Bias, Fear of Disease Seen : Doctors’ Aversion to Gays Could Hinder AIDS Fight

When UCLA medical school researchers set out last year to assess whether California doctors are prepared for the avalanche of AIDS cases in the next five years, it didn’t take them long to encounter troublesome signs.

“No,” one physician responded, with disgust. “I don’t have that kind of patient, and I won’t treat them if they happen along.”

Such physician aversion to homosexuality--measured consistently in the polls--looms increasingly as a potential barrier in the nation’s race to cope with the worsening AIDS epidemic.

With projections that by 1991 the United States will have 10 times as many AIDS cases as today, public health experts say the nation’s ability to cope with that onslaught will depend largely on the willingness of doctors and other health professionals to cast aside any biases or preconceived notions about the deadly disease.

And homophobia is only one obstacle, they caution. Another is the fear among doctors and nurses of contracting the virus from AIDS patients.

The success of educational campaigns to combat such resistance could well make the difference between whether the medical needs of the 270,000 AIDS patients expected in the next five years are met. But that task will not be easy, public heath experts acknowledge.

The disease increasingly is shifting from the homosexual population and intravenous drug users to mainstream America. This means that whereas it has been mostly the cancer specialists and infectious disease experts who have treated most AIDS patients, it will be the family doctors, the internists, the general practitioners and the community hospitals that rapidly will be desperately needed on the front lines.

Will they be willing or able to treat the growing number of AIDS patients? Will they give AIDS patients the proper treatments and counseling? Will they even give such patients the time of day? Will there be a network of home-care services to alleviate the huge demand for hospital beds? Will hospitals and physicians who open their doors to AIDS patients lose other business as a result?

“The average physician,” said Dr. William Plested, a former president of the Los Angeles County Medical Assn., “is wishing that AIDS would go away. They don’t want to face it.”

To prepare the health profession for the coming rise in AIDS cases, the federal government is planning a national training program to help all health workers cope with the problems of treating AIDS as well as to alleviate unwarranted fears they may have. But if such educational efforts are to change many minds, they will have to take into consideration the diverse cultural and ethnic attitudes toward sexuality and, in particular, homosexuality, according to public health experts.

Such educational campaigns directed at health professionals assume a new sense of urgency because public health experts do not expect sufficient planning to be carried out that would create a comprehensive and integrated system to provide for the needs of AIDS patients.

That’s because of the health care system’s traditional reluctance to coordinate and plan on a systemic basis.

The absence of such planning will mean that there will continue to be insufficient medical, social and psychological services for AIDS patients, from counseling to the deathbed. “A lack of cohesiveness and strategic planning throughout the national effort,” is the way a recent report by the Institute of Medicine described the situation.

Locally, the AIDS Project Los Angeles has sought private grants to help develop a network of services that would include nursing home care and mental health services for AIDS patients, but its efforts have not been successful.

And in Los Angeles, which ranks second in the nation in AIDS cases, after New York, long-range AIDS planning by county health agencies consists largely of one-year projections of budget needs in order to provide for the 30% of the county’s AIDS patients who now receive their care at county facilities.

Until now, there have been about 27,773 reported cases of AIDS in the nation, including more than 6,200 in California. But according to even the most conservative predictions, there will be 270,000 cases of AIDS nationwide by 1991--with about 39,000 of them in California and about 13,000 in Los Angeles. In addition, for every case of AIDS, there will be an estimated 10 cases of so-called AIDS-related complex, or ARC, which can be just as debilitating and deadly as AIDS itself.

‘In a Quandary’

“When I say the epidemic is getting worse, they say, ‘What epidemic?’ But I tell them it is coming--like a runaway freight train,” said Dr. June Osborne, dean of the University of Michigan School of Public Health.

“Everybody is in a quandary about what to do about it,” said Leonard LaBella, president of Santa Monica Hospital Medical Center, reflecting the uncertainty of many hospital administrators.

“We have the beds, but with few exceptions I don’t see carefully coordinated systems developing,” added Stephen Gamble, president of the 240-member Hospital Council of Southern California.

“Planning for health is a taboo subject in this country,” explained Dr. Caswell Evans, Los Angeles County government’s top official in charge of AIDS programs.

Like many doctors, some community hospital administrators fear that the presence of AIDS patients may scare away other patients. Most, Gamble said, “prefer not to have it announced too loudly” that they have AIDS patients.

Yet, after Sherman Oaks Community Hospital publicly announced the creation of an 11-bed AIDS unit two years ago, administrator Marc Goldberg said, “We have never had a problem with employees or other patients or doctors.”

For the hospitals, a further unknown factor in planning is the likelihood that far more AIDS patients in the future will receive treatment with drugs that can be taken orally, rather than intravenously--and thus will not require hospitalization. That could mean a proliferation of outpatient clinics, noted Dr. Peter Heseltine, a County-USC Medical Center epidemiologist.

Public health experts say that educational campaigns directed at doctors and nurses offer the best hope of creating a receptive frame of mind toward AIDS patients among the nation’s health providers.

“There was lots of homophobia before AIDS,” one Canoga Park physician said. “But now it can be used as a weapon.”

Until 1973, the medical profession had considered homosexuality a psychiatric disorder. And even though the American Psychiatric Assn. removed homosexuality from its official list of psychiatric disorders 13 years ago, polls even today find a high level of antagonism among doctors toward homosexuality.

A 1978 survey of 200 doctors conducted for the American Medical Assn., for example, found that 35% of them felt uncomfortable treating homosexuals. A similar survey of 1,000 members of the San Diego Medical Society in 1984 put that figure at 40%. And 29% said homosexuals should not be admitted to medical school.

In the most recent survey, of 91 nurses and 37 physicians questioned in a New York City hospital, almost 10% agreed with a statement that gay AIDS patients got “what they deserve.”

“Homophobia is everywhere in society and medicine is no better and probably a bit worse because it is a conservative profession,” said Dr. Richard Chaisson, a San Francisco physician.

Another challenge facing educators is how to dispel unwarranted fears among doctors and nurses of contracting AIDS. “Misconceptions about how AIDS is transmitted are still rampant in the health care community,” said Dr. Allan Noonan, chief medical officer of the Health Resources and Services Administration.

Surgeons and other operating room personnel, among all medical specialists, have the greatest fear of contracting AIDS from a patient. This is understandable because the close contact they have with blood could expose them to the AIDS virus should they accidentally stick themselves with a contaminated needle or scalpel. But follow-up studies of more than 1,000 medical personnel who have stuck themselves with contaminated needles have revealed that the risk of acquiring the virus in that manner is far less than 1%.

Still, surgeons such as Plested are not ashamed to state their fears. Plested said he is “scared to death” whenever he operates on patients with AIDS. It is difficult, he explained, to totally shut out the thoughts of the risk. “As much as science reassures us,” he said, “we have to be superhuman not to worry.”

Ironically, physicians who regularly treat AIDS patients say that fear of contracting AIDS is highest among doctors and other health workers who have the least experience with the disease.

“Over the past two or three years we’ve gotten more factual information on how the virus is transmitted and finally understand that it is a fragile virus,” said Dr. James Atkinson, a pediatric surgeon at Childrens Hospital of Los Angeles who has performed about 30 surgical procedures on children with AIDS.

Whereas many operating room personnel were apprehensive during the first operations, he said, “the people here are now more practical and less hysterical. Education and experience are the two things that smoothed us out.”

Dr. Alexandra M. Levine, associate dean of the USC School of Medicine, noted that federal researchers now believe that between 1 million and 1.5 million Americans have been exposed to the AIDS virus--and thus can infect others--even though most of them have shown no signs of illness and may even be unaware that they are infected.

Almost certainly, she said, doctors are examining such people without knowing that they may be future AIDS patients. Such doctors “are seeing the virus every day, whether they know it or not,” Levine said. “The point is that the virus is here. You can’t isolate yourself from it, even if you think you can.”

Levine plans to organize a one-week educational program in which doctors work with sick AIDS patients under the direction of an experienced tutor.

Such a one-week “hands-on” course could provide a sufficient number of doctors to handle the coming demand, at least locally, she said, judging from a recent survey of 314 Los Angeles doctors conducted by USC.

Such an approach can make a big difference, agreed a Westside hospital nurse who asked not to be identified. Straightforward lectures are helpful, she said, but they need to be supplemented by real experiences.

“We’ve had AIDS patients here since the beginning,” she said. “New nurses say there is a big difference between just listening to a lecture and learning by working with nurses and doctors who obviously aren’t afraid but who take the proper precautions.”

Today, many state and local medical associations, medical schools, hospitals and other health groups are offering lectures and programs aimed at preparing health care professionals to care for AIDS patients.

The Los Angeles County Medical Assn. in conjunction with the county Department of Health Services, for instance, has produced an instructional film dealing with the delicate process of counseling patients who have tested positive for the AIDS virus.

‘A Positive Example’

“We made this film to provide a positive example of a successful counseling session between a doctor and an AIDS antibody-positive patient,” said Dr. Neil Schram, chairman of the Los Angeles City-County AIDS Task Force who wrote the script. The characters in the film include an antibody-positive bisexual male whose wife wants to have a baby.

“As AIDS continues to spread, more and more physicians will be faced with this difficult and sensitive task,” he said.

At UCLA Medical School, Dr. Charles E. Lewis and sociologist Howard E. Freeman recently questioned 600 Los Angeles doctors, and another 1,000 doctors statewide, to assess their “competency” to handle AIDS cases. They concluded that about one-third of the primary care doctors would not be competent to treat AIDS patients.

The doctors were quizzed both before and after taking a continuing education course intended to improve their knowledge of AIDS. One factor in determining competence was the degree of discomfort each felt when discussing sexual matters with patients, especially those who are gay males.

The researchers concluded that physicians who displayed the most discomfort in such discussions were the ones most likely to lack knowledge about AIDS, both before and after having taken the course.

A major emphasis in the educational material is the message that taking sexual history is a vital practice that is widely neglected.

The AIDS epidemic also has highlighted the need to customize sex counseling courses for health professionals who come from diverse cultural backgrounds. For example, one finding in Lewis’ study is that graduates of medical schools in developing countries, especially those in Latin America, are unlikely to have been taught how to explore the sexual history of patients.

Because experts believe that taking a sexual history is an essential element in the early diagnosis of AIDS, as well as in preventive counseling, educators say it may be necessary to offer special AIDS educational programs to the large number of foreign-trained doctors in California.

Similarly, physicians who have a large black clientele need to be especially aware of the possibility that some of their patients may be closet gays, according to Evans, Los Angeles County’s director of AIDS programs. Unlike many of their white counterparts, black gays generally are less willing to identify themselves as homosexuals, perhaps because the black society is less accepting of them, Evans said.

According to Evans, 25% of the AIDS cases in Los Angeles are roughly divided between blacks and Latinos.

Despite the barriers of culture and homophobia, public health experts are optimistic that, in time, there will be enough physicians to meet the growing demand.

If nothing else, said UCLA’s Dr. Michael Gottlieb, one of the first physicians to diagnose AIDS, “economics will get them into the fray. But how do you get their hearts into it?”

Getting more doctors involved also will depend on the public “coming to terms with the fact that AIDS is a health problem that affects their families and neighbors,” he added.

“It’s a matter of the public giving doctors its blessing to become involved and giving their doctor reassurance that they won’t discriminate against those who see AIDS patients. But those things won’t happen overnight.”