have responded to a flood of patients with AIDS, but those responses were most successful where health care was better organized and financed and where the populations to be served had sufficient knowledge to understand the disease and its modes of transmission and were capable of organizing themselves in ways that supported and supplemented the health care system.

Thus, our most general conclusion about the epidemic is that its impact has hit institutions hardest where they are weakest: serving the most disadvantaged people in U.S. society. Predictions of the imminent collapse of the health care system due to the epidemic, for example, now look shrill, but, conversely, hopes that the epidemic would force the country toward more rational and equitable reform of the system now also seem unrealistic. In the panel's judgment, the HIV/AIDS epidemic has effected many transient changes in the institutions that we studied and relatively few changes that we expect to be permanent. Among the more permanent, however, two are particularly noteworthy.

First, the institutions of public health, of health care delivery, and of scientific research have become more responsive to cooperation and collaboration with "outsiders." Policies and practices have been modified in these three institutions under pressure from and in collaboration with those who are affected by the epidemic and their advocates. Many of these changes are positive and will contribute to the efficiency and efficacy of the institutions. Similarly, volunteer organizations stimulated by the challenge of the epidemic have discovered ways not only of supplying help where extant institutions were lacking, they have also influenced the policies and practices of those institutions.

Second, even in institutions with very defined purposes and strong constraints—institutions as different as religious groups and correctional agencies—the response to the epidemic has reflected awareness of the scientific realities, as well as the social implications, of HIV/AIDS. Traditionally based doctrinal constraints in the case of religious groups and the stringent requirements of civil punishment in the case of correctional agencies are powerful forces that could and did dictate rigid and narrow response. Yet, powerful as those forces were, they did not negate more reflective responses that contributed to containment of the epidemic and respected the rights of individuals. We are concerned, however, that as the epidemic strikes with greater force in socially and economically deprived communities, the directions toward more communal involvement and respect for civil and personal liberties might be constricted and diverted.

The panel believes that a failure by scientists and policy makers to appreciate the interaction between social, economic, and cultural conditions and the propagation of HIV/AIDS disease has often led to public misunderstanding and policy mistakes about the epidemic. Although in the beginning of the epidemic, gay life and behavior were certainly at the center of



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