The Reassertion of Central Authority

Finally, the AIDS epidemic may demonstrate that the American health polity best serves the public interest when institutions within it struggle to assert central authority, when they do not accept fragmentation as the goal as well as the norm of health affairs. The unwillingness of the federal government to exert strong leadership in response to AIDS has been criticized by members of Congress, journalists, and patients since the beginning of the epidemic. In the absence of federal assertiveness, however, the health departments of several cities and states have coordinated the response of the health polity to AIDS. These health departments have tried, in different ways, to counter fragmentation by linking their traditional responsibility for surveillance with their more recent mandate to manage the health system. To the extent that similar linkage of the responsibilities of public health officers occurs elsewhere, it may partially substitute for the abdication of federal leadership and, perhaps, serve as a model for future national administrations.

These lessons about policy and authority could be drawn from the history to early 1988 of the response of the American health polity to AIDS. If they are not, we may recall the 1980s as a time when many Americans became increasingly complacent about the consequences of

dread disease and unwilling to insist that the individuals and institutions of the health polity struggle against them.