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When Will We Take AIDS Seriously?

June 20, 1986|NEIL R. SCHRAM | Neil R. Schram is an internist and director of the Los Angeles City/County AIDS Task Force.

The AIDS epidemic has been with us for five years. The staggering projections made recently by the U.S. Public Health Service show that the epidemic will be with us for at least another five years.

The PHS predicts that a cumulative 270,000 cases of AIDS will be reported by the end of 1991 (compared with 21,000 by June, 1986); 3,000 will involve infants and children, most of them infected before birth. During 1991 alone, 145,000 people with AIDS will be requiring medical care. The PHS estimates that there also will be an additional 55,000 cases of misdiagnosed or unreported AIDS. The agency is unable to estimate how many people will be infected but showing no symptoms over the next five years. It does, however, forecast an exponential growth of AIDS due to heterosexual contact from 1,100 cases this year to 7,000 in 1991.

Consistent with these rising nationwide projections, Los Angeles County has been reporting an average of 100 new cases per month since March, compared with 60 per month last fall. Of the 1,852 AIDS cases reported here to date, 1,060 have ended in death.

What is most disturbing is that we have the knowledge to prevent most of those infections, but, as a society, we do not have the will. We have allowed a vocal, highly political minority to misappropriate AIDS as a moral issue, givng our government leaders an excuse to abdicate their responsibility for the health and welfare of us all.

AIDS is a health issue, and as a physician I am especially disturbed to see how reluctant my colleagues are to assume their role in the first line of defense against the epidemic. Unfortunately, physicians are most comfortable discussing viruses and symptoms of disease. Discussing sex is very difficult (as it is for patients). As a result, few physicians include questions about sexual activity as part of a routine health examination. Fewer still are likely to ask if a patient is at risk specifically for AIDS, and provide appropriate advice.

The group at highest risk is gay and bisexual men. With substantial numbers of AIDS cases now reported in all major cities, the gay community should be mounting large-scale prevention programs around the country similar to the program in San Francisco. This effort requires large funding. However, the money is not forthcoming, because too many politicians fear that advocating such funding would be interpreted as condoning or encouraging homosexuality.

Adding to the gay community's problem is the activism of some people who want to reverse the civil-rights advances that lesbians and gay men have made over the last 20 years and are using AIDS to attack those civil rights. Thus the resources that the gay community could apply to fighting the spread of the virus are diverted to battling politicians and homophobes.

Intravenous drug users constitute the second group at risk, primarily from sharing needles or equipment. It is obvious that providing sterile needles, as is done in the Netherlands, would be a significant preventive response. But, again, that is not acceptable politically. Nor is a major financial commitment to counselors and expansion of methadone maintenance programs. This is with the full knowledge that IV drug users are heterosexually active and will spread the virus to their sexual contacts (who can spread it to theirs) and their unborn children.

It is known that for a woman infected with the AIDS virus, pregnancy increases her chances of developing AIDS. The risk that the child will also be infected with the virus is substantial. The Public Health Service currently advises that parents who are at risk for AIDS be tested before pregnancy and refrain from pregnancy if either parent tests positive. That advice is clearly inadequate. Where either parent is at risk, both parents should be tested. If either parent is confirmed positive, abortion should be strongly advised. Again, this advice is politically unacceptable. Thus we expect 3,000 AIDS cases in children by 1991, and countless other infected children who won't develop the disease but are likely to be carriers for life.

It is estimated that there are 50 to 100 people infected for every person diagnosed as having AIDS. Thus by 1991 there may well be 500,000 to 1 million heterosexuals infected with the AIDS virus. Yet many heterosexuals cling to the ridiculous notion that this is a "gay disease." Contributing to this societywide denial is the reluctance of public health officials to state the risk clearly for fear of causing panic. However, the figures are there for all to see: In the same week that the PHS projections were made, the weekly AIDS report by the Centers for Disease Control showed that the number of cases due to heterosexual spread have risen for the first time from 1% of the total to 2%. And a significant part of the 6% of AIDS cases listed as "unknown cause" are thought likely to be due to heterosexual spread.

For years we have recognized what is needed to slow this epidemic: an appreciation of the enormity of the problem so that we can mobilize our available resources. Daily the problem grows even more enormous, and very soon hundreds of thousands of Americans will be stricken. Apart from the unspeakable suffering of these victims and their loved ones, the tragedy is that our society is so immobilized by prudishness or politics or moralizing that we cannot or will not deal with these issues.

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