Epidemiology of HIV in Intravenous Drug Users and Public Health Policy in Germany

Article excerpt

The paper assesses AIDS and drug policy development in Germany between 1982 and 1996 and relates it to the development of epidemiological research in HIV among injecting drug users (IDUs). In a historical review, this paper outlines how results of epidemiological HIV surveillance studies among IDUs and public health responses were mutually dependent. The authors argue that a specific development in HIV policy encouraged a confounding of basic methodological concepts (validity and precision) in epidemiological research, which in turn led to misinterpretation of available data on seroprevalence trends in Germany. In order to overcome methodological shortcomings under given legal and practical restrictions, pragmatic approaches to increase validity of seroprevalence and risk factor estimations are discussed.

Introduction

In 1987, the Swedish epidemiologist Michael G. Koch published a comprehensive, state-of-the-art treatise on the epidemiological, clinical, and immunological as well as the broader political and public health aspects of the AIDS-epidemic (Koch 1987). Focusing on Germany, Koch's book was well received by many of the leading German AIDS epidemiologists. It was widely viewed by researchers, medical practitioners, and policy makers as a timely and useful guide to this new and puzzling public health challenge. In his summary remarks, Koch drew a doomsday-like picture of the devastating consequences that AIDS could bring to Western Europe if society failed to implement certain repressive, and, from his point of view, necessary, legal and political measures (e.g., mandatory testing, notification and control of seropostive people, and contact tracing).

"Over a longer period of time, this viral disease could prove to be the most effective corrective of unbridled population growth, comparable only to the most devastating famines.... It is not unlikely that, for the first time in the history of mankind, this will slow down the exponential growth of global population in away that will change the representation of different continents and races considerably.... According to this gloomy and doubtless pessimistic scenario, the center of European culture would shift to the east. For many reasons, East-Germany and Czechoslovakia would become the successors of the European tradition and life-style. Prague would become the Paris, Dresden the Frankfurt, Krakow the Vienna and Warsaw the London of this future world" (Koch 1987:245-246, translation by the authors).

The aim of this paper is to selectively chart the development of the relationship between German public health policy and AIDS-related epidemiology, particularly with respect to intravenous drug use.

Koch's summation recalls the atmosphere of 'apocalyptic hysteria' that, often combined with ethnocentric and cold war rhetoric, affected not only politicians and the tabloid press, but also a number of epidemiologists in Germany during the 1980s. Koch's scenario additionally illustrates how some epidemiologists did not restrict themselves to the medical aspects of the epidemic, but also claimed competence in abroad range of legal, social, psychological, and political dimensions of the problem. From today's viewpoint, it is stunning how many articles, written by medical scientists and published in medical journals, dealt with non-medical aspects of AIDS, and did so in a speculative and often patronizing manner1. The striking feature of this development is not that medical scientists took their own stands in a highly emotional debate, but rather that they tended to do so without clearly discriminating their data-based findings from their personal and political Weltanschauungen. A number of epidemiologists gained key positions in directly influencing the process of problem definition and policy formation. Koch, for instance, was appointed official scientific advisor for AIDS by the state government of Bavaria, which, as we will discuss below, played a special role within the German AIDS policy. …