]]]]]]]]]]]]]]]]]]]          TRIAGE              [[[[[[[[[[[[[[[[ 
                        The case of AIDS             (12/25/1988)
                     Dr. Eric Stephen Berger
Eric  Stephen  Berger,  M.D.,  is  the  Medical  Director  of the
             American Council on Science and Health.
     (From PRIORITIES, , publ. by ACSH, Winter 1989, pp. 16-17)

            [Kindly uploaded by Freeman 10602PANC]

   One  of  the  most significant  AIDS-related  stories  of 1988
received only scant  coverage in the  American media: The Defense
Department  removed  asymptomatic  AIDS-infected  personnel  from
sensitive jobs.  The rationale for  this action was that the AIDS
virus   frequently  causes   impaired  mental   functioning.   In
mid-December the New York Times and the Washington Post ran brief
articles  on  this  provocative  story,  but  there  was  no news
follow-up, editorial comment or electronic media coverage.
   Throughout  the   epidemic,  studies   have  demonstrated  the
affinity of the HIV  virus for the nervous  system.  Indeed, in a
substantial number  of cases,  neurologic symptoms  are the first
indication of  AIDS infection.   In the  December 1987  Annals of
Internal Medicine, researchers reported that 87% of AIDS patients
studied  manifested  impaired   and  atypical  neuropsychological
performance.    But  of   even   greater  significance   was  the
observation  that  44% of  HIV  seropositive  patients, otherwise
symptom-free,    demonstrated    the    same   neuropsychological
abnormalities,  and  had  the  same  functional  deficiencies  as
patients with full-blown AIDS.  This means that, when tested with
specific  tasks,  the  patients  were  unable  to  perform  to  a
predetermined,    acceptable   level.     The    tests   measured
intelligence,  short-term and  visual memory,  mental processing,
and  cognitive  abilities;  a   test  procedure  called  ``global
neuropsychologic assessment.''
   The  Times  article  stated  that  the  Department  of Defense
decision to dismiss  those carrying antibodies  of the AIDS virus
from sensitive positions was  ``based on recent studies (showing)
... subtle changes in mental  abilities'' in people with no other
sign of AIDS-related disease.  Government spokesman Dr. Edmund C.
Tramont, at the Walter Reed Army Medical Center, stated that ``if
a person's  brain is not  functioning correctly, you  do not want
him  flying  high-performance aircraft  ...  or  driving tanks.''
This seems to be a very reasonable analysis.
   My satisfaction with this  analysis, however, was short lived.
In  all to  typical  government ``doublespeak,''  Dr.  Anthony M.
Fauci, a National Institutes of  Health (NIH) AIDS expert, warned
that the above data should not  be used to institute more general
testing  programs.   This leaves  us  mere  civilians bewildered.
Does Dr. Fauci mean, for  example, that an infected airline pilot
or air traffic controller in the private sector does not pose the
same dangers as his military counterpart?  And if military pilots
are deemed to be in ``sensitive'' positions, what about other job
categories?  Should we expect some reassurance that our surgeons'
brains are ``functioning correctly''?  Ought we not wonder if the
day  care workers  guarding our  children  are demented,  or even
subtly impaired?
   A   recent   NIH-funded  study   at   Johns   Hopkins  Medical
Institutions, delivered at the Fourth International Conference on
AIDS  in  Stockholm,   found  no  loss   of  mental  function  in
HIV-infected individuals until the development of AIDS-associated
physical  symptoms.   This  conclusion  represents  a  remarkable
variance with previous studies and clinical reports.  However, in
the wake of an incredible  level of politization of this disease,
and  in  the light  (or  dark?)  of the  powerful  ``gay activist
lobby,''  one  should  ask  which  study  is  more  deserving  of
attention  by  policy makers?   Will  we  now see  a  reversal of
existing military  exclusion policy?  If  we are  to accept these
new findings,  we must  ascertain the  level, however  subtle, of
physical symptoms usually preceding mental deterioration.
   An estimated 1.5 million Americans  are infected with HIV, but
asymptomatic.   According  to the  Annals  of  Internal Medicine,
600,000  of  the  infected  but  symptom-free  population  may be
neurologically  impaired.    Just  how  may   we  determine  what
constitutes ``fit,'' who is fit, and for which jobs they are fit?
And what constitutes a ``sensitive'' job?
   A  timely  Diagnosis  article,   ``A  New  Test  for  Dementia
Syndromes,''  proposes  a  15  minute  Neurobehavioral  Cognitive
Status Examination as  a quick standardized  method of evaluation
for a broad range of mental deficits, including early Alzheimer's
disease.  Will  this test, or  a similar evaluation,  prove to be
the best determinant of  impairment, efficiently and effectively,
without unnecessary violations  of civil rights?   How often must
these tests be repeated to compensate for both seroconversion lag
time and new infections?  From  whom may we expect the definitive
answers?
   I  raise  these  questions neither  to  incite  terror  nor to
complicate unnecessarily our nation's current AIDS nightmare, but
rather  because they  are the  difficult  questions that  must be
answered.  Ignoring  the problem  will not  make it  go away.  We
know the mode  of transmission of the  AIDS virus, and reasonably
effective  preventive measures  and  lifestyle changes  have been
delineated.   There  is  no question  that  AIDS  victims deserve
compassion and adequate medical care, but it is also time to stop
putting our  heads in the  sand,  The  military establishment has
made a  decisive move to  protect enlisted personnel,  as well as
the integrity  of our  defense system.   Now the  civilian sector
must address  these findings, with  equal emphasis  placed on the
safety of the nation.

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