AIDS in Maryland: Behold death in the streets

Garey Lambert

January 12, 1993|By Garey Lambert

YOU can't talk of the dangers of snake poisoning and not mention snakes," said former Surgeon General Dr. C. Everett Koop back in 1986. He spoke in defense of his attempt to force a headstrong and anxious public to accept AIDS education. He was repulsed because Americans clung to the tragic delusion that only snake handlers were at risk of contracting AIDS, and any forthright discussion of snakes and venom was immoral.

There is now firm evidence that we are reaping a grim harvest of consequences for that self-righteous delusion. A report presented last Dec. 8 to the Council on HIV Prevention and Treatment -- which Gov. William Donald Schaefer dissolved last week -- exposes clearly that the worst of the persistent and dire warnings about AIDS are coming true in Maryland, and our health care system is failing to cope.

First, our education and prevention programs are not working. The rate of AIDS cases is 21.2 for every 100,000 Marylanders. The national rate is 18.4. Forty-nine percent of all AIDS patients admitted to hospitals are Medicaid recipients. Twelve percent are covered by Blue Cross. In 1983, the figures were 29 percent and 31 percent respectively. The change reflects the increasing numbers of poor minorities and IV drug users contracting AIDS.

Yet, while the number of impoverished, uninsured AIDS patients increases steadily, the already insufficient health care and social services support programs are being slashed drastically. For example, Maryland's "state only" Medicaid program has been eliminated, a victim of budget cuts. The program paid 34 percent of HIV-related health-care costs. Who will pay now? Where will these people go?

Salient questions, for "state only" Medicaid spent $11.8 million on AIDS care between 1985 and 1990, and even that was not enough. No Medicaid program, state or federal, covers the actual costs of care. So the hospitals, clinics and doctors were saddled with the deficit. Between 1985 and 1990, the average loss to Maryland hospitals for each AIDS patient of Medicaid was $7,853. Most, but not all of the losses were compensated through the Maryland Health Care Cost Review Commission.

Now, with the collapse of "state only" Medicaid, hospitals will suffer even greater losses -- at least $2.3 million per year. They will try to cushion the blow by charging more for rooms and services -- in other words, what the state won't reimburse will be passed on to paying patients.

Many are just not taking the chance. Only two of 46 hospitals in Maryland deal with greater than 40 percent of all hospitalizations for AIDS -- Johns Hopkins and the University of Maryland. According to hospital discharge planners, only eight of 224 licensed nursing homes accept AIDS patients. Most private physicians too are loath to accept people with HIV infection.

This aversion is often attributed to discrimination, but it may be due more to economics. While patients with insurance are covered for most AIDS-related care, doctors are compensated for only 18 percent of their costs for Medicaid patients.

The effect is predictable. In the entire Baltimore region, only five private physicians specialize in HIV disease. Only two outpatient clinics -- the Johns Hopkins Moore Clinic and the gay and lesbian community's Chase-Brexton Clinic -- care for well over half of all HIV-infected patients in Maryland. Only one hospital devotes a ward to AIDS -- Johns Hopkins.

This dearth of health care produces tragic consequences. The few providers caring for people with AIDS are overwhelmed. Several private AIDS specialists can accept no new patients. The wait for an initial evaluation at the Moore Clinic is 20 weeks! So people who should be receiving treatment are not. A study by the state AIDS Administration found that about 50 percent with AIDS in Baltimore were not treated with AZT to fight the virus, or with drugs to prevent an AIDS-related pneumonia, all "commonly accepted therapeutic standards for . . . treatment and prophylaxis."

The words are those of Dr. John Bartlett, chief of infectious diseases at Johns Hopkins. Dr. Bartlett's division oversees the entire Hopkins AIDS service, including its broad program of AIDS clinical research. He was a member of the Governor's Council on HIV Prevention and Treatment and presented the report there. As he concluded, he was asked for his opinion.

"This is just bad medicine," he said. "It's just bad medicine." Dr. Bartlett's retort was not an ill-considered reproach. For no matter how well intended Maryland's health care and social services delivery programs may be, and no matter how hard the doctors, nurses, social service workers and volunteers toil, a vast number of people who need care aren't getting it, and enormous amounts of money are being squandered on a system that is failing.

With the dissolution of the Governor's Council on HIV Prevention and Treatment, public discussion of these issues has been severely restricted. Yet, the governor may have a point when he complains that the council was too narrowly focused. Perhaps a statewide advisory and policy council is now needed. It could advise not just the governor, but the General Assembly, the state AIDS Administration, local health departments and private service organizations. It could be the statewide forum for public debate and an invaluable resource for information and ideas to address our complex problems.

In any event, substantial steps must be taken to define and address these dilemmas, for if meaningful AIDS prevention programs and comprehensive health care refrom are not soon developed, Marylanders may bear witness to people dying in the streets. Are we prepared for that? If not, then we'd better start talking seriously about snakes.

Garey Lambert is vice chairman of AIDS Action in Baltimore.

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