diseases, and occupational disorders, as well as threats to public health that have been only recently recognized as being in the domain of the health care system, such as prevention of violence and accidents. CDC maintains strong working relationships with state and territorial health officers, frequently sending epidemiologists and other personnel to work at the state or local level and providing sophisticated surveillance and technical assistance programs to assist state and local health departments in dealing with novel or emergency situations.

It was therefore logical that in the early and mid-1980s, as the United States began to confront the public health challenge posed by the AIDS epidemic, the CDC became the focal point for developing a strategy of prevention and public health response. In addition, the highly visible role that CDC epidemiologists the social effects of the aids virus in the 20th century in linking AIDS to particular life-styles and in engaging the discussion of how to prevent the spread of the epidemic by public health measures has significantly defined the public perception of the public health profession.

Public health practitioners have long been responsible for surveillance of the spread of communicable diseases and for population-based interventions to alter the course of epidemics. Over the course of the AIDS epidemic, public health providers increasingly have been drawn into supplying primary care services for HIV-infected individuals.

Especially since therapies have become available to treat HIV disease before symptoms appear, public health providers are not only implementing programs to offer individual counseling and education, but also providing diagnostic services and medical care.

It begins with the debate that has raged around whether HIV and AIDS should be treated as a condition that is exceptional or as one subject to traditional public health measures to stem the spread of infection.

The social effects of the aids virus in the 20th century

Public health policies and practices are determined and implemented at all levels of government—federal, state, and local. This chapter does not attempt to cover all of these; it focuses primarily on national issues and actions. Nor does it try to review all policy decisions and controversies; rather, it considers those concerning HIV antibody testing and screening, contact tracing of the sexual and needle-sharing partners of infected individuals, and the isolation and quarantining of infectious individuals.

The chapter concludes by considering the role of public health departments in delivering medical care, planning for health services, and reacting to political controversy. Historical Approaches To Disease Control And "Exceptionalism" The conventional approaches to public health threats were largely codified in the late nineteenth and early twentieth centuries.

Public health law tended to provide a warrant for compulsory examination and screening and for breaching the confidentiality of the clinical relationship through requiring physicians to report to public health registries the names of people diagnosed with "dangerous diseases. Although the statutes were revised over the decades, they retained the imprint of their genesis Merritt, 1986; Burris, 1989.

The most coercive elements of this public health tradition were rarely brought to bear in the mid-twentieth century because of changing patterns of morbidity and mortality, the development of effective clinical alternatives, and limitations imposed by changing conceptions of the police power of the state. Major and widespread life-style changes, not the traditional repertoire of public health interventions, are central to the vision of such documents as Healthy People 2000 U.

Department of Health and Human Services, 1991. In some contexts, coercion is still deemed effective and justifiable from a public health perspective e. Some public health traditionalists, supported by some conservative political forces, argued in favor of the similarities of AIDS to all other communicable diseases and pressed to have AIDS and HIV infection brought under the standing of broad statutory provisions for control of communicable and sexually transmitted diseases, but they were in the minority.

Out of the often bitter controversies that surfaced in the social effects of the aids virus in the 20th century epidemic's early years, people who argued that the new public health perspective, founded on education, should inform efforts to contain the spread of HIV infection, came to dominate public discourse.

Against the tradition of infectious disease control, this perspective represented the determination to treat AIDS fundamentally different, thus necessitating "exceptionalist" policies Bayer, 1991b.

The exceptionalist approach dominated in part because some important features of AIDS set it apart from most other infectious diseases. AIDS is incurable with present therapies. It largely afflicts marginalized or threatened populations who have historically rooted fears about the state and antagonism to its institutions.

It is primarily transmitted in contexts that involve consenting adults engaging in specific sexual acts or drug-using activities. Containing the spread of HIV infection, then, requires modification in intimate behaviors that would presumably be difficult to make and maintain. Hence, it was believed that the strategy of prevention ought to eschew all appearance of coercion and threats to privacy.

Failure to adopt a course that would win the cooperation of those most at risk, it was asserted, would "drive the epidemic underground. Would there be wide-scale compulsory testing? Would the names of the infected be recorded in central registries? How would such registries be used to restrict those with HIV infection?

Would the power of quarantine be used, if not against all infected persons, then against those whose behavior, it was assumed, could result in the further transmission of infection?

  • Resource allocation Confirming a World Bank report, urban poverty has turned into one of the most explosive political and economical problems of the 21st century;
  • The certainty that equality shall be respected in clinical research may be an important step toward reverting the current injustice in health resources allocation, and may also contribute to strengthen emancipate people volunteers, researchers and civil society , enabling them to learn their rights as citizens and to fight for them.

In answering these questions, an alliance of gay leaders, proponents of civil liberties, physicians, and public health officials began to shape a policy for dealing with AIDS.

Sharp disagreements emerged, however, when political pressure was brought to bear to "sanitize" the campaigns through the imposition of restrictions on the language that could be used and the pictorial material that could be displayed Barnes, 1989. Testing for HIV infection was to be undertaken only after obtaining the informed consent of those to be tested.

The tradition of compulsory or routine mass public health screening in the face of epidemic threats was rejected. The reporting of those with HIV infection to public health registries was to be avoided because it might discourage individuals from voluntarily coming forward for HIV testing.

Confidentiality of HIV-related medical records was to be rigorously protected, sometimes at the cost of warning intimates who could unknowingly be subjected to the threat of infection. The use of the power of quarantine was to be avoided even when it was found that in specific cases an individual was behaving in ways that posed a threat of infection to others.

Several critical questions were inevitably provoked by this set of policies: Were they an artifact of the early uncertainties that surrounded AIDS? Would the unique political alliance that made possible the exceptionalist perspective be sustained over time? Would policy toward AIDS provide an impetus for the reformulation of the standard approach to other sexually transmitted and communicable diseases?

As the epidemic's second decade begins, it is clear that the strength of the alliance that developed and defended the perspective of HIV exceptionalism has begun to wane Bayer, 1991b.

AIDS increasingly affects groups that are less articulate and lacking the political organization of the gay population that helped forge that alliance. In addition, there is little evidence that the response to AIDS has shaped the course of public health policy more generally. The erosion of the exceptionalist perspective and the lack of influence on broader public health policy related to disease surveillance and behavioral interventions are clear from an analysis of policy and practice with regard to HIV testing, reporting, partner notification, and quarantine and isolation.

The extent to which these changes are attributable to the changing opportunities for treatment remains a matter of debate. Proponents of aggressive but voluntary testing believed that knowledge of HIV status could be an important motivator of behavioral change, but gay leaders and their allies were skeptical. They suggested that the required changes the social effects of the aids virus in the 20th century best be produced by aggressive education and by appropriately targeted strategies of individualized counseling even if individuals did not know their status.

This debate was framed by the fears of gay men and those who spoke on their behalf that the putative benefits that testing could produce could not outweigh the negative psychological and social consequences of being identified as infected—loss of jobs, insurance, and housing.

Out of the testing debates emerged a broad consensus, often codified in state statutes, that testing should be conducted only with the informed, voluntary, and specific consent of individuals and that any testing that did occur should be preceded by counseling that would make explicit the risks and benefits of testing and followed by counseling that would explain the test's significance. However, there were a number of carefully defined, although always contested, exceptions to voluntary, individualized testing.

These screening programs have withstood court challenges Gostin, 1990. In addition, many clinicians and hospitals undertook surreptitious testing of patients, justifying their actions by the belief that the protection of health care workers and sound diagnostic work required such screening.

In a survey of HIV testing policies in 561 nonfederal, acute care hospitals Lewis and Montgomery 1990: For example, one of four hospitals the social effects of the aids virus in the 20th century does not require patients' informed consent prior to testing, and one in three does not require pretesting counseling.

Moreover, one in four hospitals surveyed does not require a patient to be notified if a test result is positive. With the announcement in mid-1989 that clinical trials had revealed the social effects of the aids virus in the 20th century efficacy of early therapeutic intervention in slowing the course of illness in asymptomatic but infected persons and in preventing the occurrence of Pneumocystis carinii pneumonia, the political debate about testing underwent a fundamental change.

Gay groups such as Project Inform in San Francisco and the Gay Men's Health Crisis in New York Lambert, 1989 began to encourage people whom they had formerly warned against testing to determine whether they were infected. Physicians pressed more vigorously for the return of AIDS to the medical mainstream so that testing might be routinely done under conditions of informed consent Rhame and Maki, 1989. And state and federal public health officials launched more aggressive testing campaigns.

Physicians and public health officials have typically avoided the language of compulsion, stressing instead routine HIV testing, testing that would be initiated by doctors caring for people they believed to be at risk. Thus, in the fall of 1990, the House of Delegates of the American Medical Association voted to declare AIDS a sexually transmitted disease, a designation that would give physicians much greater latitude to determine the conditions under which HIV testing should be undertaken.

Nowhere has the shifting perspective on testing been clearer than in the emergence of a powerful movement, supported by obstetricians and pediatricians, for the routine screening of pregnant women, who can transmit HIV infection to their offspring, and the mandatory screening of infants at high risk for infection. For pregnant women, the public health practice of testing for syphilis and hepatitis B provided a model.

For newborns, the wide-scale and broadly accepted tradition of screening for congenital conditions, such as phenylketonuria PKUserved as the standard. However, none of the arguments overcame the opposition to mandatory testing by many health and other experts. In the words of a special committee of the Institute of Medicine Hardy, 1991: History has revealed that mandatory screening programs are frequently inflexible, often because they are legislated, and that program modification over time proves difficult.

The committee opposes any mandatory newborn or prenatal screening program other than anonymous screening for surveillance purposes. In 1991 the controversy over the risk posed to patients by HIV-infected health care workers who undertake invasive procedures reopened the question of testing medical personnel Barnes et al.

Some people argued that testing was not an issue because the risk of HIV transmission is extremely small. However, others believed that infected clinicians had a duty to inform their patients about their own HIV status or to seek advice from colleagues about withdrawing from the practice of invasive procedures; for them, testing was an issue that had to be confronted. Although some believed that mandatory screening of health care workers was not called for, most who believed that infected clinicians had a moral and professional duty either to inform their patients regarding their serologic status or to desist from invasive procedures held that the "duty to inform or withdraw" imposed a correlative responsibility on institutions to identify.

Hovering over the entire debate has been the recognition that any policy of screening for health care workers would inevitably produce pressure for the mandatory testing of patients as well. The names of people who meet specified diagnostic criteria are reported to confidential public health department registries, and the addition of AIDS to the list of reported conditions provoked little controversy.

But all moves to extend such reporting requirements to HIV infection have been fiercely resisted by gay groups, civil liberties organizations, and others because of concerns about privacy and confidentiality. Public health officials in areas with a large number of AIDS cases also tended to oppose reporting because of the potential negative impact on the willingness of individuals to seek voluntary HIV testing the social effects of the aids virus in the 20th century counseling.

As a consequence, the reporting of HIV infection had become policy in only a handful of states by the mid-1980s Intergovernmental Health Policy Project, 1989. Watkins—urged in its final report the universal adoption of a policy of mandatory HIV reporting. More significant than the commission report, however, were the fissures that had begun to appear in the alliance among groups that had opposed named reporting in those states where the prevalence of HIV infection was high and where gay communities were well organized.

In New York, for example, the same suit that sought to compel the commissioner of health to declare AIDS a sexually transmitted disease demanded that HIV infection be made a reportable condition, 2 a position that was echoed in 1990 by the American Medical Association. What made the suit so remarkable was the positions of the opposing sides. Historically, clinicians have resisted efforts by public health officials to require the reporting by name of individuals with infectious diseases, arguing that such policies represented an intrusion on the doctor-patient relationship Fox, 1986.

In this instance the representatives of clinical medicine were asserting that reporting was critical to the public health but the state's chief health official did not agree. That apparent paradox can be explained by the unique political alliances that had been created early in the epidemic among gay organizations, civil liberties groups, and public health officials. But by June 1989, even that feature of the political landscape of public health had begun to change.

In an address that was met with cries of protest, Stephen Joseph, commissioner of health in New York City, told the Fifth International Conference on AIDS that the prospect of early clinical intervention necessitated "a shift toward a disease control approach to HIV infection along the lines of classic tuberculosis practices" Joseph, 1989: A central feature of such an approach would be the "reporting of seropositives" to ensure effective clinical follow-up and the initiation of "more aggressive contact tracing.

When newly elected Mayor David Dinkins selected Woodrow Myers, former commissioner of health in Indiana, to replace Joseph, his appointment was almost aborted in part because he had supported the reporting of individuals with HIV infection Lambert, 1990. The acrimonious debate was ended only by a political decision on the part of the mayor, who had drawn heavily on support within the gay community in his campaign, to stand by Myers' appointment while promising that there would be no named reporting in New York City.

In New Jersey, which shares with New York State a relatively high level of HIV infection, the commissioner of health also came to support named reporting, but the politics that surrounded the issue in New Jersey were very different. There, both houses of the state legislature endorsed without dissent a confidentiality statute that included named reporting of cases of HIV infection.

New Jersey simply exemplified a national trend: