THE ELEMENT OF TRUST IN HEALTH POLICY

Vanessa Sochat
March 13, 2006
Health Policy
 The HIV/AIDS epidemic presents a unique challenge for public health: a communicable, incurable disease

whose prevention depends directly on imposing upon individual behavior. Unlike the Cholera epidemic in London

of 1854 that was solved by a structural intervention, policy to control the transmission of HIV must consider the

rights of the infected, uninfected, and high risk populations. Preliminary actions to control the spread of HIV

stigmatized the populations most likely to be infected, which subsequently led to slow, ineffective policy. From

these failures, public health learned that successful policy must craft methods of prevention based on the

demographic, environmental, and social factors of disease while respecting the rights of all populations involved.

Essentially, HIV modified the traditional approach to epidemiology by introducing a human factor. When

prevention depends exclusively on modifying individual behavior, trust and respect are essential for success and

cooperation.

The physical environment, including human mobility and congregation, contributed to the dispersion of

the HIV virus. As a sexually transmitted disease, HIV arrived at the perfect time when homosexuals were

participating in mass sexual activity as an expression of their sexual freedom. Thus, the virus thrived in cities,

which organized this sexual and drug related activity. It is speculated that an airline steward named Gatean Dugas,

who admitted to over 250 sexual encounters a year, contracted HIV from Africans in Europe, and spread the

disease while traveling. The first two known cases of HIV in New York were sexual partners of Mr. Dugas, as well

as eight out of nineteen of the first AIDS cases reported in Los Angeles (“Canadian…”). Once HIV was inoculated in

a subsection of the homosexual population in the 1970’s, bathhouses created a free, rampant, and unprotected

sexual environment prime for its spread. San Francisco experienced extreme controversy in the mid 1980’s as the

director of the San Francisco Health Department, Mervyn Silverman, wasted three years attempting to shut down

bath houses, which he argued facilitated activity that spread HIV (“The Deadly Politics of AIDS”). The bath houses

were a symbol of gay rights, so the homosexual population resisted this policy, and in an effort to defend their

lifestyle, refused to change their behavior (“Canadian…”). This failure is a prime example of how criminalizing a

population prohibits cooperation towards preventing the spread of disease. Although bathhouses ultimately

closed in 1984, Silverman’s effort was a mistake because it had no effect on individual behavior during a critical
time period. Silverman might have utilized bathhouses to connect with the homosexual population instead of

stigmatize them (Mutchler 223).

As HIV was helped by cities, Cholera was also aided by urbanization and industrialization. Before cities,

the disease could not prosper because humans lived far enough apart to not come in contact with each others’

waste. As time passed, however, the development of centralized agricultural centers and economies allowed for

the growth of cities. Growth was further aided by the collection and recycling of waste, which yielded more crops

and consequently supported more people. The developing of water supplies and cesspools close together in these

cities created an ample opportunity for contamination, which is exactly what happened to the water supply

provided by Southwark Water Works. The water supply acted as a vehicle to feed Cholera directly into the mouths

of the population, which wasn’t always apparent to public health officials (Johnson page #). The physically filthy

environment led to misconceptions about the spread of Cholera amongst two powerful public health officials,

Dickens and Engels. They came up with miasma theory, and based on no scientific evidence or investigation, tied

the disease to the stench in the air. It was a young physician named John Snow and a London clergyman named

Henry Whitehead who decided to investigate the disease from a demographic, environmental, and social

perspective. Their process of investigation formed a basis for the epidemiological procedure practiced today, and

allowed them to disprove the false theories suggested by the health department (Johnson page #). A similar type

of misconception was reached as a result of the environment surrounding HIV transmission. Politics played a large

role in this misconception.

The political environment, focused on appealing to the majority of the public, found it in their best

interest to not mention a disease so closely tied to controversial social practices. This hushed response resulted in

a slow response to treat HIV. In 1981, the media named the new disease “GRID,” which stood for “Gay Related

Immune Disease,” and the public was under the misconception that HIV was isolated to that population (LGBT

Timeline). The heterosexual population was excused of any responsibility for controlling the disease. Although

epidemiologists knew the proper steps to take to investigate HIV, as a result of bias they failed to observe the

prevalence of HIV amongst women, infants, and intravenous drug users. Progress was incredibly slow. The Center

for Disease Control (CDC) did not properly define the illness until September of 1982, and the HIV virus was not
found until 1983. The term AIDS was not brought into any political light until three years later, in 1985. By the

time a pamphlet titled “Understanding AIDS” was mailed to every home in the United States in 1988, it was

arguably too late to control the epidemic (LGBT Timeline). HIV revealed how bias can lead to faulty conclusions in

epidemiology and slow action, and must be avoided.

This political environment starkly contrasts the environment specific to the Cholera epidemic, which was

not stigmatized to any specific population. However, living conditions and location due to socioeconomic status

might have increased probability of infection. John Snow and Henry Whitehead put social and environmental

biases aside and worked together to observe the real affected populations. Whitehead examined the living

elevation of infected and non-infected individuals, considered psychological factors, and eventually made the

connection between Cholera and water. It is arguable that Whitehead focusing on elevation could have distracted

him from identifying the water supply as the true cause of the disease, a view that he was originally skeptical of.

John Snow’s map convinced him otherwise. Snow found no statistically significant link to socioeconomic status,

but in observing death based on occupation, he found a high prevalence of death in occupations employed near

the water (Snow). He utilized this information to support his waterborne theory, as sailors and river men

commonly drank from the Thames River, and lived together in close quarters (Snow). The Thames was

contaminated with Cholera thanks to Edwin Chadwick and William Farr, two highly respected health officials, who

created policy to evacuate waste into the river. The work of these two men exemplifies the danger of socially

powerful individuals creating policy based on inadequate information, which arguably occurred during the HIV

epidemic. Once infected, however, the chance of survival with Cholera, in contrast to HIV, was not strongly tied to

socioeconomic status.

When dealing with HIV, socioeconomic status inhibits effective disease treatment. Currently, survival

with HIV depends directly on consistent access to highly active antiretroviral therapy, or HAART. Without access to

these medications, as was the case with the original emergence of the disease, death usually occurred within the

year. Additionally, inconsistent access to HIV therapy due to lack of insurance or funds leads more resistant strains

and higher medical costs (Definition of HAART). Thus, in both cases with HIV and Cholera, socioeconomic status

inhibited treatment and policy development.

 After considering these environmental, demographic, and social factors, HIV taught us that effective

policy must consider these factors on a cellular, on an individual, and on a population level. John Snow’s

investigation of Cholera was an early model for public health because he studied Cholera on these three levels. He

observed it on a cellular level by examining water samples, on an individual level by speaking with individuals

about the source of their drinking water, and on a larger scale by creating a Veronai diagram, or thematic map, to

study the movement of Cholera through the population. After piecing together all of these factors, he speculated

microorganisms to be the primary source of disease (Susso 519). He introduced this idea of germ theory in a

speech to the Medical Society of London in 1849 and in his publication On the Communication of Cholera, which

led to the removal of the Broad Street pump handle, and the halt of the epidemic (Colwell 286). This procedure

grounded the approach to the HIV epidemic, but it is arguable that for HIV public health targeted the wrong

population.

HIV can be studied in a similar way, but the solution is not so simple. On a cellular level, the most

effective treatment might be a vaccine. However, as an HIV/AIDS vaccine has still not been discovered, policy

must address behavior on an individual level (Colwell 287). By comparing HIV and Cholera it is apparent that a

large number of people exposed to a small risk can generate more incidence of disease than the same sized

population exposed to a high risk. The chance of transmittance of the HIV virus is less than 4% per sexual

encounter compared to an almost complete certainty of contracting Cholera by drinking a glass of contaminated

water, yet HIV has killed 25 million people. Thus, attempting to change behavior in only in the highest risk

individuals is less effective than changing behavior throughout an entire population (Bedimo 385). Public health

officials learned this idea the hard way after only focusing on the homosexual population, and imposing upon the

sexual freedom of this group.

HIV taught public health that privacy is essential for effective policy. In the midst of an epidemic, there is

incentive to take any measure, including diminishing human rights, to save lives. According to the Universal

Declaration of Human Rights, the right to privacy now extends to sexual orientation (“Human Rights and the HIV

Paradox”). Although Silverman viewed closing down bathhouses as his responsibility to protect the public and

slow the transmission of HIV, it imposed upon the sexual freedom of the homosexual population. Through this
failure, public health learned the value of respecting this freedom and encouraging individual responsibility.

Individuals must have incentive to take responsibility for their behavior, which can be done by providing the

correct resources. Today, by encouraging condom use, facilitating educational events, and providing HIV testing

onsite, many bath houses have become venues of prevention (Mutchler 223). Encouraging privacy and prevention

for HIV is a challenge to public health because society values protecting rights of infected people more so than

preventing new people from becoming infected (Parkes 672). Thus, policy that confidentially and anonymously

provides resources and services has led to the best outcomes concerning disease prevention.

Current successful policy to slow HIV transmission is a prime example for the need to respect individual

privacy. Washington DC is notorious for having the highest level of new AIDS cases in the entirety of the United

States. In 2006, a campaign was launched that prompted residents to be anonymously and confidentially tested

for HIV. A new technology, oral swabs, delivers results within twenty minutes, informing the individual of his or

her status. . This policy is based on the fact that individuals who are aware of their status are more likely to

engage in preventative action (“City Tests...”). In contrast, campaigns that stigmatize sexual behavior, namely

efforts to promote abstinence, have been largely ineffective (Hauser 4). On the other hand, policy that does not

impose upon individual sexual behavior, such as the dispersion of condoms, has contributed to low rates of AIDS in

both North America and central Europe, and is cost effective (Bedimo 384). The ABC, or “Abstain, be faithful, Use

Condoms” Approach in Uganda, which encouraged monogamy, condom use, and abstinence, has caused HIV

transmission rates to decline from fifteen to five percent (Cohen 1). This policy was successful because it relayed a

national message that HIV prevention was important, and the responsibility of the citizens. Similar programs are

succeeding in Brazil, Zambia, Cambodia, Thailand, Jamaica, and the Dominican Republic (Cohen 3). This policy is a

prime example of trust leading to successful policy, which was possible thanks to public health learning from

mistakes dealing with the HIV epidemic.

As HIV changed the way we think about studying demographic and environmental factors, it also

influenced medicinal practices. Screening blood transfusions, specifically for the HIV antigen in 1985, decreased

chance of transmittance from one in one hundred to one in one thousand from 1983 to 1985. Thanks to additional

screening and questions regarding behavior, in 2001 the risk of contracting HIV from a blood transfusion was one
in a million (Busch 960). Universal Precautions were suggested by the CDC in 1987 as a safeguard to protect

physicians and patients from individuals whose infection status was not known (“Universal Infection Control

Precautions”). The dispersion of sterile needles has also contributed to lower transmission rates amongst

intravenous drug users (“Human Rights and the HIV Paradox”). These policy implementations are more structural

like Snow’s pump modification and focus on a preventative mode of medicine. With the knowledge that many

diseases originate from other species, called zoonoses, health officials can take measures to avoid human-animal

contact. However, as HIV has demonstrated, infectious diseases will always be a problem due to mutation and

environmental, social, and demographic factors (Morse 11).

Public health has learned the importance of valuing trust to impact individual behavior, and there is still a

long way to go, as men who have sex with men account for forty two percent of new HIV infections in the United

States (Tracking the Hidden Epidemics). Although public health experienced the danger of criminalizing activity,

the United States is arguably still limited by social and religious factors in promoting abstinence until marriage.

Stigmatizing and attempting to prevent all sexual activity to encourage prevention amongst youth can be

compared to attempting to abolish bath houses. Both policies suggest very drastic solutions that the majority of

target groups have not followed. Failure to implement successful policy with HIV has caused the public health

sector to transition from a top down to a bottom up approach when attributing responsibility to disease

prevention. Although there might always be a conflict between individual rights and public health policy, by

creating a supportive social environment and respecting privacy, at least the health and private sector might

cooperate to face the challenges ahead.

 Works Cited

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“Canadian Said to Have Had Key Role in the Spread of AIDS.” New York Times 7 Oct, 1987.

“City Tests Reveal Infection Rate Double the U.S. Average.” The Washington Post 20 Sept. 2006.

Definition of HAART. National Cancer Institute. 11 March 2007 <http://www.cancer.gov/Templates/

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(2002): 384-392.

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<www.advocatesforyouth.org>.

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7-15.

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Extra Credit

Dr. James Curran and Robert Gallo took action during the HIV/AIDS epidemic that most closely resembles
that of John Snow and Henry Whitehead. Dr. Curran, a CDC official, acted like John Snow in the sense he was the
motivator to investigate the disease. He studied the many cases of Karposi’s Sarcoma and pneumonia, which were
the first manifestations of full blown AIDS (In Their Own Words). By considering environmental and social factors
like sexual activity, he accredited these individual cases to an infectious disease. He then studied the epidemiology
of this mysterious disease and used this information to consider methods of prevention. As Snow presented his
research to the London Medical Society, Curran facilitated communication between the CDC and the National
Institute of Health (NIH), where Robert Gallo was employed as a lab chief. Although Gallo’s role was controversial,
he was a driving force behind research that led to the discovery of the HIV virus and link to AIDS in 1983. As Snow
developed procedure to test water samples for Cholera, Gallo created procedure to screen blood for HIV. The
political and social environments can be compared as well. During the Cholera epidemic, public health officials
were very skeptical of anything that strayed from miasma theory, and during the HIV epidemic, there was
skepticism towards the concept of a retrovirus in humans (HIV & AIDS – Robert Gallo).