The Social Impact of AIDS in the United States (1993) / Chapter Skim
Currently Skimming:
2 The Practice of Public Health
2 The Practice of Public Health
Pages 23-45
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From page 23... ...
State governments have the primary responsibility for public health: each state and territory has a chief public health officer, a public health department, and a system of county and city health departments with links to the state system. The authorities and responsibilities of the state and territorial health officers vary, but all share a common mission of protecting the public against various types of infectious or communicable diseases.
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From page 24... ...
It begins with the debate that has raged around whether HIV and AIDS should be treated as a condition that is exceptional or as one subject to traditional public health measures to stem the spread of infection. This controversy centers around the question of whether the history of responses to lethal infectious disease provides relevant lessons for containing the spread of HIV infection and whether policies developed for the control of sexually transmitted disease (STDs)
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From page 25... ...
But the HIV/AIDS epidemic also resembles the conditions that have become the major threats to public health in the post-antibiotic era linked to patterns of behavior that are rooted in the normative structures of the communities at risk. Some public health traditionalists, supported by some conservative political forces, argued in favor of the similarities of AIDS to all other communicable diseases and pressed to have AIDS and HIV infection brought under the standing of broad statutory provisions for control of communicable and sexually transmitted diseases, but they were in the minority.
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From page 26... ...
Would the power of quarantine be used, if not against all infected persons, then against those whose behavior, it was assumed, could result in the further transmission of infection? In answering these questions, an alliance of gay leaders, proponents of civil liberties, physicians, and public health officials began to shape a policy for dealing with AIDS.
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From page 27... ...
In addition, there is little evidence that the response to AIDS has shaped the course of public health policy more generally. The erosion of the exceptionalist perspective and the lack of influence or broader public health policy related to disease surveillance and behavioral interventions are clear from an analysis of policy and practice with regard to HIV testing, reporting, partner notification, and quarantine and isolation.
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From page 28... ...
Thus, in the fall of 1990, the House of Delegates of the American Medical Association voted to declare AIDS a sexually transmitted disease, a designation that would give physicians much greater latitude to determine the conditions under which HIV testing should be undertaken. Nowhere has the shifting perspective on testing been clearer than in the emergence of a powerful movement, supported by obstetricians and pediatricians, for the routine screening of pregnant women, who can transmit HIV infection to their offspring, and the mandatory screening of infants at high risk for infection.
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From page 29... ...
Although some believed that mandatory screening of health care workers was not called for, most who believed that infected clinicians had a moral and professional dub either to inform their patients regarding their serologic status or to desist from invasive procedures held that the "duty to inform or withdraw" imposed a correlative responsibility on institutions to identify. Hovering over the entire debate has been the recognition that any policy of screening for health care workers would inevitably produce pressure for the mandatory testing of patients as well.
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From page 30... ...
That apparent paradox can be explained by the unique political alliances that had been created early in the epidemic among gay organizations, civil liberties groups, and public health officials. But by June 1989, even that feature of the political landscape of public health had begun to change.
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From page 31... ...
Although reporting of HIV-infected individuals is still not widespread ire the United States, the move toward early clinical intervention may be ultimately incompatible with the preservation of anonymity, so crucial to testing programs in the epidemic's early years. Partner Notification and Contact Tracing The move toward named reporting was only partly based on the argument that state health departments needed the names of individuals to ensure adequate clinical follow-up.
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From page 32... ...
Despite the central and well-established role of contact tracing in venereal disease control, the notification of sexual and needlesharing partners in the context of AIDS had been a source of ongoing conflict between gay groups and civil liberties organizations, on one hand, and many public health officials, on the other hand (Potterat et al., 1989~. Contact tracing was always predicated on the willingness of those with sexually transmitted diseases to provide public health workers with the names of their partners in exchange for a promise of anonymity, and it had been viewed by AIDS activists as a threat to confidentiality and as a potentially coercive intervention.
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From page 33... ...
Thus, local epidemiologic factors as well as political forces continued to influence the course of public health policy. Confidentiality Versus the Physician's "Duty to Warn" Both the early and lingering resistance to partner notification can in part be explained by the confusion between the standard public health approach to controlling sexually transmitted diseases and policies and practices that are rooted in a very different tradition, one entailing a "duty to warn" or protect those who might be threatened by individuals with communicable conditions.
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From page 34... ...
, the Association of State and Territorial Health Officials (1988) , and the American Bar Association (1989~.
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From page 35... ...
These statements represented the traditional claims of public health practice. Although there was opposition to all efforts to bring AIDS within the scope of state quarantine statutes, more than a dozen states did so between 1987 and 1990.3 Many of them used the occasion to modernize their disease control laws to reflect contemporary constitutional standards that detail procedural guarantees and to require that restrictions on freedom represent the "least restrictive alternative" available to achieve a "compelling state interest." In this regard, a return to traditional public health did in fact produce an important modification in central elements of the tradition, namely, an incorporation of more contemporary standards of civil rights.
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From page 36... ...
Use of Criminal Statutes After an initial hesitation to use existing public health statutes that attach criminal penalties to knowing transmission of venereal disease, and some confusion over their applicability, states began to enact new legislation that criminalized behaviors linked to the spread of AIDS. This legislative activity coincided with political receptivity to extend the authority of public health officials to control individuals whose behavior posed a risk of HIV transmission.
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From page 37... ...
. In addition, the field of health promotion and disease prevention, although growing, was largely directed toward behaviors that contribute to chronic diseases: some attention was being paid to pregnancy and prevention of sexually transmitted diseases, but the emphasis had turned toward nutrition, weight control, smoking cessation, and other activities more closely linked to the major noninfectious killers.
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From page 38... ...
Clinics that are financed by or staffed and run by city, county, or state health departments have long provided treatment for gonorrhea, tuberculosis, and a variety of other usually communicable diseases, and, more recently, prenatal care for poor women. Such facilities can be categorical ones (e.g., tuberculosis, sexually transmitted disease, mental health, or prenatal care clinics)
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From page 39... ...
Sexually transmitted diseases (STDs) bear a special relationship to AIDS because people with such diseases may be biologically at higher risk to acquire or spread HIV infection and because, in an era of "safer sex," they give prima facie evidence of unsafe sexual behavior.
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From page 40... ...
At the state level, public health departments are under considerable pressure to anticipate and plan for the specific health care needs of HIVinfected people, a task not traditionally carried out by these departments. Although most states have some form of "state health plan," they are not typically involved in detailed discussions of the types and amounts of clinical services required by people with specific diseases, such as lung cancer or diabetes.
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From page 41... ...
As the first decade of the epidemic drew to an end and as gay organizations increasingly shifted their organizational efforts toward issues involving access to therapeutic trials and treatment, public health officials began to reassert their professional dominance over the policy process. In doing so, they began to rediscover the relevance of their professional traditions to the control of the AIDS epidemic, although considerable questions remained about whether traditional measures would have any demonstrable impact on the epidemic's course.
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From page 42... ...
Even the most ardent advocates of the relevance of traditional public health practice, the strongest opponents of HIV exceptionalism, recognize that mass educational campaigns will remain the single most important element in the public health strategy to contain HIV infection. And much was learned in the first decade of the AIDS epidemic about how to mobilize an effective public health education campaign about the importance of engaging those who speak on behalf of those most at risk in the process of fashioning such efforts.
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From page 43... ...
Conference of Local Health Officers (1988) Guide to Public Health Practice: HIV Partner Notification Strategies.
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From page 44... ...
(1991) Guidelines for prophylaxis against Pneumocystis carinii pneumonia for children infected with human immunodeficiency virus.
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From page 45... ...
Muth (1989) Partner notification in the control of human immunodeficiency virus infection.
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