The Rich Nation Person With AIDS heals in his bed. He is of course white, middle-class, and educated. We see him as an American, though he might also be European or Australian. He's probably a gay man, but the scene works just as well for a woman or a straight man. Expensive triple-combination medications are at hand to keep down, or perhaps annihilate, the virus. To help pass the time there is a television set, a laptop computer, books, and newspapers. He can keep in touch with friends by phone, and these same friends have sent him cards, flowers, and a teddy bear to cheer him up. He is well-fed, well-loved, well cared for, and has every hope of resuming a long and productive life.

Also in the room (the world) is the Poor Nation PWA: ill-housed, badly doctored, ignored, and quickly dead.

The only misleading aspect of this excellent cartoon is that it shows only one roommate. To rightly represent the real condition of AIDS in our time, there should be about fifty roommates: perhaps thirty-five Africans, thirteen Asians, and two Latin Americans, all of them strewn about the floor moaning and rotting, much as in that Atlanta field hospital scene in Gone With the Wind. Now that is something truly to depress one.

The cartoon puts this question: "Hey, 'AIDS expert', the guy in the Rich World AIDS Ward is doing very well indeed, and really doesn't need your help anymore; so where are you going to put your talent and energies?"

Where, indeed, should a well-meaning 'AIDS expert' put his energies? It seems there are four choices, arguments for each of which I present below:

(A) Help the poor roommate(s). "Surely it's righteous thing, the moral thing, the obvious thing, to help fifty poor people instead of one rich one! Take your AIDS skills wherever you can do the most good- if you're Latino, go work in Mexico City. If you're Filipino-American, they could really use your expertise in Manila. Even if you're a white boy who only speaks English, you wouldn't be out of place in southern Africa. There's a crying need to get policymakers educated, outreach workers trained, rural clinics established... And if you're too timid to do God's work among the wretched of the world, you can at least send money. Just think how far the proceeds of one AIDS Walk, one Dance-a-Thon, one Stop AIDS Project fundraiser, would go if spent in Harare or Lusaka!"

(B) Keep fighting HIV just as before. "Oh no, the guy in the bed does still need your help. AIDS isn't over yet, even here. The combination drugs may be working now, but HIV is constantly mutating, and it'll probably overcome those antiviral drugs, and we'll be right back where we started! Also, new infections are happening all the time- forty thousand in the U.S., and five hundred here in S.F., every year. That's a potential Vietnam-War's worth of American dead every couple of years, on and on, until we get a lot better at doing HIV prevention."

(C) Shift the fight to the new virus. "HIV may be on the wane, but that's only because it's so hard to transmit. Suddenly we have hepatitis C, easily transmitted and already infecting four or five times as many people. And what if there's an epidemic of an Ebola-type virus, or an airborne form of HIV? We've got to teach everyone in any of those 'risk groups' to be absolutely, 100% committed to safe practices-- it's condoms and clean needles for a lifetime! We must always keep faith that public health education will lead to better personal hygiene, less substance abuse, healthier diets, regular exercise, and other good things that'll prevent diseases known and unknown, and that a dollar of that education is worth ten dollars of hospitals and doctors to treat the diseases."

(D) Help the guy get his life back. "That guy in the hospital bed is a gay middle class American just like you. He thought he was sure to die, and had given up on everything. Now he needs to put his life back together, starting with a job and a career. Help him rebuild his life; help him reconnect with the gay community. Above all, help him regain the sense of freedom and exuberance we all had before the Age of AIDS. Anything you can do to rebuild the cohesion and esprit and poetry of the gay community will help."

So, what's the right choice among these four forks in one's "career road"?

In my essay "The Cultural Evolution of AIDS Agencies" (MidCity Numbers, September 1996) I described the fourth and final stage of agency evolution: "Agencies are created to respond to a problem. When that problem is past its peak and when (somewhat later) funds to deal with the problem also peak out and begin declining, an age of decay sets in."

I am convinced that the Decadent Age for AIDS agencies in America cannot be far off. Therefore, I reject choice (B), "Keep fighting HIV just as before", for my own working life. I do not want to be part of an agency where "employees with talent or imagination are long gone [and where] the remaining staff can often do their day's work with amazing efficiency [leaving] plenty of time to get personal tasks done and to comment on the world with acerbic wit." Plenty of worthwhile work remains to be done- but creative, imagination-challenging work? I doubt it. Not for me a comfortable future in the AIDS Industry, "overpaid, underworked, and rested".

I'm pretty sure I'll also reject choice (A), "Help the poor roommates", even though my Benthamite heart aches for the greatest good for the greatest number. It smacks of the White Man's Burden, which nowadays takes the form of sincere efforts to help the Third World but which actually make things worse. We have already chalked up many disasters along the line of translating, wholesale, tactics that work in one culture (for example, frank explicit talk about male-male sex) into another culture where they backfire. Just sending money is no better: in places like Russia or Nigeria, it simply disappears.

That leaves choices (C), "Shift the fight to the new virus", and (D), "Help the guy get his life back". My inclination is toward the former. I think a new MidCity Numbers: A Monthly Bulletin of HCV-Related Statistics could do a world of good. I also think that sometime in 2001 or 2002, there will be a sea-change in attitude in the American public, whereby it will suddenly become more keen to hear about hepatitis-C than about AIDS.

The one reservation I have with choice (C) is that the fight against HCV will be tougher to win because so much higher a standard of "safe behavior" is needed. We beat HIV among local injection drug users because they were enabled to reduce unsafe practices by maybe 80%. Do I have the stamina to stick with the campaign until unsafe IDU practices are down by the 95%-98% that's required? I'm not confident that I do. Perhaps after sixteen years in the fight against HIV, and twenty-seven years working to help people overcome substance abuse, it's time for me turn away from the work of helping sick people get healthy, and try my hand at helping healthy people get healthier.

(MidCity Numbers, December 1998)