Cities Bear Brunt of AIDS Burden

IN Philadelphia, the school board has just joined a growing list of school districts nationwide allowing condom distribution in high schools.Here in San Francisco, mayoral and city health officials are meeting to discuss a project study for California's first legal clean-needle exchange for drug users. In Washington, D.C., this week, a Senate committee urged a $70 million increase in funds for cities dealing with AIDS victims. Urged by a unified front of the nation's big- and little-city mayors, a ground swell of activity in the battle against AIDS (acquired immune deficiency syndrome) is percolating at local levels countrywide. Frustrated by a lack of direction from the top, overwhelmed by lack of federal funding and growing case loads, cities are taking the lead to both cope with the challenge in creative new ways and urge the federal government to do so as well. "The cities are up against the AIDS epidemic, and they are getting no leadership from the president or federal government," says United States Rep. James McDermott (D) of Washington, co-chairman of the Congressional Urban Caucus. "They would rather confront the problem with logic than hysteria." Since the first cases of AIDS were reported among a small group of gay men in several large cities in 1981, over 110,000 Americans have died of the disease. A recent 26-city report for by the US Conference of Mayors Task Force on AIDS states: "Over one million Americans are now estimated to be infected with HIV virus." The study notes that 56 percent of all AIDS patients in the US live in the 26 cities covered in the report. Seventy-five percent of the cities reported severe staff shortages, job burnout, and inadequate facilities. Seventy-two percent had no identifiable source of funding for expansion of services or prevention efforts to respond to growing caseloads.

City action In releasing the report, San Francisco Mayor Art Agnos said AIDS is "overwhelming the resources of urban health-care systems, with no relief in sight." To deal with the epidemic, the conference of mayors unanimously adopted a sweeping, 12-point plan with several controversial recommendations including condom distribution in high schools and legalization of needle-exchange programs for drug addicts. The plan calls for a comprehensive federal policy on AIDS and more federal funding for public facilities treating patients. Other points include testing, prevention education, and a national standard of medical ethics and counseling. (See box below.) "The mayors' plan has been a particularly compelling voice in articulating why more funding should accompany the Ryan White Care Act," says Michael Iskowitz, counsel on AIDS to Sen. Edward Kennedy (D) of Massachusetts. That bipartisan effort authorized $875 million for aid to cities and states, and for early intervention and research programs. However, only $100 million was appropriated last year, none of which went to research. The Senate this week is recommending a $70 million increase. "The mayors and the task force [study] have played a vital role in lobbying" for that increased funding," says Jeff Levi, director of government affairs for the AIDS Action Council in Washington, D.C. "It is sad and shocking that, 10 years into this epidemic, we are still at the basic stages of education and prevention," says Scott Burris, a professor of law at Temple University and author of the book "AIDS and the Law: A Guide for the Public." Dr. Burris says public focus on the disease is sidetracked into legislative battles over whether health-care workers ought to be tested for AIDS - a process that would cost far more than state and federal governments now spend on AIDS-prevention programs combined. Though more than $1 billion has been spent on various programs over the years, he says, no research has been done to gauge the effectiveness of various approaches. "We are still fighting battles over what language is offensive in pamphlets ... and whether or not network TV should allow condom ads," says Burris. "The problem is not knowing what to do, it is devoting resources and will." "It's not politically pleasant to talk about sex in the schools, nor give condoms away [at schools], nor politically pleasant to give drug addicts needles," says Don Francis, AIDS consultant to Mayor Agnos. "But that is what we in public health feel is necessary." Dr. Francis points out that one of the reasons AIDS has not been dealt with more directly in national policy is that the virus has a long incubation period. "That sets up a perfect denial system for individuals and society; politically it is very difficult to address something over such a long period." Another problem is misconceptions about the disease. According to Agnos, one misunderstanding is that AIDS is a disease primarily restricted to gay white males. The study shows the epidemic is growing among blacks in such cities as Newark, N.J., and Chicago; and in Baltimore the sharpest increases have been among intravenous drug users. "We know where HIV is being spread and how - it's among the poor by sex and drug use," adds Mr. Burris. "That's where our resources should be - not on sort of high-fear 'Did-I-get-it-from-my-dentist?' stuff." Observers note that in an era of tightened budgets at local, state, and federal levels, social-service programs, prevention, and health services are being cut. "Federal priorities are with foreign wars and savings-and-loan bailouts," notes McDermott. But Rayford Kytle, spokesman for the Public Health Service in the US Department of Health and Human Services (HHS), says the federal battle against AIDS is being fought on several fronts. Coordinated by the National Aids Program Office in HHS are: the Centers for Disease Control, which run information and prevention programs; the National Institutes for Health, which will spend $1.95 billion this year for research and drug development; the Alcohol Abuse and Mental Health Administration, and the National Cancer Institute.

Federal action Government spending related to AIDS in fiscal year 1992 will be $4.27 billion, with more federal research and prevention funding now devoted to AIDS than any other disease except cancer. As a result of such research, Mr. Kytle says, those diagnosed with the HIV virus (which causes AIDS) are living longer: only 40 percent survival rate past 18 months in 1985, compared to 60 percent by 1987. Even so, observers say, more is being done at the city level. "The mayors' plan and task force findings are creating the understanding for the need for" increased funding, says Mr. Levi. "Since the beginning of the epidemic, they have been leading the appropriate response in overcoming public hysteria over AIDS."