Book Review

AIDS — Politics, Policies, and Patients

Dragon within the Gates: The Once and Future AIDS Epidemic

N Engl J Med 1993; 328:449-450February 11, 1993

Article

Dragon within the Gates: The Once and Future AIDS Epidemic
By Stephen C. Joseph. 228 pp. New York, Carroll and Graf, 1992. $20.95. ISBN: 0-88184-905-7

Stephen Joseph was commissioner of health in New York City from 1986 to 1990 during the administration of Mayor Edward Koch. Confronted by the AIDS epidemic, Joseph chose to make it his issue, adopting a posture that was in striking contrast to that of his predecessor, David Sencer. In arguing for an aggressive campaign to halt the spread of HIV infection, Joseph emerged as one of the nation's leading health officials. His years as commissioner were filled with controversy. In 1988, he began a long, difficult struggle to initiate a needle-exchange program in New York as a way of slowing the spread of HIV infection among intravenous drug users and, in so doing, confronted entrenched resistance, most critically from the leadership of the African-American community, which dubbed him a racist. In that same year he antagonized New York's gay community and AIDS activists by endorsing a report that suggested that the number of persons with HIV infection in the city was half the earlier estimate of 400,000. In the summer of 1989, he outraged the AIDS community by proposing that the time had come to adopt a traditional public health approach to the HIV epidemic, one that would emphasize widescale voluntary testing, the mandatory reporting of the names of those with HIV infection to a public health registry, and the use of contact tracing to notify the partners of those who carried the virus that causes AIDS. Finally, his strong advocacy of the use of condoms and his efforts to place messages urging such use on public-transport vehicles and on television provoked the antipathy of the Roman Catholic Church.

In Dragon within the Gates, Joseph seeks to recapture the challenge of his years as health commissioner and to make clear his prescriptions for controlling the AIDS epidemic. The book is thus part personal memoir, part testament. In recounting the story of his tenure as commissioner, Joseph is at his best when he describes the events surrounding the needle-exchange controversy, to which he devotes an entire chapter. It is not surprising that those events, as well as those surrounding other issues, bear the imprint of one man's point of view; this is a memoir, after all. Nevertheless, I had hoped for more information, for details that were not reported in the press at the time. Finally, Joseph uses the book as an occasion to settle scores. Those in the gay community who opposed his efforts to fashion a response to AIDS that reflected traditional public health values are particular targets. Surprisingly, he is all but silent on, and relatively gentle in dealing with, religious opposition to his condom-distribution efforts.

As a testament, Dragon within the Gates repeatedly underscores Joseph's beliefs that we failed to protect the public health because we were unwilling to press for widescale HIV testing, and because we failed to adopt standard public health reporting and contact tracing. For Joseph, politics had taken command, replacing the science of public health. He never takes a step back, however, to examine the extent to which our growing understanding of the complex problem of AIDS-related behavioral change may suggest that his prescriptions might not have produced the desired results. Thus, although he notes that counseling and education might not be very effective in fostering behavioral change, he never confronts -- even in order to criticize them -- the studies that raise questions about the behavioral effects of voluntary HIV testing.

Joseph does, however, ultimately acknowledge that the control of the AIDS epidemic might require a different, even radically different, response when he turns to the link between HIV transmission and drug use., and here there are some surprises. A harsh denunciation of America's failure to confront drug abuse informs the final chapter of Dragon within the Gates. That he would support greater efforts to provide treatment is not so striking. What is notable is the emphasis he places on a vastly increased reliance on the criminal law, including the death penalty, as well as on the use of U.S. military might, in dealing with the drug trade.

All this is strong talk. Like the rest of the book, it will not be to everyone's liking. But it is vintage Joseph.

Ronald Bayer, Ph.D.
Columbia University, New York, NY 10032