AIDS and Public Health
Although Edward Brandt, then assistant secretary of health and human services, called AIDS the nation's "number-one priority" in public health in mid-1983, the federal government's response has been poorly coordinated and haphazard. In 1985 the Office of Technology Assessment (OTA) issued a report analyzing the federal government's response to AIDS; the report revealed a number of significant shortcomings. First, the government had been slow to respond: Although the Centers for Disease Control (CDC) had identified AIDS in 1981, research at the National Institutes of Health (NIH) did not begin in earnest until 1983; bureaucratic procedures appear to have prevented a more timely response to this public health emergency. Second, when NIH did take up the AIDS problem, research funding was inadequate. In 1982 and 1983 the administration did not budget any money for AIDS research; nevertheless, Congress allocated $33 million. The following year, the
administration asked for $39 million. Congress appropriated $61 million. In 1986 Congress allocated $234 million, but the Reagan administration proposed cutting this to $213.2 million; this, despite the fact that cases had been doubling every year.[35] Underlying this debate over funding was the controversial nature of AIDS itself and its close association with homosexuality. Funding for the research and treatment of sexually transmitted diseases has always been suspect in the federal health budget.
The OTA report also pointed out the inattention paid to social and psychological factors associated with the disease—especially noteworthy in that preventive measures offered the only immediate hope of slowing the epidemic. Nevertheless, funds for education have been meager. In 1986 the CDC had $25 million available for education, although a full program would have required three times that amount. As Harvey V. Fineberg, dean of the Harvard School of Public Health, noted, "We understand enough about the cause and spread of the AIDS virus to give people the knowledge they need to protect themselves."[36] And yet, outside the gay community, this is not being done.
Sex education has typically been an area of significant controversy, and this has proved especially true with respect to education programs about the AIDS epidemic for schoolchildren of various ages. As Walter Dowdle of the CDC explained: "The sense of urgency is somewhat different here. It's not a matter of philosophy and religious taboos. We are talking about prevention in life and death situations."[37] The federal government, however, refused to issue educational materials explicitly advising "safe sex" practices, apparently fearing they would be construed as an "endorsement" of homosexuality. In this respect, federal officials were as fearful as the Victorian legislators (discussed by the Porters in the last chapter) that public health education might seem to "condone" vice.
Although behavioral means are the only current hope for preventing the further spread of the disease, as the history of the sexually transmitted diseases makes clear, altering behavior is no simple matter. Sexuality is a powerful force, certainly subject to individual will, but not completely so. Such problems as intravenous drug use highlight the issue of addiction, which clearly points to the fact that behavior is not always subject to control. Behavioral practices, though clearly related to patterns of disease, are poorly understood in contemporary biomedicine. Indeed, the underlying assumption about behavior, and one deeply ingrained in our culture, is that it is entirely voluntary. According to this logic, individuals "should" modify their behavior once appropriately in-
formed about risks. Moreover, we know too little about how to assist individuals who seek to make and maintain difficult behavioral alterations. This is as true for sexual behavior as it is for drug addiction, the two principal mechanisms for the transmission of the AIDS virus. Preventive medicine and health promotion have had inadequate attention in modern medicine, where the emphasis has been on treatment, cure, and technology—the search for "magic bullets."