1. “Bureaucracy” in From Max Weber, Gerth, H. H. and Mills, C. Wright, eds. (New York, 1946), 196–244Google Scholar.

On state autonomy, see Block, Fred, “The Ruling Class Does Not Rule: Notes on the Marxist Theory of the State,” Socialist Review 33 (1977): 6–28Google Scholar; Dahrendorf, Ralf, Class and Class Conflict in Industrial Society (Stanford, Calif., 1959)Google Scholar; Miliband, Ralph, The State in Capitalist Society (New York, 1969)Google Scholar; Poulantzas, Nicos, Political Power and Social Classes (London, 1976)Google Scholar; Poulantzas, Nicos and Miliband, Ralph, “The Problem of the Capitalist State,” in Blackburn, Robin, editor, Ideology in Social Science: Readings in Critical Social Theory (New York, 1973), 238–62Google Scholar.

On state-centered theory, see Evans, Peter, Rueschemeyer, Dietrich, and Skocpol, Theda, eds., Bringing the State Back In (Cambridge, 1985)Google Scholar; Heclo, Hugh, Modern Social Politics in Britain and Sweden (New Haven, 1974)Google Scholar; Krasner, Stephen, Defending the National Interest (Princeton, 1978)Google Scholar; Nordlinger, Eric, On the Autonomy of the Democratic State (Cambridge, Mass., 1981)Google Scholar; and Sacks, Paul, “State Structure and the Asymmetrical Society,” Comparative Politics 12(3): 349–76Google Scholar.

2. I will use the term “policy experts” throughout this article to refer to the physicians, epidemiologists, policy wonks, and public health officials charged with designing and implementing federal, state, and local public health policy. Their “expertise” is to be contrasted with that of activists, politicians, private physicians, journalists, and lay people, all of whom may have strongly held opinions on policy matters but lack the credentials, technical knowledge, and/or institutional position of their “expert” counterparts.

3. Peter Hall, “Policy Paradigms, Social Learning, and the State: The Case of Economic Policymaking in Britain,” Comparative Politics 25: 278.

4. See Colin J. Bennett and Michael Howlett, “The Lessons of Learning: Reconciling Theories of Policy Learning and Policy Change,” Policy Sciences 25: 275–94; and May, Peter J., “Policy Learning and Failure,” Journal of Public Policy 12(4): 331–54CrossRefGoogle Scholar, for reviews of different approaches to “social learning” in policy studies.

5. March, James G. and Olsen, Johan P. voice a similar opinion in “The New Institutionalism: Organizational Factors in Political Life,” American Political Science Review 78(3): 734–49CrossRefGoogle Scholar.

6. Several pieces by Allan M. Brandt address this issue. See Nu Magic Bullet: A Social History of Venereal Disease in the United States Since 1880 (New York, 1985)Google Scholar; “AIDS in Historical Perspective: Four Lessons from the History of Sexually Transmitted Diseases,” American Journal of Public Health 78(4): 367–71Google Scholar; and “Syphilis and Its Relation to AIDS,” Science 239: 375–80. See also Fox, Daniel M., “Social Policy and City Politics: Tuberculosis Reporting in New York, 1889–1900,” Bulletin of The History of Medicine 49(2): 169–95Google Scholar, and idem, “From TB to AIDS: Value Conflicts in Reporting Disease,” Hastings Center Report (December 1986): 11–16.

7. The following authors are among those who emphasize the role of political activism in the AIDS policymaking process: Bayer, Ronald, Private Acts, Social Consequences: AIDS and the Politics of Public Health (New York, 1989)Google Scholar; Richard Restak, “Worry About Survival of Society First; Then AIDS Victims' Rights,” Washington Post, 8 August 1985; Shilts, Randy, And The Band Played On: Politics, People, and the AIDS Epidemic (New York, 1987)Google Scholar; and Helen Mathews Smith, “The Deadly Politics of AIDS,” Wall Street Journal, 25 October 1995.

8. Panem, Sandra, The AIDS Bureaucracy (Cambridge, Mass., 1988)Google Scholar, and Perrow, Charles and Guillen, Mauro, The AIDS Disaster: The Failure of Organizations in New York and in the Nation (New Haven, 1990)Google Scholar, examine the impact of organizational structure on the public health system's response to AIDS.

9. The role of policy experts in health-care policy and public health policy should be differentiated here. In the domain of health-care policy, doctors can hardly be considered “policy experts,” given their general lack of administrative and legislative experience at the public level. In the public health system, on the other hand, doctors and scientists are specially trained to be public administrators and policy analysts. The dilemmas of the AIDS crisis point to the need for more serious inquiry and analysis of the public health system as a “policy domain” in its own right, distinct from that of the health-care system.

10. AIDS policymakers have also had to consider several other preventive issues, such as intravenous drug use, intrauterine transmission, prostitution, and the prison population; however, I will not discuss them in detail here. Cases were chosen from local, state, and federal policymaking domains so that the role of the United States public health system's highly decentralized organizational structure could be factored into the analysis.

11. In support of this argument, see Patton, Cindy, Sex and Germs: The Politcs of AIDS (Boston, 1985)Google Scholar; and Patton, , Inventing AIDS (New York, 1990)Google Scholar.

12. Friedman, Lawrence M., The Republic of Choice: Law, Authority, and Culture (Cambridge, Mass., 1990)Google Scholar; and Skrentny, John David, The Ironies of Affirmative Action (Chicago, 1996)Google Scholar.

13. The courts and Congress have passed a number of measures to protect Persons With AIDS (PWAs) from discrimination. In Arline v. School Board of Nassau County (772 F. 2d 759 [11th Cir. 1985]), the courts extended section 504 of the Federal Rehabilitation Act of 1973 (29 U.S.C. Sect. 794), which protects the handicapped from discrimination, to protect PWAs (and people with infectious diseases in general) from exclusion from jobs, school, etc., without sufficient medical justification. Furthermore, the 1990 Americans With Disabilities Act explicitly extends antidiscrimination protection to Persons With AIDS.

14. Two landmark cases in this vein are O'Connor and Donaldson, 422 U.S. 463 (1975), and Jacobson v. Massachusetts, 197 U.S. 11 (1905).

15. Larry Gostin and William J. Curran, “The Limits of Compulsion in Controlling AIDS,” Hastings Center Report (December 1986): 24–29; idem, “Legal Control Measures for AIDS: Reporting Requirements, Surveillance, Quarantine, and Regulation of Public Meeting Places,” American Journal of Public Health 77(2): 214–18; Mohr, Richard D., “Policy, Ritual, Purity: Gays and Mandatory AIDS Testing,” Law, Medicine, and Health Care 15(4): 178–85Google Scholar; Osborn, June, “HIV Antibody Testing Uses and Limitations,” in Abt, Clark C. and Hardy, Kathleen M., eds., AIDS and the Courts (Cambridge, Mass., 1990), 45–53Google Scholar; and Rabin, Judith, “The AIDS Epidemic and Gay Bathhouses: A Constitutional Analysis,” Journal of Health Politics, Policy, and Law 10(4): 729–47Google Scholar.

16. Bowers v. Hardwick, 106 S.Ct. 2841.

17. Bayer, Private Acts, Social Consequences; Gould, Peter, The Slow Plague: A Geography of the AIDS Pandemic (Oxford, 1993)Google Scholar; Restak, “Worry About Survival of Society First”; Smith, “The Deadly Politics of AIDS.”

18. Randy Shilts conveys a strong sense of the conflict and controversy within the gay community over AIDS policy issues in And the Band Played On.

19. Not surprisingly, this finding is in accord with Gamson's comparative study of the success and failure of various social movement organizations, The Strategy of Social Protest (Homewood, Ill., 1975)Google Scholar.

20. In an analysis not included in this article, the general level of gay activism regarding AIDS was measured in New York City and San Francisco via a comparative search of the annual indices of the New York Times and the San Francisco Chronicle. Both indices were searched yearly under the headings “Demonstrations-Protests,” “Homosexuality,” and “AIDS.” Although the level of AIDS protest activity varied between the two cities, both experienced a general increase in AIDS-related activism after 1985.

21. Another relevant feature of the organizational structure of health services in the United States is the decentralized structure of medical and social service organizations. AIDS can be a long and debilitating disease, usually ending in death. This makes access to a wide range of services and subsidies essential for many PWAs. However, these services are provided by a bevy of uncoordinated governmental and nonprofit agencies, ranging from the Social Security Administation to local Meals-on-Wheels programs, which can greatly complicate an AIDS patient's efforts to seek out such services. Accessibility might be enhanced under a more centralized system.

22. The relationship between local and state-level authorities varies from place to place, however. New York City, for example, ceded responsibility for several public health functions to the state health department following the intense fiscal crisis of the 1970s. On the institutional structure of state and local health-care organizations in New York State, see Imperato, P. J., The Administration of a Public Health Agency (New York, 1983)Google Scholar.

23. Wing, Kenneth R., The Law and the Public's Health (Ann Arbor, Mich., 1985)Google Scholar.

24. Burstein, Paul, “Policy Domains: Organization, Culture, and Policy Outcomes,” Annual Review of Sociology 17 (1991): 327–50Google Scholar; Kaufman, Herbert, “The Political Ingredient of Public Health Services: A Neglected Area of Research,” reprinted in McKinlay, John B., ed., Politics and Law in Health Care Policy (New York, 1973)Google Scholar; and Kingdon, John W., Agendas, Alternatives, and Public Policies (Boston, 1984)Google Scholar.

25. Shilts, And the Band Played On, 18.

26. Gostin and Curran, “Legal Control Measures for AIDS,” 216.

27. John C. Cutler and R. C. Arnold, “Venereal Disease Control by Health Departments in the Past: Lessons for the Present.” American Journal of Public Health 78(4): 372.

28. Rabin, “The AIDS Epidemic and Gay Bathhouses”; Carol Levine and Joyce Bermel, eds., “AIDS: Public Health and Civil Liberties,” Hastings Center Report: Special Supplement (December 1986): 1–36.

29. Prior to the war, there was no systematic federal policy regarding venereal disease.

30. Brandt, No Magic Bullet, 84–92.

31. At present, twenty-four states, Puerto Rico, and the District of Columbia still require blood tests for venereal disease prior to marriage. (See “Marriage Laws,” The World Almanac [New York, 1995]: 727Google ScholarPubMed.) However, New Jersey public health officials have recently suggested eliminating its premarital testing law, arguing that it is “an anachronism.” (“Opposing a Blood Test,” New York Times, 19 September 1996.)

32. Brandt, No Magic Bullet, 142–54.

33. “Case Finding in the Control of Syphilis,” American Journal of Public Health 36(1946): 529Google Scholar. (The author's name is not given.)

34. Sylvester W. Trythall, “The Premarital Law: History and a Survey of Its Effectiveness in Michigan,” JAMA 187(12): 901. The author maintains the value of the invasive paradigm nonetheless, arguing that premarital blood testing provides a much needed opportunity for marital counseling, “a valuable aid in establishing a harmonious family situation.”

35. Felman, Yehudi M., “Should Premarital Syphilis Serologies Continue to Be Mandated by Law?” JAMA 240(5): 459–60CrossRefGoogle ScholarPubMed.

36. Daniel L. Wikler, “Persuasion and Coercion for Health: Ethical Issues in Governmental Efforts to Change Life-Styles,” Health and Society 56(3).

37. In an analysis not included in this article, all articles on syphilis testing policy published in the American Journal of Public Health between 1946 and 1970 were examined for their relative position on mandatory testing. While there was a minor resurgence in support for invasive testing policies between 1955 and 1965, the majority of articles expressed doubts about the justifiability of such measures. Nonetheless, the absence of articles supporting mandatory testing may simply reflect the fact that such measures were already in effect in many states.

38. Cited in Shilts, And the Band Played On, 379.

39. “Integrating the Public Health, Medical, and Legal Responses to AIDS,” in Abt and Hardy, AIDS and the Courts, 68.

40. Epstein, Steven, Impure Science: AIDS, Activism, and the Politics of Knowledge (Berkeley and Los Angeles, 1996)Google ScholarPubMed.

41. Neustadt, Richard E. and Fineberg, Harvey V., M.D., The Swine Flu Affair: Decision-Making on a Slippery Disease (Washington, D.C., 1978)Google Scholar; Wecht, Cyril H., “The Swine Flu Immunization Program: Scientific Venture or Political Folly?” reprinted in Hogue, L. Lynn, ed., Public Health and the Law (Maryland, 1980), 177–89Google Scholar.

42. Given individuals' unpredictable reactions to vaccinations, liability suits can be a particularly costly part of distributing new vaccines. Private drug manufacturers were reluctant to provide the vaccine for exactly this reason.

43. Neustadt and Fineberg, The Swine Flu Affair, 97; iv.

44. Another important detail of Sencer's career is worth mentioning: while working at the CDC (before the Swine Flu incident), Sencer presided over an internal investigation of the Tuskegee syphilis trials, a now infamous program whereby a number of African American syphilis patients were left untreated in order to study the debilitating effects of the disease over time. When the trials eventually came to the public's attention, they created an uproar of sentiment against experiments which, though not scientifically irrelevant, were racially tinged and in such clear violation of patients' rights. Although Sencer himself was not responsible for the Tuskegee experiments, his experience on the investigating panel may have honed his fear of invasive procedures and bad publicity.

45. Shirts, And the Band Played On, 379.

46. Bayer, Private Acts, Social Consequences, 234–235.

47. Centers for Disease Control, “Update on Kaposi's Sarcoma and Opportunistic Infections in Previously Healthy Persons—United States,” Morbidity and Mortality Weekly Report 31:300–301.

48. In The AIDS Bureaucracy, Sandra Panem suspects that Weiss and Waxman were on a witch-hunt, looking for CDC scapegoats to blame for the epidemic (31–35).

49. Shilts, And the Band Played On, 311–12, 322.

50. Gostin and Curran, “The Limits of Compulsion”; Gostin and Curran, “Legal Control Measures”; Rabin, “The AIDS Epidemic and Gay Bathhouses.”

51. In time there was an ideological split among gay activists over the best way to deal with them. Within San Francisco's population of politically active gay men, those loyal to the vision of former gay activist Harvey Milk wanted to alert the gay community to the dangers of unprotected sex and close down the bathhouses. Members of the Alice B. Toklas Memorial Democratic Club, on the other hand, took a more moderate approach, arguing that advocacy for bathhouse closures was akin to submitting to homophobia and would help kill the gay liberation movement. By the summer of 1983, much of San Francisco's gay community was split over the issue: either you were a “sexual Nazi” committed to suppressing gay men's freedom of sexuality, or you were a “know-nothing,” proverbially playing Nero's fiddle while Rome burned. For more detail on the controversy see Shilts, And the Band Played On, 278–80.

52. Bayer, Private Acts, Social Consequences, 34. Bayer's observations are based on personal interviews with Dr. Silverman and other public health officials about their experiences during the first decade of the AIDS epidemic. Nonetheless, Bayer, himself a professor of public health, appears to be a colleague and friend of many of the public health officials discussed in his book, which may have biased his observations somewhat. His account of the AIDS epidemic generally tends to extol the wisdom of policy experts and blame the reactionary efforts of gay activists and health-care administrators.

53. Ibid., 38, 54 (emphasis added).

54. Ibid., 51.

55. Shilts discounts the results of this latter study on account of the fact that it was partially funded by the Northern California Bathhouse Owners Association, a lobby group vociferously opposed to the closures. And the Band Played On, 532. Darrow study cited in Bayer, Private Acts, Social Consequences, 43.

56. Cited in Bayer, Private Acts, Social Consequences, 33.

57. Ibid., 39.

58. For contrasting accounts of the San Francisco bathhouse controversy, see Shilts, And the Band Played On, 489–91, 498–99; and Bayer, Private Acts, Social Consequences, 31–53.

59. Maurice Carroll, “State May Shut Bathhouses in Drive to Combat AIDS,” New York Times, 24 October 1985, B3.

60. “Schools and Transit Are Among the Topics of Mayoral Debate,” New York Times, 25 October 1985, B6.

61. “N.Y. Health Chief Resigns in Dispute over AIDS,” San Francisco Chronicle, 3 December 1985, 31.

62. “Two Cities Consider a Bathhouses Ban,” New York Times, 22 November 1985, B13.

63. E. R. Shipp, “Concern over Spread of AIDS Generates a Spate of New Laws Nation wide,” New York Times, 26 October 1985, 1.

64. Some researchers still dispute the role of HIV in AIDS. For more specific sociological accounts of the “discovery” of AIDS, see Epstein, Impure Science, and Patton, Inventing AIDS.

65. Bayer, Private Acts, Social Consequences, 80.

66. “Prevention of Acquired Immune Deficiency Syndrome (AIDS): Report of Inter- Agency Recommendations,” Morbidity and Mortality Weekly Report, 4 March 1983, 32 (8): 100–102Google Scholar.

67. Shilts, And the Band Played On, 307–9. Dr. Edgar Engleman, medical director of the Stanford blood bank, was himself a specialist in the AIDS-related field of helper and suppressor lymphocytes, and Stanford had recently purchased a machine suitable to running appropriate tests.

68. Papers cited in ibid., 410.

69. Bayer, Private Acts, Social Consequences, 91.

70. Ibid., 96.

71. Shilts, And the Band Played On, 433.

72. Bayer, Private Acts, Social Consequences, 87.

73. Shilts, And the Band Placed On, 521.

74. Ibid., 542–43.

75. Bayer, Private Acts, Social Consequencies, 191–99.

76. Cited in ibid., 120.

77. Ibid., 201.

78. Ibid., 134.

79. Needless to say, medical opinion was not unanimous on this issue. Some members of the American Medical Association proposed a resolution in December 1985 recommending that “each of our 50 states encourage introduction of legislation” to require HIV tests for all couples seeking a marriage license. This resolution did not pass, however, and it seems safe to say that most public health officials and medical scientists felt that mandatory testing was ill-advised. (“A.M.A. to Debate AIDS Test,” New York Times, 9 December 1985.)

80. Much of this testimony is reviewed and summarized in United States Congress Committee on Small Business, 100th Congress, “Hearing Before the Subcommittee on Regulation and Business Opportunities on Quality AIDS Testing,” Serial No. 100–32 (Washington, D.C., 1988).

81. Mary A. Dempsey, “AIDS Hearing Does Not Sway Lawmakers,” Lansing Window, 7 June 1986.

82. To my knowledge, premarital HIV testing has never been put into effect in Texas. Phone calls to several Texas AIDS-information hotlines and legal advice centers, as well as to the National Conference of State Legislatures (Denver) failed to provide any definitive response, but no one said they knew of such a policy ever having been put into effect in the state.

83. Ann M. Wolfe, “Fifty State Survey of State Statutes Concerning Venereal Disease As It May Relate to AIDS,” Congressional Research Service (Microfilm, 1987–88), Reel 10: 0109.

84. “Illinois Legislature Passes Several Bills on AIDS, Including Testing of Couples to Be Married,” Chicago Tribune, 1 July 1987, 1:10.

85. “Marriage License Applicants Cross State Line Because of New Illinois Law Requiring AIDS Testing,” Chicago Tribune, 5 February 1988, 2:1.

86. Osborn, “HIV Antibody Testing Uses and Limitations,” 45–53.

87. Some states do permit mandatory HIV testing under other circumstances, however, such as arrest for sex crimes or application for private health insurance.

88. Haider-Markel, Donald P. and Meier, Kenneth J., “The Politics of Gay and Lesbian Rights: Expanding the Scope of the Conflict,” Journal of Politics 58(2): 332–49CrossRefGoogle Scholar.

89. Simon, Herbert, Administrative Behavior (New York, 1945), 186Google Scholar.