At Last, the Battle Is Joined

By J.D. Reed

"AIDS is surreptitiously spreading throughout our population, and yet we have no accurate measure of its scope. It is time we knew exactly what we are facing."

With those words and after months of cautious deliberation and disagreement within his Administration, President Ronald Reagan finally unveiled a plan for combatting AIDS -- and further fueled the furious debate over how best to contain the virus. The question is fast becoming one of the most hotly contested issues both in Washington and on the international political agenda. As evidence of growing concern, 6,082 AIDS researchers and public health officials from 50 countries gathered in Washington for the largest conference ever devoted exclusively to the disease.

The President's remarks were one of several dramatic expressions in the capital last week of the intense national debate over a key issue involving AIDS control: mandatory testing. Reagan drew boos and hisses during a May 31 speech at a private AIDS fund-raising dinner when he urged "routine" testing of inmates in federal prisons and patients in Veterans Administration hospitals. He also asked that all foreigners seeking residence visas be screened for exposure to the virus and strongly encouraged states to test marriage-license applicants.

A day later, Vice President George Bush, echoing the themes stressed by the President, was roundly booed by an audience gathered at the Washington Hilton for the third International Conference on AIDS. In an aside that was picked up on an open television microphone, Bush, taken aback by the reaction, asked, "Who was that? Some gay group out there?" Before his speech, an estimated 350 protesters, some of them suffering from AIDS, had staged a noisy demonstration in front of the White House. District of Columbia police, wearing yellow rubber gloves to protect against possible AIDS-virus infection, arrested 64 of the protesters.

There were other signs of official preoccupation with AIDS. The threat of the disease is slated to come up when Reagan and six other leaders of major industrial democracies* meet at the economic summit in Venice this week. That the battle against AIDS will require international cooperation was a point repeatedly made by top AIDS researchers at the Washington conference. Speaker after speaker emphasized the lengthening reach of the AIDS virus around the globe -- and the potential magnitude of the problem for policymakers. Said U.S. Deputy Assistant Secretary for Health Lowell T. Harmison: "We are at war with a global disease."

Some American health officials welcomed the President's call for screening. At week's end Health and Human Services Secretary Otis Bowen announced plans to chart the dimensions of the disease by testing 45,000 randomly selected volunteers. There are now more than 36,000 cases of AIDS in the U.S., and as many as 1.5 million people, or about one in every 30 men between the ages of 20 and 50, may already carry the virus. "The President's statement was something I could agree with," said Surgeon General C. Everett Koop, who opposes mandatory testing because it might scare away those in high-risk groups who need both screening and counseling. Under the President's plan, Koop stressed, "individuals have a right to opt out."

Critics of wide-scale testing, however, pointed out that screening 43,000 federal prisoners, 1.4 million patients a year in Veterans Administration hospitals and thousands of foreigners who annually flood immigration offices would present enormous logistical problems. Such large-scale testing is unlikely to achieve results commensurate with the huge price tag.

From past experience with infectious diseases, many health officials believe the marriage test in particular will not effectively reach the high-risk groups -- homosexual and bisexual men and intravenous drug abusers, who collectively make up 91% of U.S. AIDS cases. Indeed, researchers at the AIDS conference presented evidence of a continuing rise in the number of new infections among IV drug users in the U.S., most of them black or Hispanic, who are spreading the virus to the heterosexual community.

Still, Congress signaled its basic approval of the President's AIDS program. By a 96-to-0 vote last week the Senate amended a $9.4 billion supplemental- appropriations bill to require the testing of immigrants; entry will be denied to those found to have been exposed to the AIDS virus. The Senate also approved $77 million for anti-AIDS programs. The House is expected to pass a similar measure later this year.

Washington is not the only capital where health officials and politicians have been struggling to shape a policy to fight AIDS. So far, 51,535 AIDS cases have been reported to the Geneva-based World Health Organization by 112 countries, not including some hard-hit African countries. As many as 10 million people are believed to be AIDS carriers, and according to some estimates, 100 million could have the virus by the end of the century. Many governments, mostly in Western Europe, have responded far more swiftly and decisively than the U.S. to the deadly challenge by developing public education programs.

The Netherlands, which had 260 reported cases of AIDS as of April 1, began a government-sponsored "condom campaign" two months ago to encourage the use of prophylactics during sex, and continues to provide free sterilized needles to drug addicts. In Britain, where 750 AIDS cases had been reported by last month, the government last November allocated $32 million to produce a blitz of warnings and advice. Billboards were erected across the country that read AIDS: DON'T DIE OF IGNORANCE. Now, however, the London government has begun to question its approach. A recent study has concluded that the campaign needlessly raised general anxieties about AIDS but missed those individuals in population groups at high risk. Later this month the British government will launch another effort aimed at drug users.

Despite the protests of civil rights groups about discrimination against people with AIDS, some governments have mandated limited screening. France, for example, will soon require testing before couples are issued marriage licenses. In the Soviet Union, which has reported only 54 cases of AIDS, tens of thousands of tests have been carried out, although the government has not disclosed what segments of the population were screened.

Xenophobic fears in Asia have led to a wave of tough anti-AIDS legislation. China has reported only two deaths from AIDS, but authorities have ordered the testing of more than 4,000 foreign students. In Japan, which admits to 38 cases of AIDS, the Diet (parliament) may soon pass legislation that would deny entry to foreigners who test positive if they present a threat to public health; the bill is mostly aimed at prostitutes, bar girls and foreign sailors. With little more than a year to go before Seoul is host to the 1988 Summer Olympics, South Korea has passed a law that subjects anyone found guilty of knowingly spreading the virus to up to two years in prison.

Governments are also beginning to face the question of who will pay health- care costs for AIDS suffers. American insurers estimate the cost of providing hospital and medical treatment for a single patient at more than $75,000 from diagnosis to death. Around the world, hospitals and medical staffs are ill- equipped to deal with the rising costs and numbers of AIDS cases. Dr. Anthony Pinching of London's St. Mary's Hospital Medical School warns that his facility, which has cared for over 170 AIDS patients, is facing economic burnout. Reason: it lacks funds to hire additional staff and expand its facilities.

Even as the AIDS policy debate rages, however, many painful questions remain unanswered. How, for example, will the U.S. cope with the AIDS medical bill? A Rand Corp. study released last week concludes that the cost of treating a projected 400,000 U.S. AIDS sufferers from 1986 to 1991 may exceed $37 billion, with about $10 million borne by the Medicaid program. Also, who , will treat the patients? New York City, where more than 700 of the 35,794 available hospital beds are already occupied by AIDS patients, has proposed devoting one hospital exclusively to their care.

Perhaps the most fundamental question facing U.S. policymakers is whether they are willing to protect the ordinary rights of those infected with the AIDS virus without resorting to racist or homophobic programs. High-risk groups, after all, are those from which the public will clamor most for protection. Many public health officials feel that education, treatment and counseling programs for homosexuals and intravenous drug users offer the best return on the tax dollar. "IV drug use is the main source of heterosexual spread in this country," says Don C. Des Jarlais, an epidemiologist at the New York State Division of Substance Abuse Services. "That's where we have to concentrate our efforts. There is still time."

FOOTNOTE: *Britain, France, West Germany, Italy, Canada and Japan.

With reporting by Dick Thompson/Washington, with other bureaus