Anna Farago

January 29, 1999

With the publication of her thesis, entitled AIDS, Tuberculosis, and the Public Policy of Infectious Disease, Sally Heymann received a Ph.D. in Public Policy from Harvard University in 1992. The thesis begins by recounting the history of public policy measures taken to combat sexually transmitted diseases (STDs) and Tuberculosis (TB) in the United States. It then addresses the current state of infectious disease control, investigating methods of curbing the spread of AIDS and TB in the United States and Africa. The author focuses her discussion of AIDS on analytical tools which can be used to weigh the risks and benefits, from both individual and community perspectives, of a blood transfusion. She also addresses the rising incidence of disease disease interactions, specifically between AIDS and TB, and how policy makers must develop an awareness of an increasingly multi-tiered problem. Heymann concludes that because community needs and conditions are vastly different all over the world, health workers and policy makers should utilize mathematical models to determine the appropriate strategies for controlling infectious diseases.

As part of the introductory section, the author describes the history of STDs in the United States, using syphilis and TB as her main examples. The discussion focuses on societal reactions to the spread of the diseases. Giving thoughtful examples to guide the reader, Heymann works through a range of societal effects. She describes the perceived contrast between "innocent" and "guilty" victims of syphilis (depending on how it was acquired) and the varying treatment given to the two groups. Furthermore, she indicates the ways that social class and race also contributed to the treatment of infected people. In a clear and insightful progression of thought, Heymann then explains how these factors affected the shaping of policy measures, debated from both moral and medical perspectives, taken to contain diseases. This section of the thesis is quite strong; it provides a thorough and objective analysis of historical public policy approaches to infectious disease control. Additionally, she makes an interesting connection by drawing explicit parallels between the societal responses to syphilis in the early half of the century and current reactions to AIDS.

With this historical backdrop, Heymann then approaches questions of disease control in the present day. Unfortunately, because the text is seven years old her analysis of the spread of AIDS is quite outdated. Therefore, the statistics and mathematical predictions she provides cannot be used in a discussion of the current state of AIDS. However, from a qualitative perspective, Heymann's approach is interesting. Considering Africa in one chapter and then the United States in the next, she exemplifies the differences between the two contexts and why these differences should be recognized. For example, in Africa the need for blood transfusions is much higher than in the US because of the prevalence of anemia, but due to the lack of resources in many parts of Africa, blood donors are much less likely to be accurately screened for AIDS. Therefore, Heymann predicts that individuals weighing the decision of whether to receive a transfusion must also account for the likelihood of acquiring an infectious disease depending on the source of the donated blood. The contents of the donated blood should also be considered; multiple donors contribute to a unit of clotting factors, whereas only one donor provides blood needed for erythrocyte replenishment. Heymann's complexity of analysis stands in contrast to traditional reactions of health professionals, who often respond to the threat of disease spread by simply decreasing the frequency of transfusions across the board. Thus, the methodology used in this section is useful for understanding how to logically and rationally approach disease control.

Heymann then moves from the individual's decision to the impact on their larger society. Using TB as an example, she demonstrates that the spread of secondary infections is associated with rising rates of autoimmune diseases. In her discussion of treatments for TB in the context of AIDS, Heymann successfully describes the moral debate between the benefits to society and the rights of individuals and how these factors contribute to the shaping of public policy. As was the case with syphilis, she again shows that social class and race contribute to unequal levels of treatment. Although the qualitative discussion in this section is useful, as it is in the last, Heymann falls short of actually proposing policy measures that can be taken to address the current disparities. Because her discussion of the current problem and the complexity of considerations is so complete, Heymann's lack of any conclusive proposals is slightly disappointing. However, she acknowledges that the complexity is too overwhelming to be handled in any singular policy measures by instead concluding that health care professionals must account for all factors contributing to the individual and societal consequences of treatment before making a recommendation in any given situation.

The strength of this thesis lies in the thoroughness with which Heymann investigates the historical considerations and contexts that factored into the formation of public health policies. The true insights behind her analysis are the parallels that she draws both explicitly and implicitly between historical situations and the methods by which disease control is accomplished in the present day. In this manner, Heymann reveals the ways that discrimination continues to plague the formation of policy surrounding the current AIDS crisis. Unfortunately, because of its age this thesis will be of little help to people looking for statistics describing AIDS and TB. However, as a discussion of the ways that individual and societal reactions to a disease affect methods of treatment and control, this text offers a series of concise examples that are pulled together into a clear, well-written analysis of public health policy.

Source Used:

Heymann, Sally J., AIDS, Tuberculosis, and the Public Policy of Infectious Disease Control (Ann Arbor, MI: University Microfilms International Dissertation Services, 1992).