Private Acts, Social Consequences, by Ronald Bayer, New York: Free Press, 282 pages, $22.95
In the wake of Randy Shilts's magisterial account of the AIDS epidemic and governments' failure to respond to it, And the Band Played On, the stream of AIDS books has swollen substantially. Ronald Bayer's Private Acts, Social Consequences takes up the challenge of recovering and articulating the arguments for and against a variety of policy proposals intended to cope with the little-understood epidemic.
Consider the range of proposals: close gay bathhouses in major cities; test all donated blood for antibodies to HIV (the suspected cause of AIDS); screen various identifiable populations (gays, prisoners, military recruits) for antibodies; exclude all gay men from donating blood; trace the sexual contacts of those with antibodies; isolate and even quarantine those infected with AIDS; produce sexually explicit "safe sex" educational materials for gays, the general public, and school children. Initially, some of these proposals seemed wise and prudent, others pointless and ineffective, and yet others clearly counterproductive.
The ongoing arguments, counterarguments, and resultant compromises between public health authorities and leaders of the gay community provide the dynamic of Bayer's book. In each case, Bayer, a professor at the Columbia University School of Public Health, poses the issue and details the arguments as they developed. As journalism, his work is comprehensive and valuable. And as a sometime participant in those arguments, I found my adrenaline once again rising as I was reminded of what seemed to be at stake and how uncertain the outcome was at the time. Unexpectedly, this potentially bland book on public health policy became gripping reading.
Take just one example. Seen by some as symbols of gay sexual irresponsibility, bathhouses where gay men did sex seemed plausible targets for closure. But in fact, most gays did not go to bathhouses, and it turned out they were statistically insignificant in HIV transmission. Moreover, some bathhouses not only distributed condoms but also were a locus for educating those who would, in all likelihood, continue to be sexually active, bathhouses or no. And so the arguments went back and forth.
Public health has a long authoritarian tradition, which Bayer acknowledges. Its policy tools were developed long before modern preventive medicine and the advent of a clear understanding of disease transmission. Then too, until recent times, courts gave health authorities broad powers.
It is not surprising that in most of the arguments over AIDS policy, public health authorities faced gay community groups who, along with their civil liberties allies, were unwilling to abandon recently hard-won privacy rights and due-process safeguards even—especially—in the face of a devastating epidemic. Gay leaders repeatedly pointed out that despite government appeals to the "public good," "collective well-being," and "community health," people were infected with AIDS one by one and by behavior that they could easily be educated to avoid.
Bayer stigmatizes gays' preference for widespread education efforts as based on an "ideology of individualism," an "asocial individualism," "a narrow premise of self-defense," and even "an individualism that would, ironically, subvert the very meaning of intimacy." Yet to accept such an analysis would be very much in error. This "individualism" was no mere ideology but resulted from the felt experience of most gay men, coping with hostility and prejudice on a daily basis. Bayer passes all too lightly over sodomy laws just recently upheld by the Supreme Court. He averts his gaze from the conspicuous homophobia of national figures such as Sens. Jesse Helms (R–N.C.) and Gordon Humphrey (R–N.H.), Rep. William Dannemeyer (R–Calif.), former Atty. Gen. Ed Meese, and former Education Secretary William Bennett. Government inattention to AIDS during the early years of the epidemic led many gays to suspect that the Reagan administration simply wished it to take its natural course. None of this strengthened faith in the sincerity of governments.
Slowly, public health authorities came to realize that, whatever their desires, they needed the confidence of the gay community. Otherwise they would scare off—"drive underground"—the very people they most needed to reach with messages about antibody testing and safer sexual behavior. Even contact tracing required the trusting cooperation of people willing to provide names and addresses of sexual contacts.
Ultimately, public health policy had to take into account the concerns and desires of all the affected parties. Policy was forged in the matrix of public opinion and the limited trust of target groups. This leads Bayer to assert his central contention: health policy is essentially political in nature—"the pragmatics of public health" differ substantially from "the logic of public health."
Bayer sees public health authorities as fumbling their way toward what should have been their goal at the outset—generating a "Culture of Restraint and Responsibility" among those at risk. He repeats this phrase like an incantation 18 times throughout the book before he finally explains it in one disappointing paragraph at the end. It amounts to no more than a recommendation for more explicit safe-sex education, drug treatment programs, needle-exchange programs, anonymous antibody testing, nondiscrimination against the infected, and so forth. Yet all these recommendations have been accepted, even urged, by the gay community. It is hard to imagine what Bayer conceives to be his own contribution.
Health officials have, in fact, resisted almost all these proposals. Instead, they apparently preferred, when they responded at all, high-profile but largely useless symbols such as closing bathhouses or threatening to quarantine an occasional infected prostitute—as though people had no way to protect themselves from such a person and exchange of money constituted a risk factor. Bayer even quotes one Texas health official as admitting, "You've got to look at the public's reaction.…People want to have some reassurance that public health agencies are in control of the situation." In short, AIDS is a public relations problem. Oddly, Bayer seems to approve.
In fact, it was precisely in view of the paralysis or merely symbolic responses of health authorities that gay men realized they needed to take action on their own. Having condemned gays for "asocial individualism," Bayer is stunned to find that the gay community brought the virus transmission rate down to near-zero. He cannot acknowledge that the "protect yourself" message not only worked but was simply the old-fashioned American virtue of personal prudence based on old-fashioned "enlightened self-interest."
Nor, contrary to Bayer, is that individualism inconsistent with intimacy or a sense of community—or their common root, friendship. Gays begged health officials for help in educating their communities, pleaded for help as they took care of the sick, begged for better research on the disease. And as health officials turned a deaf ear, gays wrote about the disease for the gay press. They printed obituaries about the dead, paid for and passed out safe-sex pamphlets, distributed condoms, expanded old gay health clinics to try to handle the enormous new burden of AIDS. They opened residences for people with AIDS, conducted fundraisers, held auctions, charged entry fees at popular bars. They closed many bathhouses—by not attending them. They lobbied the mainstream media for better, more-accurate coverage of the disease. In short, they created their own Culture of Restraint and Responsibility.
In fact, the gay community is an excellent modern example of a rapidly formed volunteer effort emerging to cope with a governmentally neglected emergency. Even now, gays have formed Community Research Initiatives to test proposed AIDS treatments in the light of the Food and Drug Administration's sluggish response. Bayer, with his bias toward government, misses the real story. Since he is so demonstrably an able journalist, that is a shame.
Paul Varnell writes for the Windy City Times.