Neighborhoods Where AIDS Grows

GEORGE F. WILL

March 13, 1993|By GEORGE F. WILL

Washington. -- A reasonable surmise is that, about 50 years ago, in east and central Africa, some hunters and their families who ate monkeys became infected with a low-virulence (and for a long time quiescent) progenitor of what is now known to be the virus that causes AIDS. Thus on the continent where the human race may have begun, there began an epidemic.

Its dynamics have now led some researchers to an encouraging conclusion: In America, the disease is largely concentrated in perhaps 30 neighborhoods nationwide. Change behavior in those places and the epidemic will recede.

When Dr. Stephen C. Joseph was practicing medicine in central Africa in the early 1970s he saw many cases of undiagnosed wasting syndromes, progressive infections and bizarre malignancies. By 1981 five gay men in Los Angeles had similar afflictions. By 1986, when Joseph became commissioner of health in New York City, he knew what was happening, and why.

As he writes in his harrowing book, ''Dragon Within the Gates: The Once and Future AIDS Epidemic,'' an epidemic requires not only a microbe but also an appropriate social context. AIDS found two contexts in New York. ''The artistic, cultural and fashion enterprises which are particularly important to New York's world standing and economy,'' writes Dr. Joseph, ''have traditionally included large numbers of gay men.''

Then in the late 1980s there came a great epidemiologic shift, away from gay white males and toward minority heterosexuals -- needle-sharing intravenous drug abusers and their sexual partners.

AIDS has been particularly disconcerting because the nation had come to believe that it was no longer vulnerable to mass infectious disease. But modernity actually abetted the epidemic.

In Uganda and Tanzania it was spread by roadside prostitutes whose clients were truckers and soldiers traveling on the modern road system. Africa has been increasingly integrated into the world flow of transportation, commerce, tourism and traveling students. This is a century of global interconnections, so pandemics -- infectious diseases spread globally -- are now more possible than ever.

Furthermore, AIDS, like lung cancer, coronary artery disease and motor-vehicle accidents, is a characteristic 20th-century epidemic: It is closely related to current behavior. Related, in fact, to voluntary, conscious and intimate behavior, that involving sex and drugs. And much of the high-risk behavior is highly concentrated in a few small areas.

Last Sunday Gina Kolata, a science writer for the New York Times, reported that some experts now believe that the AIDS tTC epidemic in America ''can be all but stamped out,'' without a vaccine or wonder drug. The strategy would involve concentrating on prevention of risky behavior that is particularly prevalent in 25 to 30 neighborhoods nationwide, in such cities as New York, Miami, Los Angeles, San Francisco, Houston, Newark and Camden, New Jersey.

However, Ms. Kolata says, among the measures public-health officials want to concentrate in those neighborhoods are some that many conservatives oppose, including free distribution of clean hypodermic needles, many more drug-treatment programs and explicit sex education ''adapted to the language and mores of affected neighborhoods.''

The political impediments to rational AIDS policies involve much more than just conservatism. AIDS in America has been associated with stigmatized and illegal behavior, and has been concentrated among marginalized groups -- homosexuals and inner-city poor -- that feel vulnerable to oppression.

So there has been a concerted effort to ''democratize'' the disease. The politically correct message has been that everyone is vulnerable -- ''AIDS does not discriminate.'' And there has been resistance to targeting the risky behavior of particular groups.

Such behavior is resurgent. Two days before the Times carried Ms. Kolata's article it carried another story under this headline: ''In the Age of AIDS, Sex Clubs Proliferate Again.'' The city now has about 50 such clubs, a majority catering to gay men. Patrons can have anonymous sex with multiple partners. One club even advertises ''HIV Positive Night'' to attract people already infected.

Dr. Joseph struggled to get such establishments closed in the 1980s, when there were 200 new AIDS cases reported in the city each month. Today 500 new cases are reported each month. But the city government, perhaps weary of doing battle with gay groups and civil-liberties lawyers, now professes to hope that the clubs can be made a net plus for public health by being encouraged or required to distribute condoms and employ monitors to supervise sexual activity. As though people patronize such places in order to be supervised.

The primary public-health task in an epidemic is to protect the uninfected. Until there is an arsenal of AIDS medicines, the epidemic will remain less a medical challenge than a test of political will.

''AIDS,'' writes Dr. Joseph, ''is the first major public-health issue in this century for which political values rather than health requirements set the agenda.'' If we are serious that will stop, and so, perhaps, will the epidemic.

George F. Will is syndicated columnist.

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