Caught in Debate Over Coercive, Voluntary Measures : AIDS Battle: Should Officials Get Tough?

After a long day of promoting her program of AIDS education and counseling throughout Oregon, the director of the state’s health division stopped at an airport coffee shop in Medford one recent evening and ordered a slab of pie smothered in ice cream.

Kristine Gebbie is a hefty woman and a powerful speaker. For 14 hours, she had been confidently laying out her position.

“I can make a good intellectual argument for education being what I will kick in the most with, education for behavior change,” she said over the pie. “But, in fact, that’s not been one of our strong points socially. I can intellectually tell you everything you need to know about being fit and being of average body weight, and I’m still lugging an awful lot of pounds around that I shouldn’t lug around, because I can’t make my hands and my mouth match what my intellect knows about eating habits. . . .

“And yet, here I am, standing up and saying I think I can educate Oregonians to change their behavior spreading this virus. That hurts inside, because I know I’m pushing what really makes sense, but I’m not really sure we can deliver what goes with it, and that scares me. It doesn’t scare me enough to say, so, abandon education, let’s go to the repressive-control means. The risks of doing that are far too great for me. I can’t get there, but I remain very uncomfortable.”

Talks with health officers such as Gebbie, toiling on the front-line against AIDS, suggest a world nothing like the hard edges and absolute positions that color current public discussions of the disease. Their vision is less certain, more shaded.

As public pressure mounts for tough, coercive measures in the fight against AIDS, and with President Reagan pledging to see the deadly disease go “the way of smallpox and polio,” health officials in the states find themselves in a tightening vise.

The firm consensus is that coercive measures, such as mandatory testing, won’t stop AIDS, but they are no more certain the voluntary measures they are pushing, such as public education and persuasion, will do the job.

Until a vaccine comes along, they say, we can only hope to slow the spreading of AIDS.

Debates over testing, quarantine, criminal sanctions and educational campaigns seem to these public health officers only partially relevant.

“All this talk about testing is just touching the toenail of the problem,” said epidemiologist Tom Betz, chief of Texas’ communicable disease unit.

Behavior Changes Needed

The only effective way to deal with AIDS, they say, would be one that led to profound, permanent changes in the behavior of millions, behavior involving deeply personal acts committed in private.

We do not know how to change behavior in this way, they say. We wouldn’t know how to do this even if we were willing to forgo fundamental civil liberties.

The health officials tend to put their chips on the tools of education and persuasion rather than on coercion, but they emphasize that both approaches have significant limits.

The uses of power and voluntarism crowd the thoughts of Thomas M. Vernon, executive director of the Colorado Department of Health. He has decided that the promises of both are illusory.

“We cannot put our faith in either of them,” he said. “We are not going to stop this epidemic in its tracks.”

So looking to the future, health officials speak urgently about the need for a “maturity” and “rationality” on the part of the American public--an acceptance and understanding that the AIDS problem will not be solved soon--but they are afraid this will not be the public response.

Projected AIDS Pattern

The number of AIDS cases will rise sharply over the next five years, no matter what is done today, as those already infected fall ill. With more than 40,000 AIDS cases now, the projected total by 1991 is 270,000 cases. Health officials say they expect pressure from the public and politicians to do something to stop AIDS will only grow more intense.

They worry that this will lead to unwise and ineffective overreactions, such as statutes requiring widespread testing, breaches of confidence and quarantines.

“This will really polarize the nation,” said Betz. “It’s going to get radical. There’s nothing to do but count bodies until a vaccine is found.”

The fear of overreactive measures, health officials acknowledge, already has created a pressure on them to act--even if they are unsure what should be done--to hold off something worse. Yet, when they do act, they often draw criticism and threats of non-cooperation from gay and civil-rights groups.

So they are handcuffed by both practical and political considerations. Their methods of fighting AIDS represent trade-offs cobbled together, classical public health approaches mixed with what they think will work and what their communities will allow.

Effect Uncertain

They do not know whether their efforts are succeeding. All the same, they firmly believe what they are doing is better than any present alternative. There just are no perfect answers right now, they say.

For several reasons, they believe coercive measures will not work.

Some raise ethical and philosophical issues. They fear that restrictive measures would shatter the country’s basic traditions, including the deeply rooted respect for individual liberty and privacy. At stake now is not just how to fight a virus, they say, but the future of American society.

“You might get well down the road to testing every Oregonian,” said Gebbie, “but two-thirds of the way there, or half the way, or a quarter of the way, all sorts of questions will start crashing down. The repercussions will be so great you will wish you never did the first test.”

Even as a practical matter, however, the health officers do not believe coercion will work.

A number of them put much weight on the opinions of Ronald Bayer, a bioethicist at the Hastings Center who has studied and written widely about AIDS.

Authorities Lack Power

There is little in the public dimension of AIDS that authorities can act upon, Bayer argues.

The individuals against whom the authorities could act aggressively are only those few whose outward behavior shows them to be dangerous to the public health, he reasons. Forced testing, prosecution, isolation--whatever we do to these highly publicized cases--will have little impact on the larger crisis.

The real problem lies with the hundreds of thousands of people who continue undetected, in privacy, to use unsafe sexual practices or fail to warn their partners, or inject drugs with shared needles.

“I’m unwilling to take refuge in saying that these cases are extremely rare,” said Bayer. “What I think we have to recognize is that the cases we will be able to see and act upon with public health authority may be extremely rare, though the reality of the behavior may be much broader.”

Most health officials believe the only effective mandatory screening would be testing of such high-risk individuals. Testing groups such as everyone who applies for a marriage license or checks into a hospital would not come close to identifying these high-risk people, so universal screening would be needed.

That would require an enormous and costly apparatus and, even then, would reveal only who was infected, not who was behaving irresponsibly.

Quarantine Only Choice

Without a cure, health officials would have little alternative short of quarantining for life all those who tested positive--an estimated 1.5 million people at present--against acts they might commit in the future.

Dr. Robert Bernstein, Texas health commissioner, braved a firestorm of local and national protest in late 1985, when he proposed adding AIDS to the list of diseases subject to quarantine, something he considered standard public health policy. Bernstein is a gruff-talking former commandant at the Walter Reed Army Medical Center, a shrewd internist wrapped in a deceptive country manner that encourages some to use the sobriquet Billy Bob in talking of him.

He has never contemplated mandatory testing.

“So what if you lined up all the Texans, and did testing?” he said. “It would be very interesting, and important for education, but so long as you don’t have a cure, how are you helping the situation? I am not afraid of proposing tough measures, but what would they be? It has to be effective. I have no idea what that would be. Do you?”

He stared at his visitor, then explained that he did not mean the question contentiously. He really wanted to know.

Question of What to Do

“What would you do?” he asked again.

Without a cure, AIDS testing has value only if the results will influence behavior, public health officials say.

But they do not know whether being tested changes behavior. They have only anecdotal evidence and small pieces of data from questionable studies. Information is mixed and blurred.

The figures show a significant decline in the rate of rectal gonorrhea among gays, which suggests that education efforts have curbed unsafe anal intercourse. Results of some research suggest that people who learn they are AIDS-antibody-positive do tend to modify their behavior.

Yet several studies, including the largest AIDS epidemiological project now tracking gay men, the Multicenter Aids Cohort Study, indicate that at least a third continue to practice unsafe sex despite education, testing and counseling.

That is a sobering antidote to enthusiasm for AIDS education, Bayer said.

The notion that persuasion through counseling might not fully succeed is one that health officers examine only after their first efforts to promote campaigns of education. When the topic arises, though, they talk freely about it.

Other Campaigns Fail

Other attempts to modify behavior through health-promotion campaigns have not done very well, they say. Witness the limited success of attempts to change driving behavior, to discourage smoking and alcohol consumption, to promote use of seat belts.

Even more to the point, they said, are the failure of sex education efforts to reduce the pregnancy rate among teen-agers, the failure of education to curb syphilis before penicillin was developed.

“What do you do with people?” said Dr. Charles E. Alexander, state epidemiologist in Texas. “You can’t police them--forget the Constitution--I mean, just physically. . . .

“I was in the Navy 20 years, in preventive medicine. In Korea in the early ‘50s, we had a high barbed-wire fence around the base, and that couldn’t stop the soldiers from having sex with local women. They’d do it through the fence. Not enough people are going to change. That’s the realist in me talking. People don’t relate what they are doing tonight with what happens seven years from now. I think they’ll need to see some friends dying around them.”

The health officials wish that all sides in the national debate would acknowledge the ambiguities. That does not, however, seem to be happening.

Polarized Public Opinion

So instead, they apprehensively watch an increasingly virulent polarity in the nation, one that they feel obscures the true problems.

On the one hand, the polls show the public more and more embracing the ideas of mandatory testing, criminal sanctions, quarantine and breaches of confidentiality.

State and national politicians reflect those sentiments in the types of legislation they are proposing, prosecutors in the criminal sanctions they are pressing. About 100 bills calling for various forms of mandatory testing have been introduced this year. Premarital screening for AIDS is being considered in 34 states.

Gebbie said she found it necessary earlier this year to storm the state Capitol in Salem to block just such a bill. The state senator who proposed it said he did so because AIDS was a “go home” issue, one his constituents would ask him about. “We have to show we’re doing something about this,” he explained.

On the other hand, it seems to the health officers that assorted gay and civil-rights advocates are demonstrating no more appreciation for the complexity of the issue.

At the Third International Conference on AIDS, last June in Washington, Ron Bayer attended a panel discussion of ethical and legal issues. When no one addressed the matter of infected persons who knowingly infect others, Bayer brought it up.

Question Called Insulting

The first response, from a member of the panel, was to the effect that Bayer’s was a “homophobic” and insulting question. Then someone in the audience shouted that everyone has an obligation to protect himself.

Last April, when Colorado Gov. Roy Romer signed a bill requiring the reporting by name of all AIDS-positive persons, a Denver gay-rights attorney promptly told a news conference that Romer had “just signed his first death warrant.”

All of this confounds Vernon, the Colorado health director.

“Most of my work takes me into areas where I see ambiguity,” he said, “but I’m sitting across from someone who is banging the table. I’m not against them, but I don’t know how they could be so sure. We don’t know that we are absolutely right.”

Social maturity is what’s needed, Bayer said. Instead of a grand vision of stopping AIDS, the public must settle for the more modest goal of slowing it for the many years that lie ahead until a vaccine is developed.

“I think the hardest thing for America to do over the next five years will be to recognize the limits of what we can do,” Bayer said. “For the next five years, the numbers are going to continue to mount very rapidly. In some ways, it is like the resolve that you need to fight a war.”

Less-Than-Pat Answers

The Health officials’ doubts about whether reason will win out stem, in part, from their sense that a central element of American culture has always been the idea that there are no limits on what the individual can achieve.

What the health officials have to offer, they are acutely aware, is something far less appealing.

Times researcher Nina Green contributed to this story.