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Aran Ron, M.D., and David E. Rogers, M.D.

*G. Tuchman, A. K. Daniels, and J. Benet, Hearth and Home: Images of Women in the Mass Media (New York: Oxford University Press, 1978).

'C. Guilfoy, "AIDS Forum: Politics and Science Collide,” Gay Community News, 23 February 1983.

"Anthony Fauci, "The Acquired Immune Deficiency Syndrome: The Ever Broadening Clinical Syndrome,” Journal of the American Medical Association 249 (6 May 1980):2375-76.

'D. Altman, AIDS in the Mind of America (Garden City, N.Y.: Anchor Press, Doubleday, 1987).

8 William F. Buckley, "Identify All Carriers," New York Times, 18 March 1986. "United States AIDS Program, AIDS Weekly Surveillance Report (Atlanta, Ga.: Center for Infectious Diseases, Centers for Disease Control, 6 June 1988). 10 Timothy Westmoreland, “AIDS and the Political Process: A Federal Perspective," in AIDS, Public Policy Dimensions (New York: United Hospital Fund and the Institute for Health Policy Studies, 1987).

''Office of Technology Assessment, Review of The Public Health Services Response to AIDS, A Technical Memorandum (Washington, D.C.: United States Printing Office, February 1985).

12Randy Shilts, And the Band Played On (New York: St. Martins Press, 1987), 186. 13 Robert J. and K. Donelan, "Discrimination Against People with AIDS: The Public's Perspective," New England Journal of Medicine 319 (13 October 1988): 1022-26.

14 Address by Dr. Stephen Joseph, commissioner of health, New York City, presented at the American Public Health Association Physicians' Forum dinner, 18 October 1987.

15AIDS Surveillance Unit, AIDS Surveillance Update (New York: New York City Department of Health, 30 November 1988).

16 Address by Dr. Joseph.

17 Bruce Lambert, "Study Finds Antibodies for AIDS in 1 in 61 Babies in New York City," New York Times, 13 January 1988.

18 Bureau of Communicable Disease Control, AIDS Surveillance Monthly Update (Albany, N.Y.: New York State Department of Health, June-July 1988).

19 Report of the Presidential Commission on the Human Immunodeficiency Virus Epidemic, 0-214-701: Q3 (Washington, D.C.: United States Printing Office, 1988).

20J. K. Inglehart, "Financing the Struggle against AIDS," New England Journal of Medicine 317 (16 July 1987):180-84.

Mr. WEISS. Thank you, Dr. Arno.
Dr. Brown.

STATEMENT OF LAWRENCE S. BROWN, JR., M.D., M.P.H, SENIOR VICE PRESIDENT FOR RESEARCH AND MEDICAL AFFAIRS, URBAN RESOURCE INSTITUTE, ADDICTION RESEARCH AND TREATMENT CORP.

Dr. BROWN. Mr. Chairman, please accept my gratitude for the opportunity to share some of the experiences and thoughts with you and members of the subcommittee.

My experiences come from two major perspectives. One is as an internist based at Harlem Hospital in New York City. The other is as the physician for the medical care and research at the Addiction Research and Treatment Corp., an organization that is community based and responsible for primary medical care delivery to over 2,000 patients addicted to opiates, attending clinics in Brooklyn and Manhattan of New York City.

Additionally, I've had the opportunity to serve on review committees and advisory committees of the National Institute on Drug Abuse, the National Institute on Mental Health, the National Institute of Allergy and Infectious Diseases. So, I feel as if I've become a sophisticated observer of bad events. I think that many of us can probably share in that same feeling.

Since the identification of the first case of AIDS, we have witnessed dramatic challenges to the integrity and capacity of the American health care delivery system.

The weaknesses have included, but are not limited to, the availability of health manpower, the appropriateness of financing health care and how we transfer the technology that represents the miracles of medicine such that all citizens of this country surely have the opportunity to benefit from these advances.

I have approximately about 13 points that I would like to raise with you.

It's clear, as was expressed earlier, that the HIV epidemic has extended beyond those persons who fit within the CDC classification of AIDS or those persons who in fact may have evidence of serological positivity. They extend to persons who have tuberculosis and persons who have sexually transmitted diseases.

As a physician who's on one of the busiest medical services at Harlem Hospital where we average approximately one patient with an HIV-related diagnosis every other day-and this is only one medical ward out of the six-it has become clear to us that given the staffing patterns and the resources that we have available to us, we have to treat a preponderance of patients presumptively.

We can neither wait for the diagnosis to be made or, if procedures have been performed, wait for the results of those procedures.

It's also become kind of odd to us, the dilemma of where we have excellently trained Harlem Hospital physicians that are being asked to be transferred to other parts of this country that also desperately need physicians, but it is taking from the have-nots to give more to other have-nots.

Clearly the medical consequences of the HIV epidemic as mentioned previously are particularly devastating on those portions of the American public already overrepresented by excess morbidity and mortality from cancer, cardio- and cerebro-vascular diseases, liver diseases, diabetes, homicide, and chemical dependency.

As Dr. William Hopkins so eloquently pointed out, for the American ethnic/racial minorities, AIDS represents the seventh horseman of the apocalypse.

Evidence points to the prevalence of intravenous drug abuse and other HIV-exposing drug abuse-related behaviors such as selling sex for drugs or money-as the driving forces behind the increasing over representation by black and Hispanic Americans in AIDS case reporting.

Despite these clear indicators of the devastating toll of the HIV epidemic on these populations, the advances of AZT and aerosolized pentamidine do not extend to these populations.

The waiting time to be seen in many of our clinics are measured in terms of months.

For the moment, let's again explore in some greater depth some of the obstacles to the delivery of health care and human services in the HIV epidemic and recognizing that these existed prior to HIV epidemic but in fact are even more acutely felt.

The decreasing number of physicians practicing in primary medical care most certainly has had a dramatic effect. While this began before the 1980's, this is most acutely appreciated in facilities that care for the poor.

The underrepresentation of black, Hispanic, and Native Americans in the health care manpower force also represents a significant impact.

This is manifested not only in the hospital wards across this country but also in the faculties of the institutions that train health care personnel.

This is important because, as evidence points out, these ethnic and racial minorities are more likely to serve other ethnic and racial minorities-members of the socioeconomically disenfranchised.

While foreign medical graduates have been the key to providing support to the shrinking health manpower force serving the poor, an inability to understand a patient's cultural influences or to converse in a patient's native language represent monumental obstacles in patient-physician communications.

For this reason the advances in medicine are poorly transferred to black and Hispanic Americans. Black and Hispanic health providers, who are most likely to care, again, for these subpopulations, are unlikely to have admitting privileges to these hospitals and academic institutions.

Consequently, the advances in diagnostic approaches or therapeutic interventions available at medical schools and hospitals associated with academic institutions, are not available to major populations of the poor.

I'd like to change a little bit of my direction.

One of my other points is to talk about the experience at the National Institute of Allergy and Infectious Diseases, where most of the persons who are participating in their clinical trials come from

gay white males. Unfortunately, this is in fact the opposite of the trends in AIDS and HIV infection in this country today.

Women, black and Hispanic Americans, and the drug addicted do not participate in AIDS clinical trials in numbers proportionate to the impact of HIV disease or to their composition in the U.S. population. This feature of the AIDS clinical trials persists because the academic institutions who conduct these studies are the same facilities who do not traditionally care for the poor, ethnic/racial minorities, or the drug addicted. Not only does this represent less benefit to these subpopulations, but also represents less desirable science. For us to have drugs that are going to have the widest application, we have to test them in populations that make sense and in populations where they are more likely to be utilized.

Finally, one of the clearly major obstacles in terms of providing HIV-related health care is that which deals with health care financing.

The rise in HIV-related funding has occurred at the expense of support of other causes of morbidity and mortality. Many State and local health departments talk about the fact that they've had to shift funding from other important disease entities in order to pay for funding for HIV-related initiatives.

Reimbursement is also a driving force. As this country reimburses more costly and more specialized medical practitioners, those who provide primary care are less likely to be plentiful in number. This is evidenced by the choices of medical school graduates. They're choosing more economically reimburseable careers as opposed to primary care professions.

I also feel compelled to bring to you as a final chapter of that which deals with health care finance, the inefficiency that often plagues block grant and cooperative agreements between the agencies of the Health and Human Services Department and State and city health departments.

While I recognize the principles and distinct advantages of the federalism approach, I often wonder if there would be some benefit to this country to evaluate how that money is being spent and the inefficiencies and costs to lives and dollars that take place by virtue of that system.

I would also say that it might be useful for the Federal Government to get some interest on the dollars that are in fact held in abeyance between the transfer from the Federal Government to city and State departments in order to deliver a valuable service. In summary, the HIV epidemic has exposed precious inequities and inefficiencies in health care delivery today. These obstacles to the provision of HIV-related services include the decreasing numbers of primary medical care providers, the continuing emphasis on costly in-hospital and hospital-based tertiary care services and the continuing lack of adequate primary care facilities. These problems are felt most deeply by the poor and ethnic/racial minorities.

As it relates to AIDS, this state of affairs also threatens the performance of research, including the clinical applications of various drugs under investigation for HIV-infection disease.

Good research requires that the ingredients of adequate health care and social services are firmly in place.

Mr. Chairman, please, again, accept my thanks for this opportunity to speak in front of you.

While these issues we must address are monumental, I truly believe the knowledge and expertise exists to surmount these obstacles.

To me it appears to be a matter of national resolve.

Thank you.

[The prepared statement of Dr. Brown follows:]