June 3, 1997

When social historians a century hence come to write the story of our times -- the story of America in the waning decades of the twentieth century -- they will have no better lens for viewing the present than the one provided by the AIDS epidemic. Acquired immune deficiency syndrome has not, of course, struck all segments of our society equally, but the disease has provoked strong political and emotional reactions across the board in a manner that is socially diagnostic. As a result the AIDS epidemic encapsulates a record of sexual mores and sexual practices; of drug abuse and drug policy; of medical science and medical bureaucracy; of urban, religious, and celebrity politics; of the problems of the underclass; of the shifting currents of national psychology; and of issues such as immigration, health insurance, job discrimination, and the viral threat from increasingly accessible parts of the world beyond our shores. It is nearly impossible to think of an element of our society, be it garbage disposal or the arts, kindergarten education or the military, in which AIDS has not somehow figured during these past fifteen years.

It is hardly surprising that an issue that cuts so relentlessly and obliviously across lines of social demarcation has aroused deep passions. Those passions have been stirred with special vigor by the fundamental question of how dogged, not to mention intrusive or coercive, should be the steps taken by public-health authorities in finding cases of HIV infection -- and in dealing subsequently with those people discovered to be infected. Should we have been using from the outset more of the "traditional" public-health measures employed against other diseases, such as aggressive attempts to identify infected people (name reporting) and the people with whom they've been in contact (partner notification)? Or do the special circumstances of AIDS -- an incurable illness that initially infected a particular demographic subset -- justify "exceptionalist" new approaches that veer away from established measures but that may in fact help us to deal more effectively with future epidemics?

Some "traditional-minded" authorities have set teeth on edge among AIDS activists and civil libertarians with statements (regarding AIDS) like the following: "Detention and quarantine are legitimate and important measures for the community to have in reserve." (The quotation is from Dr. Stephen C. Joseph, New York City's former health commissioner.) At the same time, some "exceptionalist" activist groups have set other teeth on edge by seeming to regard issues of privacy and lifestyle as paramount and non-negotiable.

How different is AIDS from other public-health threats? How different, therefore, should be our public-health response? These are the questions that lie at the heart of Chandler Burr's article "The AIDS Exception: Privacy vs. Public Health" and they are questions on which health professionals increasingly disagree.

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Now, a few more questions to begin the discussion:


  • We are all accustomed to issues in which principle and pragmatism collide. But it might be said that where public-health strategies are concerned the only "principle" is pragmatism itself. Bearing in mind that, according to the Centers for Disease Control and Prevention (CDC), half of the nearly one million people thought to be infected with the HIV virus aren't aware of their infection, have our current public-health approaches to AIDS been a pragmatic success? By what measure?


  • One of the main objections to making more strenuous systematic efforts to test more people for HIV -- and to find and contact the sexual and needle-sharing partners of people who test positive for HIV -- is that these efforts will prove counterproductive: fear of the health-care system will drive infected people underground. What reason is there to believe that this would happen? Alternatively, what reason is there to believe that it would not?


  • To traditionalist-oriented respondents: What is the most telling insight of the exceptionalist argument? To the exceptionalist-oriented respondents: What is the most telling insight of the traditionalist argument?


-- Cullen Murphy

Introduction and opening questions, by Cullen Murphy

Round One -- posted on June 3, 1997