evidence for poor interviewing, the importance of good interviewing skills, and learning good interviewing. When I initially read the book, I felt that this was an outstanding book for medical students and residents. But upon reflection, it would be a good book for those of us in general and family practice, and for all physicians to review their interviewing techniques, and should provide a mechanism for better communication between the patient and the physician.
Professor R. Gerard College of Human Medicine
Michigan State University East Lansing, Michigan, U.S.A.
Brookings Dialogues on Public Policy. Toward a National Policy on Drug and Aids Testin By M. Falco and W. Cikins ( l? ds.) The Brookings Institution, Washington DC, 1989 81 pp., ISBN 0-8157-2733-X. $12.95.
This volume is the product of two Brookings conferences on drug and AIDS testing, at which the participants addressed themselves to the ever-increasing political pressure and public fear created by the spread of AIDS and the (ab)use of illicit drugs in the USA.
On tirst reading the title Toward a National Policy on Drug and AIDS Testing it might seem unreasonable to combine an epidemiological public health issue with the sociopolitical problem of increasing drug (ab)usage. Yet as one begins to consider the wider policy implications of mandatory testing for either HIV antibodies or drug metabolites, one appreciates that coercive testing for either inevitably overrides fundamental individual rights. Consequently any such testing programmes must share certain policy issues.
In the first chapter, Mathea Falco introduces some of the topics on which the conference discussions focused. These she divides into two broad groups: the Zero-tolerance argument which condemns any illicit drug use and any sexual activity outside a strictly monogamous marriage; and the Differentiated tolerance argument which distinguishes among behaviour and seeks to protect individual rights as well as public health. After this introductory chapter three further authors present a review of the considerations of particular groups of panellists focusing in turn on the medical, private, and political implications of mandatory HIV testing.
June Osborne begins her review of the medical considerations of drug and HIV antibody testing by outlining the parameters within which a programme of diagnostic HIV tests and drug detection tests should be set. It was agreed that without clarity of purpose such tests could have a negative effect on public and individual well-being. Therefore, the primary goals of any testing programme must include behaviour modification through counselling and access to rehabilitation treatment for drug abusers. The collection of epidemiological data should always play a secondary role. Extensive, accessible and compassionate counselling must be inextricably linked to any mandatory testing, since. without it testing would become a counterproductive mechanism for the control of AIDS or drugs abuse.
Osborne goes on to provide a brief history of HIV in the USA as well as a summary of the modes of HIV transmission. Transmission is the key issue which has linked HIV and drugs, since it has been recognised that the sharing of needles in intravenous drug use provides one of the major infection routes. The panellists therefore discussed in some detail the nature of this transmission route and the extent to which drug detection testing could reduce its impact.
Russel Iulculno of the American Council for Life Insurance reviews the private sector discussions on Drug and HIV testing. The debate here focuses on the role of markets. On the whole, insurers
feel justified in using tests as a means risk classification, yet many also accept the role of insurers as a social utility. guaranteeing access to medical and financial support. A further section of the private sector review concentrates on the use of mandatory drug testing in the work place. A range of possibilities is presented and discussed, including pre-employment testing, random in-service testing and testing only on the grounds of impaired performance. The panel addressed itself also to the problem of confidential handling of test results and to the need for positive assistance in the form of counselling and rehabilitation in the case of positive test results.
In the Enal section Norman Zinberg summarises some of the major political issues raised by mandatory testing. He focuses particularly on the growing hysteria about contagion and risk, bred largely of misinformation. He seeks to make positive distinctions between AIDS and seropositivity and between various drug groups. While accepting that a link between AIDS and drugs exists, Zinberg stresses that the two are not necessarily linked. He goes on to elucidate and evaluate the question of false positives and negatives which would inevitably increase in any mandatory testing programme.
As a whole, the collection provides an ideal starting point for any discussion in the policy issues of HIV and drug testing, since most of the important questions are raised. Occasionally, however, the authors summsrised and condensed the proceedings of the Brookings conference to the point of inaccuracy. This is particularly evident in the often indiscriminate variation between the terms AIDS and HIV, and the generalised use of the word drug, rather than the name of a specific drug.
Mrs. P. Wilson Centre for Socio-legal Studies
Oxford University Oxford, United Kingdom