Neither education nor coercion will stop AIDS, public health officials say. They are uncertain what will prevail. But still, they must act.
Kristine Gebbie, director of the Oregon state health division, was talking about that one recent morning.
"I don't think I can go about my business just wringing my hands and saying: 'There are no right answers. Oh, my gosh, this is so awful. There is no way to go.' Meanwhile, the world is going right over you. You take the best shot at where you can go."
Their best shot right now, the health officers believe, is greatly expanded, widespread voluntary testing and counseling, offered in a variety of facilities that serve high-risk populations. Those would include venereal disease clinics, drug abuse clinics, community and migrant health centers and family planning clinics.
Testing Will Come
AIDS experts at the national Centers for Disease Control believe such testing will come in time, as federal legislation and public attitude create diminished discrimination and increased confidentiality.
"The issue never has been quite as simple as voluntary versus mandatory," said Dr. Walter Dowdle, the Centers for Disease Control's AIDS director. "The CDC says that testing should be pushed. That's different from voluntary, which implies something passive. It should be pushed for high risk, but not forced. . . . Gradually, the test will become more and more accepted. Clearly this is going to happen."
Expanding voluntary testing, however, will only intensify the present debate over a host of tough problems.
Will the testing be done anonymously or by name? Will positive results be reported to state authorities? Will that be done by name or by demographic data only? Will all partners of those infected then be notified? Will they be told who infected them? Will recalcitrant patients, unwilling to warn others or modify their behavior, be quarantined?
It is here that the public health officers now find themselves most frequently enmeshed in agonizing dilemmas. To them, there seem to be few unequivocal answers.
Two of the more highly regarded state health officers in the country are Gebbie and Thomas M. Vernon, executive director of Colorado's Department of Health. They respect and admire each other and share many of the same values and instincts. But at a crucial fork in the road, they chose separate paths in the fight against AIDS.
The differences in their decisions and their experiences reflect the complicated nature of the issues now facing health officials.
Vernon has insisted on applying traditional, classic public health policy to AIDS, drawing parallels between that disease and others he has fought, including tuberculosis and syphilis.
"If we can't use these methods, we are doing substantially less than we know how to do," he said. "There are tried and true methodologies which have worked in the control of communicable disease before. To the extent they are applicable, they should be utilized."
On the other hand, Gebbie, concluding that AIDS cannot be fit into previous disease models, has modified the traditional approach.
"It became clear that if we sort of forced the usual public health pattern onto this disease," she said, "it would have the perverse effect of looking elegant and accomplishing little. . . . Since my goal is to stop AIDS, not to prove that classic public health behavior works, I'm prepared to be flexible."
Traditional public health measures involve testing by name, reporting to the state health agency all positive cases, tracing and notifying others who might have been exposed and, when necessary, quarantining the most dangerously contagious cases.
Those are the tools used against syphilis, against tuberculosis, against smallpox. Those are the tools public health officers instinctively reach for.
When they thought to do so with AIDS, however, they found parts of their community screaming at them. No, AIDS does not fit that model, the gay and civil rights activists were saying. You have no cure to offer this time. The social stigma and discrimination are far greater threats with this disease. Using names and reporting and contact tracing will drive away those you most need to reach.
Gebbie and Vernon considered.
Despite the outcry, both felt there were some parallels between AIDS and these other diseases.
Something to Be Hidden
There was a time when syphilis lacked a cure, after all. There was a time when syphilis presented to a respected family a horrible social stigma. A father dying of brain damage from syphilis was something to be hidden, denied.
And yet, Gebbie and Vernon also knew there were times past when the tools of their profession were abused. Early public health officers fighting smallpox, for example, were given to strapping on a gun, galloping off to various stagecoach lines and hauling off travelers with pockmarks.
There was a fine line to walk here, they came to see.