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Editorial Health July 1989 Established 1911
Volume 79, No.7

EDITOR The Deadliest Plague

Alfred Yankauer, MD, MPH
"For it seemed to me as if then I stood at a distance, aloof from the uproar of life; as if
ASSISTANT EDITOR the tumult, the fever and the strife were suspended; a respite were granted from the secret
Patricia Hartge, ScD burdens of the heart.. Here was the panacea for all human woes; here was the secret
. .

of happiness." 1

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

AJPH July 1989, Vol. 79, No. 7 821


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

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

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