Saving Patient Brian
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Posted: February 11, 2004
1:00 a.m. Eastern
By Dr. Miriam Grossman
© 2004 WorldNetDaily.com
Brian has two problems. For the first, he wants help; for the second he doesn't. Brian complains he is addicted to cigarettes. It's bad for his health, expensive and stinks up the car. His boyfriend hates it. So Brian has decided to quit – this time for real – using medication. That's why he made an appointment with me.
In the course of our discussion, I learn that Brian, a bright college student, and his partner, an actor, often pick up other men. "It's hard to be monogamous," he explains. Neither use protection, nor has Brian ever been tested for HIV. He does not discuss HIV status with his casual partners, or with his boyfriend. The topic of safer sex makes him nervous, and he'd rather not think about it.
As a psychiatrist at the counseling center of a large university, I hear many fascinating tales. Students share the intimate details of their lives and struggles, and it's not boring. Nevertheless, once I'm behind the wheel of my car at the end of the day, my thoughts are no longer with my patients. Rarely do I "bring my work home."
Brian is an exception. I can't get him off my mind. Brian, his boyfriend and their partners may all be, or about to become, infected with a lethal virus.
Remembering our meeting, I realize that my face betrayed my alarm, because Brian was quick to acknowledge his irresponsibility. Notably, he also said I was the first physician to discuss this topic with him – an astonishing fact given Brian's openness about his orientation. I want to tell him he is endangering his life and that he must change his behavior at once. He must be tested, and, if necessary, begin treatment.
But I proceed gingerly, fearing that I might spook him and lose him as a patient. I remind myself that he did not present for help with this dangerous behavior, but rather for his tobacco addiction. So Brian and I discuss problem No. 1, but I also encourage him to limit his contacts, and to use protection. We agree to meet again. Brian thanks me cordially and leaves. I remain alarmed: When we meet again, will he be newly infected?
There must be something else I can do to protect my patient. But what? A colleague at the student health service is sympathetic, but can offer no solution. "It's an uncomfortable ethical dilemma for physicians," he says. "You can only recommend testing and discourage unsafe activities. Your hands are tied unless you know someone is positive."
I looked up our HIV-AIDS laws, a guide provided by our state department of health. "The Office of AIDS is committed to assess, prevent, and interrupt the transmission of HIV," the first paragraph reads. Sounds good. Yet what follows is more about protecting the infected than the healthy: prohibitions against mandatory testing, insurance discrimination, and disclosure of HIV status in worker's compensation cases.
HIV infected persons, considered disabled, are also protected by federal and state statutes which prohibit discrimination in employment, housing and public accommodations. The Health and Safety Code requires the reporting of a positive HIV test to the local health officer, using a "non-name code" to assure anonymity to the infected person. The code permits, but does not require, notification of exposed contacts.
The notification process, however, must not identify the HIV-infected person. So if one of Brian's partners were HIV positive, my patient would be in a position to be informed of his exposure only if the infected person appears for voluntary testing and if he or his physician decides to notify others.
I am not reassured.
On the Centers for Disease Control's website (Division of HIV-AIDS Prevention) I find information about health education and risk reduction. The document emphasizes the need for non-judgmental patient care and reminds me that "disenfranchised minorities" are suspicious and distrustful of public health officials. In particular, "for African Americans, the Tuskegee Study continues to cast its own specter of doubt as to whether or not public health officials are truly committed to ensuring the public's health."
Basically, they argue that "respect and regard for the perceptions of those being served will help eliminate barriers to HIV protection and will build the bridges to better health." The behavior known to be the easiest and most common sexual route of HIV transmission – anal intercourse – is not even mentioned.
I next turn to the American Medical Association website, which features this newsflash, a quote from its president-elect: "For the past five years, our nation has averaged 40,000-45,000 new HIV infections every year ... that suggests that something more, perhaps something different needs to be done to help prevent the spread of HIV." And what is that innovation? "An emphasis on educating HIV positive individuals about how to prevent transmission."
The article notes that the CDC, the NIH and other agencies have recommended the "new and innovative strategies." It does not report, however, that 77 percent of infected persons are presumably unaware of their condition.
My next stop is at the Gay and Lesbian Medical Association. Surely they are concerned about protecting their own. One of the reasons for the continuing increases in HIV incidence, I am informed, is the poor interpersonal skills of health providers. Both patients and physicians feel awkward discussing the topic. Prevention messages do not get through. On a positive note, guidelines are offered for conducting sensitive and non-judgmental assessments by providers.
Lastly, the county department of health offers me a 113-page document: "HIV Prevention Program." It appears they are following in the CDC's footsteps, taking prevention one step further. Here, I learn that fighting oppression can prevent HIV. Racism, homophobia, AIDS discrimination and stigma – these are the culprits permitting the deadly virus to propagate.
Racism? Oppression? Where did this come from? In medical school, I learned that there are standard procedures for fighting epidemics. Using traditional public health-control tools we – in the developed world, at least – have somehow managed to bring under control horrific diseases, such as cholera, polio and syphilis. This apparently was achieved without pouring billions of taxpayer dollars into programs promoting cultural sensitivity. Yet this was in the pre-AIDS era: I took the Hippocratic Oath a year before the identification of Gay-Related Immune Deficiency Syndrome, as it was originally designated in 1981.
And speaking of the Hippocratic Oath, I swore "to prevent disease whenever I can," and to "remember that I remain a member of society, with special obligations to all my fellow human beings." These responsibilities I take to heart. And that's why, as I drive home today, I am racked by a sense of helplessness. What can I do to prevent my patient from acquiring and transmitting an infection that will likely kill him in the prime of his life?
Why is legislation focused on protecting the rights of the infected, at the expense of the uninfected? HIV infection is entirely preventable. It seems reasonable to advocate that those who are HIV positive must be promptly identified and treated, and that the healthy must be protected. Fighting stigma and oppression is important, but if existing measures for combating this epidemic are not implemented, Brian – like the 500,000 AIDS victims before him – is doomed. Does anyone care?
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Miriam Grossman, M.D., is a staff psychiatrist with UCLA Student Psychological Services in Los Angeles, Calif. |
