Stop Trifling With AIDS : What Deserves Higher Priority Than Forestalling a Plague?

AIDS is a time bomb, ticking with a seven-year fuse inside 2 million Americans. If “too little and too late” is not to be the epitaph on the tombstone of American society, we must stop trifling with this epidemic and respond in a way consistent with our democratic values.

AIDS--acquired immune-deficiency syndrome--is currently defined narrowly and excludes more prevalent AIDS-related illnesses. On May 17 an expanded medical definition of AIDS was proposed, which would measure the spread of the epidemic more accurately.

The available statistics and their extrapolations are discussed in the Institute of Medicine 1986 report, “Confronting AIDS.” In a population base consisting primarily of homosexuals and drug users, as many as 2 million Americans may already be infected. Cases have been doubling every year, an exponential rate of growth. As best we know, the chance of dying for those infected is very high.

Within present standards of medical practice, the cost of treatment for the acutely ill, among whom we must assume most of the 2 million infected will be, is approximately $200,000 per patient. Even if there were no further spread of AIDS, current standards of health care imply that society already faces a direct expense of about half a trillion dollars. This does not include the indirect costs of lost production, the impact of higher than expected mortality rates on insurance companies, the lost contributions to Social Security, and the lost federal, state and local tax revenues.

As large as it is, this expense could prove inconsequential should AIDS spread to the general population. If the epidemic is not contained, 10 years from now we could face the cost of caring for millions of gravely ill AIDS patients. Using today’s standards of care, the direct medical costs alone could be on the order of $1 trillion annually in today’s money--an expenditure that is clearly impossible.

Such dire predictions are not the work of alarmists. Central and West Africa’s experiences demonstrate that AIDS viruses can be transmitted throughout a general population. In the United States the most obvious avenues of breakout to the general population are through the urban poor who live in close proximity to prostitutes and drug users; bisexual males and their spouses, clients of prostitutes, teen-agers and the sexually promiscuous; people who receive transfusions and use blood products, and inadequately monitored immigration, which may include Mariel-type deportations of disease carriers to the shores of our compassionate nation.

If through these avenues AIDS gains a larger population base and continues to spread exponentially, the problem will become unmanageable. Infection rates among the urban poor already show an ominous increase. Surveys report that 70% of teen-agers are sexually active. Claims concerning the accuracy of negative AIDs tests, and hence of the safety of the blood supply, ignore the fact that the recently infected can test negative; also, the presence of the more recently discovered HIV-2 AIDS virus is not routinely detected by the standard screening test. There is no monitoring of immigration from countries known to have a very high incidence of AIDS in the general population.

The natural tendency to require tangible evidence before acting has fostered a wait-and-see attitude toward the spread of AIDS into the general population. However, with an approximate seven-year latency period before the symptoms become evident, and with an infection rate almost doubling annually, compelling evidence of the breakout of AIDS will come too late. Waiting to see before taking realistic public-health measures will condemn many millions to death and inflict extraordinary economic costs on society.

When faced with a challenge of this potential magnitude, strategic planning is in order, and public-health measures are a basic requirement. There are steps that can be taken. Public-health policy can be formulated aimed at preventing, or failing that, delaying the spread of AIDS into ever widening circles of the population. The maximum goal of such a policy is to contain the epidemic. The minimum goal is to slow its spread to buy time for medical research.

No single public-health measure will do the job. Condoms alone cannot stop the epidemic, but safer sex combined with a strengthening of traditional moral values and a revival of monogamous relationships will help to reduce the transmission rate. Until more certain tests are available, the practice of purchasing the blood supply must be stopped, as this draws blood disproportionately from high-risk groups. The purchase of blood from Africa, where the HIV-2 virus is more prevalent, would seem to be particularly ill-advised. Facilities should be established that allow families and individuals to stockpile blood for operations and emergencies. Enforcement of laws prohibiting prostitution would be life-saving. The closing of bath houses is long overdue.

We must not repeat the tragedy of past wasted chances, as when the gay leadership, not realizing the seriousness of the problem, placed protection of a life style higher than survival, and thereby helped to seal the fate of the male homosexual population.

To avoid under- and over-reacting, the public and the major institutions of American life must be fully informed. Sound public policy requires a data base on the number of infected, their distribution among geographical regions and social groups, and rates of transmission. Otherwise, there is no basis on which to develop realistic budgets or to plan the location of the new facilities that will be required to provide hospice care for large numbers of AIDS patients.

An equally urgent need is to get the U.S. budget under control. Many of the things on which Congress is spending money are of much lower priority than forestalling a plague. The medical research profession offers hope but no guarantees. Nevertheless, a crash program to develop vaccines, treatments and cures is certainly required. Immunity from litigation may be required to accelerate the introduction of vaccines and treatments.

A new institutional framework for managing the cost of AIDs care will certainly be required. An economic growth policy to provide additional resources is more important than ever.

Meanwhile, people in close proximity to known high-risk groups must be saturated with warnings. Leaders of popular culture such as athletes and rock personalities will be needed in order to reach teen-agers and the urban poor whose lives are already overburdened with multiple problems.

The public must become aware of the dangers of irresponsible sexual behavior, and must counter the still-prevalent atmosphere of “sexual freedom.” The price that millions are already fated to pay cannot be overstated.

While understating the problem is the wrong way to cope with public fear, public fear is the wrong aspect of the problem on which to focus. If we act soon, there are ways to cope with the disaster. The need for action transcends the institutions, politics and rivalries of American life. It is time to go forward with realistic public-health measures and medical research, along with the budgetary and institutional planning necessary to care for large numbers of acutely ill patients. We must face this challenge quickly with courage, faith and resolve.