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]]]]]]]]]]]]]]]]]]] 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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