The AIDS Pandemic: Complacency, Injustice, and Unfulfilled Expectations
http://www.100md.com
《新英格兰医药杂志》
Lawrence O. Gostin notes in his new book, The AIDS Pandemic, that AIDS has provoked more legislation and litigation than any other disease in modern history. As evidenced by this compilation of previously published essays, it would be equally true to say that Gostin has done more than any other scholar to illuminate the legal issues concerning AIDS.
What is particularly striking about the book is how well it demonstrates the complex interaction between sociopolitical forces and the law. This is best illustrated by the handling of health care workers in the United States who are infected with the human immunodeficiency virus (HIV).
In 1990, a cluster of six cases of HIV-infection was linked to a Florida dentist. In response, the Centers for Disease Control and Prevention (CDC) recommended that health care workers infected with HIV (or infected with hepatitis B and with serologic evidence of hepatitis B e antigen) obtain approval from an expert panel and inform their patients of their serologic status before engaging in "exposure-prone procedures." Although the CDC had the power only to recommend this action, Congress mandated that states follow the CDC's guidance, and the courts have upheld the reassignment of infected health care workers.
The reaction to the Florida cases was extreme, for several reasons. The method by which HIV was transmitted in the dental cluster was never established. No other cases of transmission from health care workers to patients were known at that time. Having to notify patients of one's serologic status before a procedure constitutes a violation of the privacy of the health care worker and effectively makes it impossible for practitioners to continue performing procedures, thereby violating their rights under the Americans with Disabilities Act. Prior well-documented instances of problems among health care workers (e.g., substance use and incompetence) that led to serious outcomes for patients had not resulted in such intrusive measures against an entire profession.
Many health care workers also felt that society had created a double standard. Multiple cases of health care workers' becoming infected from treating their patients had been documented, and the courts had correctly ruled that health care workers could not discriminate against HIV-infected patients. Although almost all heath care workers would acknowledge that their profession requires them to take on risks that the average person would not choose to take (e.g., caring for persons with a communicable disease during an epidemic), many felt that it was unfair that they were required to put themselves at risk of infection through a well-documented mode of transmission from their patients, but patients could not be put at risk for a rare and undocumented mode of transmission from health care workers.
Although extreme, the initial response to the Florida case can be forgiven. Highly active antiretroviral therapy for HIV and AIDS was not available until 1996, and acquiring HIV during the early 1990s was felt to be the equivalent of a death sentence. To some, the uncertainty about how the transmission occurred in Florida argued for the need for broad prohibitions.
What is unforgivable, as detailed by Gostin, is that the CDC recommendation and the laws that support it have not been changed more than a decade later, despite the acquisition of new data. Exhaustive investigations of the patients of HIV-infected physicians, including those who perform invasive procedures, have not detected a single additional infection.
The reasons that the rules governing health care workers have not changed are social and political. Whether appropriately or not, most people want to know whether their physician is infected with HIV, and politicians are unwilling to change a law that enjoys wide support, however discriminatory it may be.
Throughout the book, Gostin appropriately advocates the objective determination of laws, policies, and interventions for disease prevention, with consideration of the underlying issues of civil and human rights. And each of his essays, on topics as disparate as partner notification, immigration policy, and aid to the underdeveloped world, fulfills this standard. It is for that reason that I found myself more disheartened after reading the book. I had not fully appreciated how large the gap is between our AIDS policies and what they should be.
Mitchell H. Katz, M.D.
San Francisco Department of Public Health
San Francisco, CA 94102
mitch.katz@sfdph.org((Studies in Social Medici)
What is particularly striking about the book is how well it demonstrates the complex interaction between sociopolitical forces and the law. This is best illustrated by the handling of health care workers in the United States who are infected with the human immunodeficiency virus (HIV).
In 1990, a cluster of six cases of HIV-infection was linked to a Florida dentist. In response, the Centers for Disease Control and Prevention (CDC) recommended that health care workers infected with HIV (or infected with hepatitis B and with serologic evidence of hepatitis B e antigen) obtain approval from an expert panel and inform their patients of their serologic status before engaging in "exposure-prone procedures." Although the CDC had the power only to recommend this action, Congress mandated that states follow the CDC's guidance, and the courts have upheld the reassignment of infected health care workers.
The reaction to the Florida cases was extreme, for several reasons. The method by which HIV was transmitted in the dental cluster was never established. No other cases of transmission from health care workers to patients were known at that time. Having to notify patients of one's serologic status before a procedure constitutes a violation of the privacy of the health care worker and effectively makes it impossible for practitioners to continue performing procedures, thereby violating their rights under the Americans with Disabilities Act. Prior well-documented instances of problems among health care workers (e.g., substance use and incompetence) that led to serious outcomes for patients had not resulted in such intrusive measures against an entire profession.
Many health care workers also felt that society had created a double standard. Multiple cases of health care workers' becoming infected from treating their patients had been documented, and the courts had correctly ruled that health care workers could not discriminate against HIV-infected patients. Although almost all heath care workers would acknowledge that their profession requires them to take on risks that the average person would not choose to take (e.g., caring for persons with a communicable disease during an epidemic), many felt that it was unfair that they were required to put themselves at risk of infection through a well-documented mode of transmission from their patients, but patients could not be put at risk for a rare and undocumented mode of transmission from health care workers.
Although extreme, the initial response to the Florida case can be forgiven. Highly active antiretroviral therapy for HIV and AIDS was not available until 1996, and acquiring HIV during the early 1990s was felt to be the equivalent of a death sentence. To some, the uncertainty about how the transmission occurred in Florida argued for the need for broad prohibitions.
What is unforgivable, as detailed by Gostin, is that the CDC recommendation and the laws that support it have not been changed more than a decade later, despite the acquisition of new data. Exhaustive investigations of the patients of HIV-infected physicians, including those who perform invasive procedures, have not detected a single additional infection.
The reasons that the rules governing health care workers have not changed are social and political. Whether appropriately or not, most people want to know whether their physician is infected with HIV, and politicians are unwilling to change a law that enjoys wide support, however discriminatory it may be.
Throughout the book, Gostin appropriately advocates the objective determination of laws, policies, and interventions for disease prevention, with consideration of the underlying issues of civil and human rights. And each of his essays, on topics as disparate as partner notification, immigration policy, and aid to the underdeveloped world, fulfills this standard. It is for that reason that I found myself more disheartened after reading the book. I had not fully appreciated how large the gap is between our AIDS policies and what they should be.
Mitchell H. Katz, M.D.
San Francisco Department of Public Health
San Francisco, CA 94102
mitch.katz@sfdph.org((Studies in Social Medici)