DAWNING ANSWERS  
How the HIV/AIDS Epidemic Has Helped to
Strengthen Public Health

Edited by: Ronald O Valdiserri, MD, MPH
Oxford University Press 2003  209 pp
$39.95 US



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Reviewed by Gordon Nary

Multiple-authored chapter books are essentially a product of the editor’s vision, choice of authors, and editing skills. Dawning Answers’ editor is Ron Valdiserri, Deputy Director of the National Center for HIV, STD, and TB Prevention of the US Centers for Disease Control and Prevention, who also authored two of the chapters in this collection.  His planning and editing of the complementary chapters of Dawning Answers reflects each of the collected authors’ perceptions of and insights into the faceted truths that we have learned from the AIDS experience. Although the book does not address some of the political obstacles to the application of some of the dawning answers to more effective HIV prevention policies, Dr. Valdiserri has constructed a book that Gestaltists will applaud since the whole of Dawning Answers far exceeds the sum of the essays contained.

Chapter Commentaries:

HIV/AIDS in Historical Profile.  
Ronald O. Valdiserri

I wish that Dr, Valdiserri would consider expanding this chapter into an entire book. The 156 citations at the end of this opening chapter reflect an insightful interdisciplinary perspective of the history of the HIVAIDS pandemic that deserves to be expanded. There is also an appendix chart titled  “HIV/AIDS: Chronology of an Unfolding Epidemic” that one of the pharmaceutical manufacturers should consider enlarging as a wall chart and distributing to AIDS service organizations.

The history of the AIDS pandemic is one of the few histories to which most of us involved in HIV care, prevention, and advocacy can directly relate. For some, many of the AIDS benchmarks are also benchmarks of our lives. They are benchmarks of frustration,  loss, occasional burnout, anger, promise, hope, and a reaffirmation of our collective abilities to more effectively care and support people affected by life-threatening illness.

Dr. Valdiserri concludes this chapter with a note of hope ‘ He quotes Tony Kushner from Angels in
America  - “This disease will be the death of many of us, but not nearly all…. The World only spins forward.”  
 -  and states his belief in the role of behavior modification as part of the solution to HIV/AIDS prevention, and  “that multiple lines of evidence support the feasibility of developing an effective vaccine against HIV.”

HIV and AIDS Surveillance: Public Health Lessons Learned.
James W. Buehler

Dr. Buehler focuses on five lessons learned from the HIV/AIDS surveillance experience: the value of multiple surveillance methods for monitoring complicated diseases; the need for focused behavioral surveillance as a critical adjunct to ”general population” surveys when behaviors disproportionately affect high-risk populations; a multidisciplinary approach to epidemiological surveillance that intersects with other public health concerns; and the protection of privacy and confidentiality when addressing public health concerns.

He concludes with his observation that the “impact of HIV/AIDS on groups such as men who have sex with men and injection drug users who have long been stigmatized by society, its disproportionate impact on persons of minority race or ethnicity, the active and sometimes boisterous involvement of advocacy groups, and the striking advances in HIV prevention and treatment­­­-all have combined to place unprecedented and urgent demands on planners and managers of surveillance systems."

HIV/AIDS’ Contribution to Community Mobilization and Health Planning Efforts.
Ronald O. Valdiserri

Dr. Valdiserri details several lessons learned from two decades of experience in community mobilization. In addition to the diversity of  structure of successful community mobilization efforts,  he also comments on the experience of community participation in clinical trials, contributions to local and national  healthcare planning initiatives,  and community HIV prevention programs. He concludes with the adage that “Governmental and community-based organizations providing public health services  will be hard-pressed to achieve success without the backing of the communities for whom these services are intended.“

Innovations and Approaches to Preventing HIV/AIDS: Applications to Other Health Promotion Activities.
Ann O’Leary, David R. Holtgrave, Linda Wright-DeAgurro, and Robert M. Mallow

This chapter opens with an overview of some of the challenges in responding to disease prevention in marginalized communities – those affected by poverty, unemployment, and lack of access to quality  healthcare services – and the venues where high-risk behavior takes place and/or other related risks are addressed.  They also comment on how affected community members were trained to participate in prevention programs among their peers, and how the lessons learned in  HIV prevention programs have been applied to other public health challenges.

The interrelation of HIV and other cofactors such  as drug use, mental illness, trauma, etc.  are briefly reviewed along with some of the challenges that outreach workers face in attempting to change HIV  high-risk behaviors, and in dealing with couples and group behavior. Although the successes are well-detailed, the authors could have also addressed some of the continuing challanges

The Impact of HIV/AIDS on the Development of Public Health Law. 
Scott Burris and Lawrence O. Gostin

This is another chapter than deserves and possibly demands an entire book. As the authors point out “perhaps the best measure of the impact of public health law is that one chapter can only scratch the surface of the changes and challenges this continuing epidemic has brought to the field. One leaves the topic with only two certainties for the future: the law can do much more to help assure the conditions in which people can be healthy; and that our experience with HIV/AIDS has given us a clearer vision of the future.“

The authors explain that “…law is not simply a set of rules, but a collection of rules, institutions, behaviors and attitudes deeply embedded in our social structure”, provide an overview of HIV legislation and regulation and remind us that “the drama of litigation should not divert attention from the legislative and administrative processes that are the true engines of the law as a tool of public health policy.”  We are reminded of some of the phobia-based state legislation such as Illinois’ mandated premarital HIV testing and Utah’s positive banning of marriage between HIV+ people. The impact of federal legislation on spending limitations on all aspects of HIV prevention and care is discussed, along with the legal  use of coercive efforts to control human behavior as a public health measure. 

Of particular interest are the authors' recommendations of the positive role that healthcare providers can assume in addressing their patients’ social risks. The authors conclude that “…patients need help in addressing their perceived risks and making sensible choices about whether the risk of testing or partner notification or healthcare outweighs its benefits…”

The subsection titled  “The Health and Human Rights Framework”  may well justify the book’s title of Dawning Answers.  The authors point out that “vast scholarship and litigation in international fora were required to define and enforce civil and political rights. Social and economic rights, notably the right to health, deserve the same rigorous and sustained attention.”

The Evolution of National Funding Policies for HIV Prevention and Treatment. 
Jeffrey Levi

One could refer to this as the Jerry McGuire chapter –“ Show me the money.”  Dr. Levi postulates that “HIV gave policymakers in terms of the financing an opportunity to ‘think outside of the box’ in terms of the delivery and financing of prevention and care programs….” He discusses some of the new models of care that are emerging and provides an excellent overview of the evolution of national funding policies for HIV prevention.

There is an excellant subsection on the limitations of Medicaid in which the author details several  reasons why Medicaid will never be the entire solution for funding HIV prevention and care. First is Medicaid’s tight eligibility criteria that require extreme levels of poverty.  Next is the “tremendous discretion given to states in the administration of this program.” Also is the fact that Medicaid funds cannot be used to create the infrastructure necessary to create service programs for people with HIV.  Finally, Dr. Levi points out that many medical providers are not adequately trained in HIV/STI prevention and are not compensated for these services.

He concludes with four basic lessons from the HIV/AIDS funding experience; (1) “policy-makers must take advantage of the data that the public health and other medical systems collect to drive the design and implementation of interventions and  funding policies.“ (2) “public health planners must think of the entire health-care system, not just the smaller universe of public health-specific program as part of its armamentarium in responding to a public health emergency.” (3) “The design and implementation of discretionary public health programs must occur with constant attention to the underlying health-care delivery, especially the poverty-based Medicaid system.” (4) “The HIV/AIDS funding experience has shown that policy-makers responsible for health programs of all kinds must find common philosophical ground in order to accept the integration of population-based public health approaches within the individual-oriented health-care delivery system.“

AIDS and the Making of an  Ethics of Public Health. 
Ronald Bayer

This is a beautifully written and realized exploration of how AIDS transformed the dynamic between bioethics and public health. Dr. Bayer offers a cogent summary of the concept of AIDS exceptionalism and its application to the challenges of testing, reporting, and partner notification

He reminds us of how we faced and responded to questions of how best to contain a lethal disease, whether STD policies be applied to AIDS, and the factors that justified differential policies for AIDS' and the profound ethical conflicts between confidentiality, privacy, contract tracing, and partner notification.

Dr. Bayer  reexamines the impact of AIDS on research ethics: on  the role of the randomized clinical trial,  on placebo controls,  on the centrality of academic research, on the imbalance in the relationship of researchers and clinical trial subjects,  and on the distinction between research and therapy, He revisits the debates over maternal-fetal transmission of HIV and some of the ongoing debates over ethical questions raised by AIDS vaccine trials.

In a subsection on access to care, the author also revisits the ethical challenges to the US healthcare system, the patchwork system out of which the AIDS Drug Assistance Program was fashioned and why, like the End Stage Renal Disease program,  it has “left untouched the basic questions of medical inequality."  He also explores some of the challenges of global access to AIDS drugs.

In his concluding remarks, Dr. Bayer asserts that “ the greatest impact of AIDS on ethics, may be found in the way it has inspired a serious discussion of the ethics of public health as distinct from the ethics of a clinical relationship….That discussion is still in its formative stage, and remains unclear what direction it will take.”  He closes with a reminder that “among the most notable developments since the epidemic took hold has been the effort to demonstrate the linkage between human rights and public health.“

Contributions o HIV Prevention Evaluation to Public Health Program Evaluation. 
Laura C. Leviton and May E. Guinan.

This chapter essentially addresses the need for accountability in the conduct of HIV prevention programs and details methods used to evaluate these programs. The authors pay specific attention to the need for capacity-building for local evaluation, and conclude that “public health could benefit by emulating other examples et by HIV prevention, such as unique quality control safeguards, based on evaluation evidence, that facilitate use of effective HIV prevention models.”

The Evolving Impact of HIV/AIDS on Global Health.
Peter Lamprey, Kristen Ruckstuhl, and William Cates, Jr.

Lessons are relatively easy to come by, and, by definition, imply a learning process. Application of the lessons learned, however,  is a universal challenge to individuals, institutions, and governments. Application of lessons is essentially a matter of will -- will power on the part of individuals, and political will on the part of institutions and governments. In general, it would appear the social, political, and economic lessons that are well-detailed in this chapter are more than dawning answers. They have been illuminated  in dazzling intensity by the noonday sun that shines each day on 40 million men, women, and children living with AIDS.  The lessons have been with us for a decade.. We have not had the political will to apply the lessons to prevent this unfathomable statistic and share in the culpability for their unnecessary suffering

However, this unfathomable statistic could have been even higher if it were not for a few successful  significant interventions. The authors review the condom promotion program in Thailand, some effective STI management programs, the implementation of voluntary HIV counseling and testing programs, and the ARV prophylaxis programs to reduce mother to child HIV transmission. They also examine HIV/AIDS’ influence on global public health with subsections on national and international security, the mobilization of global leadership and resources,  the inextricable link between health and human rights, patient advocacy and empowerment, gender inequality, sexual health, and global public health technology.  The authors conclude that “we need to apply, on a much larger scale, the lessons learned from the past two  decades.”   Unfortunately, there are no dawning answers on how mobilize the political will to do so.

I recommend this book as an essential introduction to and reminder of what may prove to be the most important  public challenge in human history.

June 03, 2003
Gordon Nary is the executive director of Medical Advocates for Social Justice