Five months after the state health department announced it would investigate whether a former Johns Hopkins surgeon transmitted the AIDS virus to any patients, the study has barely begun and officials balk at even estimating when it will be completed.
Yesterday, Acting Health Secretary Nelson J. Sabatini confirmed that the department has yet to contact any of the late Dr. Rudolph Almaraz's patients about participating in the study. Original plans, announced last December in the heat of intense publicity and public debate over the Almaraz case, called for the study to be completed by June.
The surgeon earned national renown for his work with patients suffering from breast cancer and other malignancies. He treated about 1,800 patients over a six-year period that ended with his death from complications of AIDS on Nov. 16, 1990.
Mr. Sabatini said that before the health department could begin collecting data on the patients, the agency must work out such delicate issues as the need to safeguard patients' privacy. Other concerns included the possibility that the state could get dragged into lawsuits being waged by several patients against the doctor's estate and the hospital.
"It's a very difficult study to structure," Mr. Sabatini said. "It's an important study, but it's got to be balanced to make certain we protect the rights of the patients." Mr. Sabatini said the department approved a detailed plan several months ago, but is working on revisions.
Some of Dr. Almaraz's patients said they were puzzled that they had not heard from the health department.
"I haven't been personally contacted by the state of Maryland, and I know a lot of women and no one has been contacted," said Suzanne Ritmiller, a former Almaraz patient who said she knows eight others through a support group at the Greater Baltimore Medical Center.
"How else are they going to know what, in fact, happened with Dr. Almaraz's patients?" said Ms. Ritmiller, a GBMC nurse.
In a strikingly similar case, public health officials in Tennessee set out in January 1989 to investigate whether any patients there had contracted the human immunodeficiency virus from a surgeon who had died of AIDS that month. Two months later, the study was finished and local newspapers carried the results.
The Tennessee investigation found no evidence that anyone had been infected by the surgeon. One patient tested positive for HIV: a 31-year-old intravenous drug user who had twice served prison time for drug trafficking. Because the man had repeatedly put himself at risk through his drug use, health officials ruled out the possibility that he was infected during surgery.
During the two-month study, health officers sent letters to 2,160 of the surgeon's patients, 616 of whom agreed to share their test results. Some of the patients had already been tested; others hadn't and accepted a health department offer to get tested at three clinics set up for the occasion.
Dr. William Schaffner, one of the study's coordinators, said it was important to start and complete the study "while the issue was hot" to ensure that patients would cooperate and that medical staff wouldn't lose their enthusiasm.
"If the issue is a hot issue, you can motivate people to do things," said Dr. Schaffner, director of preventive medicine at Vanderbilt University. "The longer you wait, the longer you give people time to object, to raise their hands and to review the protocol.
"You get cooperation if you strike at the moment."
Mr. Sabatini disagreed, saying he believes Maryland may get more cooperation now that news coverage has cooled and patients are less fearful.
In Baltimore, media reports that Dr. Almaraz had died of AIDS fueled a national debate over such questions as whether HIV-infected health care workers should be allowed to perform invasive procedures on patients. So far, the federal Centers for Disease Control has identified only one practitioner who spread the virus through his work -- a Florida dentist who apparently infected three patients.
Studies such as those in Florida, Tennessee and Baltimore are considered important to the CDC's efforts to devise guidelines that could govern infected health care workers wherever they practice.
"The study is an important study," Mr. Sabatini said. "We need the findings to help formulate some national guidelines and policies." Primary funding for the research is to come from the CDC, and Mr. Sabatini said he has discussed it several times in recent weeks with Dr. William Roper, the CDC director.
Besides asking patients if they have been tested on their own, health officials plan to use records of Johns Hopkins Hospital, which last December offered free counseling and testing to most of Dr. Almaraz's 1,800 patients.
Earlier this year, a hospital spokeswoman said about 200 patients had shown up for testing -- and none had tested positive. More recently, she declined to offer any further information, saying that would have to come from the health department because it was in charge of the study.
Yesterday, a spokeswoman for Gov. William Donald Schaefer said the Baltimore study is more complicated than the one conducted in Tennessee because it will poll the patients on such issues as limiting the practices of infected physicians.
Last December, Governor Schaefer said he was "hepped up" on the subject, because a close friend who had been one of Dr. Almaraz's patients was "scared to death" over the news that the surgeon had AIDS.
"I don't get the feeling anyone's dragging their feet," said Page Boinest, a Schaefer spokeswoman. "It's just a matter of being careful."