AMERICAN JOURNAL OF
Public
Editorial Health July 1989
Volume 79, No.7
EDITOR
Alfred Yankauer, MD, MPH
ASSISTANT EDITOR
Patricia Hartge, ScD
EDITORIAL BOARD
Irene H. Butter, PhD (1990) Chair
Doris Bloch, RN, DrPH (1989)
Suzanne E. Dandoy, MD, MPH (1990)
Joy G. Dryfoos, MA (1989)
Frederick C. Green, MD (1991)
Dieter Koch-Weser, PhD, MD (1991)
Robert L. Kane, MD (1991)
Mary Grace Kovar, DrPH, MS (1991)
Philip J. Landrigan, MD (1990)
Jean Pakter, MD, MPH (1989)
Lee N. Robins, PhD (1991)
Jeannette J. Simmons, DSc, MPH (1990)
Zena Stein, MD, DrPH (1989)
Fernando M. Trevino, PhD, MPH (1990)
Julian A. Waller, MD (1989)
STAFF
William H. McBeath, MD, MPH
Executive DirectorlManaging Editor
Jaclyn Alexander
Publications Director
Doyne Bailey
Assistant Managing Editor
Brigitte Coulton
Production Editor
Mary Beth Kammann
Advertising Manager
Lucille Bow
Marilyn Butler
Annabelle Friedman
Publication Assistants
CONTRIBUTING EDITORS
George J. Annas, JD, MPH
Public Health and the Law
Jean Conelley, MLS
Book Corner
Mary Grace Kovar, DrPH, MS
New from NCHS
Barbara G. Rosenkrantz, PhD
Public Health Then and Now
Hugh H. Tilson, MD, DrPH
Notes from the Field
AJPH July 1989, Vol. 79, No. 7
Established 1911
The Deadliest Plague
"For it seemed to me as if then I stood at a distance, aloof from the uproar of life; as if
the tumult, the fever and the strife were suspended; a respite were granted from the secret
burdens of the heart.. Here was the panacea for all human woes; here was the secret
. .
of happiness." 1
Issues surrounding the acquired immunodeficiency syndrome (AIDS) continue to
plague us. In the Journal this month, we publish a series of different views on some
of these issues: reporting cases of infection, partner notification, testing (mandatory
or no), counseling, education, outreach, and confidentiality.
The accomplishments and shortcomings of the President's Commission on AIDS
are sensitively addressed by one of its members, Kristine Gebbie2; the case for partner
notification, a euphemism for what used to be termed contact tracing, is made by John
Potterat3; actions called for by a worst case scenario (underpinned by a belief that the
worst case is upon us) are described by Victor Archer4; a more optimistic view of what
is needed is presented by Willard Cates and Stephen Bowen; and we end with a
down-to-earth view from Colorado by Franklyn Judson.6
Dr. Judson's cautious optimism is tempered by his final paragraph which
introduces an issue that others have stepped around more gingerly or avoided entirely.
The issue is exposed in its starkest form by a recent editorial in the New York Times.7
The title of the editorial is "Three Plagues." The three plagues are poverty, drug
addiction, and AIDS. To borrow from the words of Saul of Tarsus-and the greatest
of these is poverty.
The Times editorial focuses on the South Bronx, a disaster area for many years,
upon which drug abuse and AIDS have saddled a burden of unbelievable horror: 23
percent of emergency room patients tested at Bronx-Lebanon Medical Center are
infected with the human immunodeficiency virus. "The situation is magnified by a
larger malady: indifference. The poor of the South Bronx do not speak loudly in the
councils of state. Other citizens readily see them, if at all, as an underclass, an
unregenerate source of addiction and crime."7
Thomas DeQuincey was a poor man when he was introduced to opium as a relief
from pain. He has described the experience in poetic terms. For the poor of South
Bronx and the urban slums of the world who have nothing in life to which to look
forward, it is not hard to understand the appeal of heroin, cocaine, or crack. If the trip
to fantasyland requires an injection, and needles are illegal and cost money, needle
sharing and shooting galleries, with AIDS in their wake, become a way of life. Des
Jarlais and his colleagues have described other appeals and compulsions of this way
of life: the camaraderie and sense of family and the necessity to avoid the hand of the
law.8
The use of cannabis and opium is older than human history, but was restricted
to ceremonial and religious purposes until relatively recent times.9 Their use became
recreational and addictive only after the introduction of tobacco into Europe and Asia,
another count against the tobacco industry. In the case of AIDS, technology struck
the final blow: the hypodermic needle was not invented until 1853 and morphine was
derived from opium at about the same time. If the oral and respiratory routes had not
been replaced by the intravenous route, AIDS might never have entered the world of
the drug abuser.
Cocaine use has a somewhat different history. Long in common use by oppressed
Andean Indians, it was introduced to Europe and North America as a local anesthetic.
821
EDITORIALS

Physicians and the upper class became addicted-witness
Sherlock Holmes-and Coca-cola is evidence (now in name
only) of its popular appeal. Its rebirth, its offspring, crack,
and its repopularization from upper classes downward are
recent phenomena.
It is ironic that for the poor farmer in the world's poorest
countries, the crop that ameliorates his poverty should
become the product that plagues the poor in the rich countries
of the world. Yet history tells us that "for any drug in
demand, there has never been a shortage of persons willing
to engage in traffic for gain,"9 so perhaps we should not be
surprised.
It is ironic that, under circumstances like those of the
South Bronx, the conservative administration of the United
States has not even faced up to the need to protect its own
interest. The modem public health movement was born when
English conservatives, not radicals, acted to protect them-
selves from the deterioration of cities and the unrest of the
poor brought on by the Industrial Revolution. National health
insurance was implemented by the wealthy conservative,
Prince Otto von Bismarck, as a means of holding back the
growing socialist movement. Stephen Smith, a founder and
first president of the American Public Health Association,
was a converted surgeon who, to combat the slum housing
where immigrants were forced to live, persuaded the com-
munity leaders of New York to legislate the first full time local
health department in the United States. No such movements
are apparent in the case of AIDS.
The Times editorial has spelled out some of the conven-
tional pubic health actions needed to contain the AIDS
plague: drug treatment on demand, clean needles, outreach
workers in large numbers and effective counseling and
education which, contrary to belief, has changed some
behaviors among drug addicts. 10 It fails to mention reporting,
voluntary testing, and partner notification. Together, all
these measures will cost money, far more than has been made
available. Yet raising taxes seems a forbidden subject. Taxing
the rich or (to our shame) taxing alcohol and tobacco, both
addictive drugs, seems to be especially forbidden.
The application of tried and true public health measures
can confidently be expected to control the AIDS epidemic
just as the application of sanitary reforms transformed life in
the cities. Yet they will not touch the deadliest of the three
plagues. Without poverty in other countries, there would be
no incentive for them to export drugs. Without poverty in our
own country, there would be no needle sharing, no AIDS
transmission in drug abusers, and drug abuse itself might be
more limited.
Will those who are poor through no fault of their own be
always with us? Poverty at home or abroad is not a plague
that will yield to conventional public health efforts or to
programs expected to produce short-term results. Nor are
such thoughts new. "Every few years, there is an awakening
of public interest in poverty and a new round of poverty
research, rediscovering the problem all over again, repeating
much of what has been said before."'"
Will the AIDS plague force us to face the plague of drug
abuse and the deadliest plague of all, poverty? We have not
done so yet.
Forty years ago C-E.A. Winslow prepared a report for
the World Health Organization on the subject of technical
assistance to developing countries. His words are equally
applicable to the efforts we make today to stop the export of
drugs from poor countries and to control the plagues of drug
abuse and AIDS in the underdeveloped areas of our own
country:
"It is not enough then, for the health administrator to
develop the soundest possible programme for his own field of
social endeavour . .. He must also sit down with experts on
agriculture, on industry, on economics, and on education and
integrate his specific health programme as part of a larger
total programme of social reconstruction."'2
REFERENCES
1. DeQuincey T: Confessions of an English opium eater. In: The Autobiog-
raphy and Confessions of Thomas DeQuincey. New York: Chas. Scribner,
1856 revision; 605, 620-621.
2. Gebbie KM: The President's Commission on AIDS-What did it do?
(Different Views) Am J Public Health 1989; 79:868-871.
3. Potterat JJ: Partner notification in the control of immunodeficiency virus
infection. (Different Views) Am J Public Health 1989; 79:874-876.
4. Archer VE: Psychological defenses and control of AIDS. (Different Views)
Am J Public Health 1989; 79:876-878.
5. Cates W Jr, Bowen GS: Education for AIDS prevention: Not our only
weapon. (Different Views) Am J Public Health 1989; 79:871-874.
6. Judson FN: What do we really know about AIDS control? (Different
Views) Am J Public Health 1989; 79:878-882.
7. Anon: Three plagues (editorial). New York Times, February 23, 1989.
8. Des Jarlais DC, Friedman S, Strug D: AIDS and needle sharing within the
IV-drug abuse sub-culture. In: The Social Dimensions of AIDS: Methods
and Theory. New York: Praeger, 1986; 111-125.
9. Blum RH and Associates: Society and Drugs. San Francisco: Jossey-Bass,
1970; 45-84.
10. Des Jarlais DC, Friedman SR, Stoneburner RL: HIV infection and
intravenous drug use: Critical issues in transmission dynamics, infection
outcomes and prevention. Rev Infect Dis 1988; 10:151-158.
11. Sachs RM, Goldstein R: Politics, ethics and poverty research. In:
Goldstein F, Sachs M (eds): Applied Poverty Research. Totowa, NJ:
Rowman and Allanheld (div. Littlefield Adams), 1984; 239.
12. Winslow C-EA: The cost of sickness and the price of health. Geneva:
World Health Organization, 1951; 83.
ALFRED YANKA UER, MD, MPH
EDITOR
Address reprint requests to Dr. Alfred Yankauer, Editor, American
Journal of Public Health, Department of Community and Family Medicine,
University of Massachusetts Medical Center, Worcester, MA 01655.
© 1989 American Journal of Public Health 0090-0036/89$1.50

Future APHA Meeting Dates/Sites

1989 OCTOBER 22-26 CHICAGO, ILLINOIS
1990 SEPTEMBER 30-OCTOBER 4 NEW YORK, NEW YORK
1991 NOVEMBER 10-14 ATLANTA, GEORGIA
1992 NOVEMBER 8-12 WASHINGTON, DC
1993 OCTOBER 24-28 SAN FRANCISCO, CALIFORNIA
1994 OCTOBER 30-NOVEMBER 3 WASHINGTON, DC
1995 NOVEMBER 12-16 SEATTLE, WASHINGTON

822 AJPH July 1989, Vol. 79, No. 7

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