AIDS and Behavior

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ALTHOUGH THE FIRST cases of AIDS were seen some five years ago, the staggering dimensions of the epidemic are only just now becoming clear. Within less than five years the handful of cases initially reported turned into thousands, with ominous predictions for the future. There are now almost 30,000 cases of AIDS recorded: half of these individuals have died.

But cases of AIDS are really only the tragic, lethal tip of an epidemiological iceberg. Many more individuals, perhaps five to ten times as many, are currently suffering some effects of infection with the AIDS virus. Epidemiologists project that between one and two million individuals have been "exposed" to the virus, meaning they carry the virus and can infect others despite the fact that they currently are healthy.

Such individuals obviously live under a dark cloud of medical uncertainty; how many of these individuals will go on to develop AIDS or AIDS Related Complex (ARC) is currently unknown. The latency period between infection and disease, though still not precisely known, can be at least as long as five years.

Complicating matters from a public health standpoint is the ominious fact that this large group of healthy carriers probably will remain infectious for life, therefore increasing the probability that the number of infected individuals will continue to grow.

No doubt the epidemic will worsen before it abates. Experts now estimate that by the early 1990's there will be more than 270,000 cumulative cases of AIDS in the United States; 179,000 individuals will have died as a result of the disease. Moreover, it is now clear that the disease is transmitted heterosexually and does not discriminate according to any predefined "risk-group." In short, AIDS is a biologically complex medical problem that has all the makings of a major medical disaster.

ALTHOUGH GOVERNMENT health officials called AIDS the nation's "number one priority" in public health in mid-1983, the federal government's response has been poorly coordinated and haphazard. Since 1982 the Reagan Administration has consistently attempted to cut congressional appropriations for AIDS--this, despite the fact that cases have been doubling every year.

Underlying this debate over funding was the controversial nature of AIDS itself and its close association with homosexuality and intravenous drug use. Funding for sexually transmitted diseases has always been suspect in the federal health budget.

Despite the fact that behavioral change offers the best hope for slowing the spread of the epidemic, funds for education have been especially meager. In 1986, the Centers for Disease Control had $25 million available for education, although a full program would have required three times as much. The federal government refused to issue educational materials explicitly advising "safe sex" practices. Apparently, it was feared that this would be construed as an "endorsement" of homosexuality.

As Harvey V. Fineberg, dean of the Harvard School of Public Health, noted, "We understand enough about the cause and spread of the AIDS virus to give people the knowledge they need to protect themselves." Yet, outside the gay community, this is not being done.

EVEN IF FUNDS for education were adequate, we need to become more sophisticated in our educational approaches. As the history of sexually transmitted diseases shows us, altering behavior is no simple matter. The underlying assumption about behavior, deeply ingrained in our culture, is that it is merely voluntary. According to this logic, once appropriately informed about risks, individuals "should" modify their behaviors.

But behavior is not always subject to rational control, as highlighted by the problem of intravenous drug addiction. Sexuality is a powerful force, certainly subject to individual will, but not completely so.

Behavioral practices, though clearly related to patterns of disease, are poorly understood in contemporary biomedicine. Modern medicine emphasizes treatment, cure and technology, but focuses relatively little attention on preventive medicine and health education.

We know little about how to assist individuals who seek to make and maintain difficult behavioral alterations. This is as true for sexual behavior as it is for the problem of drug addiction, the two principal mechanisms for the transmission of the AIDS virus.

AIDS will require a serious reevaluation of our values and attitudes concerning sexuality, behavior and disease. The time has come to begin to devise appropriate educational policies to address complex issues raised by this tragic epidemic. Educational programs at all levels, from elementary schools to colleges, must be developed. The necessity of a creative, coordinated and vigorously funded educational response to the AIDS crisis is long overdue.

Allan M. Brandt is an assistant professor of the History of Medicine and Science. He holds a joint appointment in the Department of Social Medicine and Health Policy at the Medical School and in the Department of the History of Science. He is the author of No Magic Bullet: A Social History of Venereal Disease in the United States Since 1880.