• Advice & Consent

    The AIDS Exception

    As a physician who treats patients with HIV/AIDS and a historian of medicine (I wrote Quarantine! East European Jewish Immigrants and the New York City Epidemics of 1892), I was astounded by "The AIDS Exception: Privacy vs. Public Health" (June Atlantic).

    To begin with, Chandler Burr neglects the most essential (and maddening) aspect of public health: the entire endeavor begins with the word "public," and is therefore political and contentious by nature. Despite Burr's incredulity that political and social issues appear to dominate many AIDS/HIV public-health policies, perhaps the most consistent feature of U.S. public-health efforts over the past 200 years has been a complex maelstrom of social, economic, religious, ethnic, and cultural influences that characterize each episode of epidemic disease.

    Moreover, Burr erroneously conflates public-health approaches for airborne infectious diseases such as diphtheria, influenza, measles, and to a lesser extent tuberculosis with those for the primarily sexually transmitted disease AIDS. Airborne diseases may be transmitted simply by breathing in a closed space with an infected (and coughing) person. HIV, on the other hand, is spread by unprotected sex or the commingling of blood. By not making these distinctions clear, Burr suggests that blanket procedures exist for public-health control. Different modes of transmission require different methods of prevention and containment. Yellow fever is spread by mosquitoes, making mosquito netting and insecticides important public-health investments for its control; widespread programs for condom and needle distribution and, above all, safe-sex education are the most appropriate approaches for controlling AIDS.

    Howard Markel, M.D.

    Chandler Burr proposed a singular set of rules for fighting all epidemics. The Centers for Disease Control and Prevention would like to explain why a comprehensive approach to prevention constitutes sound public health and is the most effective way to decrease the spread of HIV infection.

    The article recommends three specific tools for HIV prevention -- routine HIV testing, reporting of cases, and partner notification. The CDC has always supported these approaches as part of comprehensive HIV-prevention programs, and has worked with agencies at the state and local level to implement them as appropriate. However, these tools, among many others, must be put into the context of the unique features of the epidemic in different parts of the country.

    For example, communities with a low prevalence of HIV infection should not spend scarce resources conducting routine HIV screening in hospitals, where few cases would be detected, when providing education and services to the groups at highest risk for HIV would have a greater impact. On the other hand, in high-prevalence areas it may be most effective to couple a more widespread use of HIV counseling and testing with efforts tailored to reach those at highest risk, such as street outreach to drug users and their sexual partners. The CDC actively supports community-based decision-making about HIV-prevention programs. Our experience has shown that HIV prevention works best if it is designed and implemented in cooperation with the communities affected, rather than being mandated from the federal level.

    Protecting the public health requires voluntary individual commitment as well as sound public leadership. This is as true for preventing HIV as it is for preventing other infectious diseases. People have to come in for testing, provide their contacts' names, comply with complex treatment options, and change behavior to prevent the spread of infection. Historically, approaching individuals in an atmosphere of cooperation and trust has worked better. We can't mandate HIV away. It's just not that simple.

    Helene D. Gayle, M.D.

    Chandler Burr deserves great credit for his clear call for sound public-health policy to be applied to the AIDS epidemic, and for his praise of the legislation introduced by Representative Tom Coburn that answers that call. But Burr's declaration that "some skepticism toward legislation like Coburn's is warranted [and] conservatives representing themselves as public-health advocates are certainly vulnerable to a charge of hypocrisy" does Representative Coburn a disservice.

    Coburn is first and foremost a practitioner of obstetrics and family medicine who before his election to Congress, in 1994, earned the trust and respect of the residents of Oklahoma's Second District by delivering more than 3,000 babies. He would in fact be a hypocrite were he not to continue his concern for health and medicine as a member of Congress.

    Dick Armey

    Chandler Burr's article contains many valuable observations, but its oversimplifications have already caused mischief when misinterpreted by ideologues. Charles Krauthammer, who selectively cited it in a Washington Post editorial, paraphrased Burr to make his case that work for an AIDS vaccine is unnecessary because behavioral restraint is the answer. The ease with which pundits have deconstructed the complexities of this scourge is a disservice to those of us who have been struggling in the trenches since the start of the epidemic. Burr's article conveniently sidesteps the enormous costs of putting into place the programs he advocates. Has he calculated how many public-health workers would be required to implement an effective partner-notification program across the United States?

    Kenneth H. Mayer, M.D.

    Howard Markel adumbrates two elementary points of public health -- that "public" means a complex and difficult mixture of medicine, police power, dem- ographics, and civil rights, and that each virus bacterium's different properties mandate that it be treated with the right combination of epidemiological weapons. I make exactly these two points on the first page of my article.

    Markel's letter is, however, helpful in one way: the final sentence is as good an example as any of the anti-empirical dogma holding that only exceptionalism's elected tools -- needle exchange, condom availability, and sex education -- work against HIV/AIDS. Helene Gayle's essential point -- that in fact we need to use both these new and valuable public-health tools and the traditional tools of routine testing, confidential reporting, and partner notification, in ways appropriate for the race, sexual orientation, sex, and economic situation of various populations around the country -- is a nice counter to Markel's typically exceptionalist policy monomania.

    I should certainly have stated that Tom Coburn is a physician. His conservative view of condoms -- that they and, more important, the "pro-sex" ethos surrounding them actually encourage more and more risky sexual activity -- is quite interesting and should be pursued. But his conservative position against needle exchange is simply anti-empirical; the data show clearly that this is an effective means for slowing HIV transmission, as the American Medical Association itself recently officially affirmed.

    Kenneth Mayer says that in my article Isidestep the immense problem of the costs of traditional public health. I admit this. Part of the very complex answer to this problem is self-restraint, and another part is the best possible, most inclusive, appropriately administered, and preventive cost-containing public-health measures we can muster.

    Do We Consume Too Much?

    I am very much in sympathy with the spirit of Mark Sagoff's elegant essay "Do We Consume Too Much?" (June Atlantic), which quotes me and cites work I have contributed to. Unfortunately, Sagoff draws from two different reports very selectively, often missing crucial points in ways that mislead his readers.

    Sagoff is correct that we are not running out of nonrenewable materials such as metals and most fuels, but he ignores extensive evidence that many developing countries are facing growing shortages of renewable resources -- fuel wood, livestock fodder, subsistence crops, fish, and fresh water -- and increasing degradation of the forests, fertile soils, fisheries, and watersheds that produce them. He also ignores evidence that world oil production is likely to peak and begin to decline sometime in the next few decades. Certainly, substitutes for all these resources (except water) exist, but nearly a third of the world's population is too poor to buy them, and depends on local biological systems for subsistence, fuel wood, and livelihood. Likewise Sagoff cites our evidence that the United States is largely self-sufficient in the natural resources it consumes (with the important exception of oil) but ignores the evidence that smaller industrial countries are heavily dependent on imports of raw materials -- 35 percent of the total in Germany, more than 50 percent in Japan, 75 percent in the Netherlands. The damage done by logging forests in Southeast Asia to supply wood for Japan, for example, is amply documented. Indeed, other than in the Amazon Basin and the boreal forests of Canada and Russia, the world's frontier forests -- those that represent intact ecosystems -- have been decimated, and virtually all the remnants are severely threatened.

    I endorse Sagoff's moral and spiritual arguments for environmental preservation, and perhaps those are central for rich, well-endowed countries like the United States. For a large part of the world's population, however, environmental resources are critical not only to survival but also to any hope of social stability and progress.

    Allen L. Hammond

    Mark Sagoff levels an unfair criticism at environmentalists when he says that they are making a mistake by emphasizing the economic, market-driven assessments of natural resources instead of extolling the "aesthetic, ethical, and spiritual" value of nature. Environmentalists understand that the concepts of renewable and sustainable consumption really have nothing to do with species protection (there is no such thing as a sustainable level of human-caused extinction), and we would rather argue simply that animals deserve protection and respect because of their beauty, because they are part of a complex world, because they tell a story of struggle and survival in the face of overwhelming odds, or, if you are religious, because they are the work of the Creator. But let's be honest. How often has modern society backed species preservation for purely moral and aesthetic reasons when economic advantages could be gained through exploitation or even eradication? In nearly every environmental dilemma preservation provides economic as well as aesthetic, ethical, and spiritual payoffs. Environmentalists, focused on safeguarding nature before it is too late, are forced to choose the argument that has the best chance for immediate favorable reaction -- that is in the best economic interest of human beings. Until we arrive at the day when our society learns how to balance economic prosperity with moral and aesthetic sensitivity, environmentalists will be forced publicly to emphasize the inferior element of their work.

    Matthew Schenker

    Mark Sagoff was too optimistic. He evidently ignores the loss of temperate and tropical rain forest, the acute water shortages in our Southwest and in Africa, accumulating waste and pollution, topsoil loss, overpopulation, and so forth. If three or four billion people in the Third World want to raise their living standards to those of Greece or Portugal, where does Sagoff think the resources are going to come from?

    Edd Doerr

    Mark Sagoff replies:
    Allen Hammond correctly points to the plight of nearly a third of the world's people, who, since they are too poor to buy the kinds of technology that feed, clothe, and shelter those in wealthier nations, must live directly off the land and thus deplete its resources. I urged policies to transfer technology to those who, because they "are too poor to use sound farming practices are compelled to overexploit the resources on which they depend." As if to refute my thesis that the North excludes imports from rather than exploits the resources of the South, Hammond points out that smaller industrial nations are heavily dependent on imports of raw materials. They import raw materials, however, predominantly from other industrialized countries. Industrialized nations trade, even for raw materials, nearly exclusively among themselves.

    There is a great deal of truth in the observation by Matthew Schenker that environmentalists often must appeal to instrumental arguments for instrumental reasons -- because instrumental or economic arguments for protecting nature, however precarious, succeed better than ethical ones in swaying public policy. Yet in doing so environmentalists embrace the cost-benefit framework that is likely in the long run to undermine attempts to preserve the natural environment.

    In Translation

    Regarding "Puttermesser in Paradise," by Cynthia Ozick (May Atlantic), let me point out that "Puttermesser" does not translate from German into English as "butter knife." The English word "butter" is Butter in German also, and is pronounced more like "booter" than anything that would sound like "putter." The German word Pute is the closest to Ozick's invention; it means "turkey hen."

    Ritamarie Sustek

    Ritamarie Sustek hat recht: the English word "butter" is properly rendered in German as Butter. However, Ruth Puttermesser's surname is Yiddish, an autonomous language as independent of German as is Dutch or Swedish. In Yiddish the word for "butter" is putter.

    Advice & Consent

    Randall Rothenberg's review of my Breaking Up America ("How Powerful Is Advertising?," June Atlantic) contained a number of major misreadings that suggest a greater concern with fitting my argument into his agenda about masscult than with accurately representing the book.

    The review states that I take advertising to be the cause of social fragmentation in contemporary America. The book itself stresses that advertisers and media practitioners take their cues from their understanding of society, which they see as breaking up. Beginning in the 1970s and 1980s marketers and the media developed an interest in "detecting and exploiting social divisions" (p. 184). They, in turn, magnified those divisions. See Chapter 3 for a discussion of how and why.

    The review says that I am naive for believing "without question" the statements of advertising and media practitioners. On the contrary, in four chapters I specifically address the issue of "hype" regarding the new-media world. More important, my book centers on what ad and media firms are doing, not just saying, to develop targeting technology.

    Nor do I regard community-building E-mail, computer bulletin boards, and newsgroups as "divisive new technologies." The review ignores my theme that society needs a vigorous balance between two types of media: "segment-making" (for example, little magazines and newsgroups), which create strong communities, and "society-making" (for example, widely shared TV channels), which encourage different communities to come together to argue and share stories. American society has never achieved a satisfactory balance of the two, and is now "losing [even] the potential" to achieve it because the lure of target marketing is encouraging "a profound movement by advertisers away from society-making media" (p. 4). Contrary to the review (which accuses me of "masscult nostalgia"), the book explicitly states that "the proper response to this hypersegmentation of America is not to urge a return to the mass-market world of the 1960s and 1970s" (p. 199).

    Rothenberg is wrong as well when he writes that Breaking Up America "persists in attributing to a chaotic and variegated media system immediate and specific social and cultural consequences." I do indeed suggest social consequences -- that's the point of the book. But as I wrote (p. 199), "It will take time, perhaps decades, for the full effects of the emerging media world to take shape."

    Joseph Turow

    The Atlantic Monthly. All rights reserved.
    The Atlantic Monthly; September 1997; Letters; Volume 280, No. 3; pages 8-11.