Ethics

'Controlling the spread of infection must be regarded as an issue of prime importance to the future of the nation.'
Sir Donald Acheson, Chief MedicaI Officer, Department of Health and Social Security.

'AIDS could well become one of the worst health problems in the history of the world... An awesome health problem that could involve millions of people who are going to die as a result.'
Otis Bowen, United States Secretary of Health.

'We stand nakedly in front of a pandemic as mortal as any pandemic has ever been.'
Dr Haildon Mahler, Director General, World Health Organization.

'The major social impact of AIDS worldwide is the direct result of the dominant role of sexual transmission of human immunodeficiency virus (HIV). Thus, the brunt of illness and death is borne by the twenty to forty-nine year olds. In contrast to many public health problems which selectively affect either the very young or the old, AIDS affects the most vital segment of the population in terms of social or economic development... What political system could withstand the ultimate destabilizing impact of a twenty or twenty-five per cent or higher HIV infection rate among young adults?'
Dr Jonathan Mann, Director, Special Programme on AIDS. We agree with each of the above statements. And yet, because nothing like the full impact of AIDS has yet been felt in Britain, most lay people have still not grasped the seriousness of the crisis that faces us.

We appreciate what the government is doing - £50 million allocated for 1988 to cope with the cost of AIDS and one of the better education programmes. But we want to put two basic questions:

• Are current measures adequate to meet the scale of the crisis?
• Should some aspects of current policy be changed?

• THE PRIORITY GIVEN TO AIDS,
• THE EDUCATION PROGRAMME,
• POLICY ON HIV TESTING,
• FUNDING.

The priority given to AIDS

1. The government should declare AIDS to be a priority of the first rank in the country.

   This is because of the massive human, social and economic costs of AIDS deaths in the 1990s, if the worst projections are realized. Forecasting statistics for such a new epidemic is extremely hazardous, as there are several unknowns. Will people heed warnings about safe sex and not sharing needles? Will the pattern of the epidemic change from the mainly homosexual pattern of spread now seen in the northern hemisphere to the heterosexual pattern seen in Africa? Will there be a cure or vaccine? (This seems unlikely in the near future because the virus rapidly becomes encoded in the genetic material of the cell and so is very hard to destroy. A cure for AIDS would require a revolutionary breakthrough in medicine.)

   Despite such unknowns, we surely have to plan against the worst happening, as by the time the answers to these questions are known, it may be too late to change course. If the worst does happen, then the human cost will be massive, with many orphans and many older people with no children to care for them. The social cost will include not enough young adults to parent a full next generation, too few of this age group to staff hospitals, defence forces and so on. (Remember the impact of AIDS is concentrated, in the 18-49 age group.) And the economic cost, including hospital treatment, lost productive income and caring for orphans, could range from £24 thousand million if no more become infected than at present, to £687 thousand million if numbers infected continue to double at the present nine-monthly rate to three million people. The latter cost is, of course, many times the current total annual spending on the National Health Service.

   The level of priority now given to AIDS may have been appropriate even two years ago, when it was thought that only ten per cent of HIV infected people would eventually develop AIDS and die. But careful follow-up studies in Frankfurt have since shown that this figure could be seventy-five per cent, and many think it may prove to be ninety or even a hundred per cent.

2. The government should review the basic strategy behind all efforts to combat the epidemic.

   This follows from the above. We are facing a new disease, and new facts about it are emerging every month. With the long period that often passes between becoming seropositive and developing AIDS, these facts are only slowly becoming apparent. So strategies adopted need to be constantly rescrutinized, and channels held open to change them rapidly where necessary. This may be politically difficult, but it could prove essential for national welfare.

   Some strategies may be very difficult to implement in a democracy such as ours. For instance, one possible way of preventing further spread might be mandatory screening for the virus, followed by some form of segregation of the seropositive. We could see such a strategy being adopted in a totalitarian state, but would it prove feasible and right in a democracy? Yet countries that will continue to prosper will be those that succeed in containing AIDS.

Education Programme

In its advice on sexual relationships, the education programme has conveyed what amounts to 'The really safe way is to stick to one partner, but if this is too hard use condoms'. But in reality most people have transposed this message to make it say two dangerous and quite untrue things:

'Sex is safe if I use a condom.'
Wrong. It is safer, but not safe. Condoms sometimes fail to protect. A recent study has shown that fifteen per cent of women whose husbands used the sheath as their only method of contraception became pregnant within one year. And conception is only possible on a few days each mouth, whereas the virus can be passed at any time. Also, we are not talking about a single year but many years of sexual activity. So to rely on condoms for protection from HIV infection is like playing Russian roulette.

'I will not catch AIDS if I stick to one partner at a time.'
Wrong. 'Serial monogamy' - being faithful to the current partner until moving on to the next - is a highly risky lifestyle. We are safe only if we stick to one partner for life, - or rather, if we both do! The pattern of serial monogamy is widely accepted among younger people today. A person may easily have had eight partners before finally settling into a lifelong relationship. This involves slotting into a sexual network, which may well amount to 500 second-hand contacts by the eighth partner. It is in no way a safe way to behave today.

1. Emphasis should be laid in education campaigns on One Person, One Partner For Life as the only way to achieve zero risk of HIV infection.

   Such a campaign would also involve pointing out the great positive value of lifelong. single-partner relationships.

   Future success in containing AIDS will be more likely if today's children understand something of the dangers. And so:

2. The government should encourage education on AIDS from an early age in schools.

   Initially this may take the form of geographical and historical aspects of the epidemic, with indications that it is possible to choose a no-risk lifestyle.

Policy on HIV testing

We acknowledge that this important question has become controversial, with the BMA, for example. divided on it. We believe, however, that the three related proposals below should be implemented, for the reasons that follow. The situation has changed radically from two years ago, when a person found seropositive was thought to have a 10% chance of developing AIDS and dying, to today, when that chance is expected to be 75-100%.

1. Easy access should be given to HIV testing for the general public and for doctors.
   Tests on saliva may assist this objective.
2. As far as possible, financial disadvantages that face HIV positive people who are still healthy should be removed, as such disadvantages tend at present to dissuade people from being tested.
3. The present policy of negative counseling to dissuade people from having the test should be reversed.

   The reasons why we believe that people with risky lifestyles should be tested are these:

   • To stop people spreading the virus. The disadvantages to being tested are known and real - as real as discovering that a person is infected with any terminal illness. But these need to be set against the welfare of many others who may be infected by an unknowingly seropositive person who remains symptom-free for some years. People who know they are infected are less likely to continue with a lifestyle that puts others at risk.
   • To give a more accurate idea of the course of the epidemic. Figures of infected people are not much more than guesses at present, which is surely unacceptable for such a major epidemic where the formulation of correct strategies by government is so crucial.
   • To guard against infected women becoming pregnant. This is because their babies will probably be born with the disease.
   • To enable early medical attention when AIDS begins. Seventy-five per cent of people presenting with AIDS present with a life threatening illness, half of these with a rare chest infection. If it is known that such symptoms are AIDS-related, curative action can be taken more quickly and lives prolonged.
   • To enable the course of the illness to be slowed by drugs. It is commonly stated that, as there is no cure for AIDS, there is no advantage in a person knowing he or she is infected. Wrong. Research is developing less toxic drugs to slow the development of the disease. But world specialists such as Robert Gallo are recommending AZT treatment in low doses at an early stage of HlV infection, rather than in high doses once a person's immune system is severely damaged and full-blown AIDS is present.

Funding

We have indicated above the severe human, social and economic costs if AIDS continues to spread unchecked. The only way to avoid these is to provide adequate funding now for preventive measures. The justification for such spending is similar to that for increased defence spending under the threat of war. Not to provide adequate funding for short-term reasons actually makes the disaster more likely. Therefore, we propose that the government should:

1. Massively increase funding for AIDS, to cover education on AIDS; expansion of medical services including hospitals, home care and hospices, and programmes aimed specifically at drug addicts and prostitutes. It is essential that the steam should not go out of the education programme now, when the curve of the AIDS graph has not begun its steep climb and the public could so easily get bored with the subject and imagine the danger has somehow receded. Also, it will be too late to provide proper hospital, home care and hospice facilities once the numbers begin to increase rapidly.

   The time is now.

2. The government should assist voluntary bodies with funding, since these are expected to be in the forefront of caring for those with AIDS-related conditions. This is not an alternative to proposal 8, but a necessary complement to it. The scale of care needed is likely to be such as to call for all agencies, government and voluntary, to be fully involved. Some voluntary agencies are already in the field, but others could be drawn in. Churches, for example, might well return to their former role of health care, as they have to an extent been active in the hospice movement. Convents and monasteries might provide additional facilities for terminal care. But it would be unrealistic to expect such agencies to function without assistance with funding.
3. The government should encourage and assist with funding an independent AIDS body with responsibility for third-world countries. The impact of AIDS in some poorer countries is already beyond the ability of their resources and medical infrastructure to cope. The destabilizing effect of an unchecked rise in deaths among young adults in such countries could be horrific. Only a supranational agency in co-operation with the World Health Organization, but independent from it, can provide and direct the skills, knowledge and resources where they are most needed. And such an organization will need technical help and funding from countries such as our own. We are faced with the possibility of a worldwide disaster, and international co-operation is needed.