From San Francisco and Los Angeles to New York and Miami, cities hardest hit by AIDS say their public-health resources are being stretched to the limit by efforts to cope with the disease. Although these local governments, in the last several years, have poured millions of their tax dollars into patient care, counseling, testing, and education to counteract Acquired Immune Deficiency Syndrome, the increasing number of AIDS cases in their jurisdictions nonetheless threatens to swamp existing services. (After slow start, Houston takes steps, Page 8.)
City leaders and county health officials are renewing their plea for more federal and state AIDS spending - particularly for patient care. But with the President's AIDS commission in disarray after the departure of its top three members, Washington's future role is uncertain.
``I think we have just entered a significantly new era in our efforts to deal with the epidemic,'' says Thomas Peters, assistant director of health for San Francisco. ``We have maximized the use of local resources - health-care providers, funding, volunteers - and are entering a time when there needs to be a shift of the proportional burden.''
In hard-hit San Francisco, where local AIDS spending jumped from $180,000 in 1982 to $17.5 million in the current budget, Mayor Dianne Feinstein has recently indicated the city is about tapped out. ``She has said we've reached the point beyond which we cannot go,'' says the mayor's press secretary, Tom Eastham. ``As compassionate as the city can be and as good as its programs are, there must be some relief.''
Although San Francisco spends more on AIDS per capita than any other city or county, other metropolitan areas will experience the same funding constraints as their AIDS caseloads begin to grow, experts say.
The United States Public Health Service forecasts there will be 270,000 AIDS cases by 1991, compared with about 40,000 to date since 1981.
Many public-health officials, even those who urge the US to shoulder more of the AIDS-related expenses, concede that federal funding has already taken an exponential leap in the past six years.
Since the disease was first identified in 1981, the Public Health Service budget for AIDS has gone from $200,000 to a projected $790 million this fiscal year.
The bulk of the money will be spent on research, which the Reagan administration and Congress agree is an appropriate role for the federal government.
There is less consensus, however, on whether the US should pick up more of the cost of patient care, education, and testing, as well as other services.
The White House says such responsibilities belong to city, county, and state governments.
But an August report by the congressional General Accounting Office said federal AIDS spending was inadequate and should better address prevention, education, and testing programs.
In the short term, the outlook for a dramatic increase in federal spending is not favorable, AIDS experts say.
``If a city is waiting for federal assistance, then it has greatly erred,'' says Cliff Morrison, deputy director of the privately-funded AIDS Health Services program in San Francisco. ``I just don't think this administration will make a broad commitment to AIDS as it winds down its last year.''
In the meantime, private groups and many state governments are pitching in to meet some of the need. State appropriations to fight the spread of AIDS have increased 13-fold since fiscal year 1983-84, according to a recent survey by the Intergovernmental Health Policy Project at George Washington University.
At that time five states were spending their own funds on AIDS, compared with 30 states for fiscal year 1987-88, the survey says.
``It's very clear that no one sector should have to foot all of the bill,'' Mr. Morrison says. ``No one can do it alone.''
The AIDS crisis calls for ``unprecedented levels of government cooperation,'' agrees Sam Friedman, spokesman for the New York City Department of Health. New York, with the largest number of AIDS cases in the US, this year will withdraw $98 million from city coffers to combat AIDS - about a quarter of its overall $385 million AIDS budget.
But New York's efforts to contain AIDS will not make headway unless the US government finds a way to staunch the flow of drugs into the country, Mr. Friedman says. AIDS is transmitted by the exchange of body fluids, such as semen or blood - and the groups at highest risk in the US have been homosexual men and intravenous drug users, experts say.
San Francisco and New York are regarded as the cities with the best AIDS services, but both say their public-health systems are under increasing strain. Although the problems have surfaced here first, other communities should expect to grapple with the same difficulties in the future.
``A few years ago, New York City had 30 percent of all AIDS cases,'' Friedman says. ``Now we're down to 28 percent.'' By 1991, as AIDS becomes more widespread, New York is expected to have 15 percent of all cases, he says.