distrust and fear is grounded in a history of medical neglect and significant violations of human subjects in research, especially in the Tuskegee Study of Untreated Syphilis in the Negro Male (Jones, 1993; Gamble, 1993, 1997). A formal apology for this treatment, issued by President Clinton in 1997, should help to create a new, more favorable atmosphere on these issues (Thomas and Quinn, 1997).

Without adequate protection such as anonymous testing, case reporting without name identifiers, voluntary partner notification, and strong confidentiality regulations, those people at greatest risk who already feel significant distrust of the public health/government system may not seek HIV testing services. Consequently, there may continue to be a growth in numbers of unknowingly infected individuals, higher mortality rates than among those whose infection is detected early, tremendous budgetary strains on the health care delivery system, and more HIV-infected babies. This situation could spark public support for repressive policies against those suspected to be HIV-infected (Stoddard and Reiman, 1990; Lovvorn and Quinn, 1997).

Conclusions

Public health screening programs have helped to control epidemics of infectious disease and to target treatment for chronic diseases. The examples in this section, especially congenital syphilis and MSAFP, illustrate the tangible public health benefits of perinatal screening efforts. In practice, however, when screening is conducted in contexts of prevalent gender inequality, racial discrimination, sexual taboos, and poverty, these conditions shape the attitudes and beliefs of health system and public health decision makers as well as patients, including those who have lost confidence that the health care system will treat them fairly. Thus, if screening programs are poorly conceived, organized, or implemented, they may lead to interventions of questionable merit and enhance the vulnerability of groups and individuals.



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