U.S. president Ronald Reagan appointed a commission to study and address HIV-AIDS in the United States, but he rejected most of its recommendations. The framework for a national policy was built under his successor, George H. W. Bush, and was expanded under Bill Clinton.
U.S. president Ronald Reagan appointed the Presidential Commission on the Human Immunodeficiency Virus Epidemic (later named the Watkins Commission) on June 24, 1987, which was late in his second term and at least six years into the HIV-AIDS epidemic. His delayed response likely stemmed from his political ideology and practice. The conservative philosophy of the 1980’s delegated domestic issues to the states and localities: the federal government was considered by conservatives to be the problem, not the solution. Thus, for too long, the Reagan administration assumed that states, localities, and charities would shoulder the burdens of HIV-AIDS.
Most critical in retarding any federal action, however, was the evangelical Christian
Yet as much as the White House pretended that the epidemic was not serious, several factors undermined the opportunistic stance of governmental indifference. Personal friends of the Reagans, including actor Rock Hudson and entertainer Liberace, had died from AIDS complications. Their deaths started to change the president’s mind about the disease. There were growing public pressures to do something, even within the Republican Party, Representative Stewart McKinney
When the scope of the catastrophe could no longer be denied, appointees of Reagan, such as Surgeon General
As surgeon general, Koop wielded little actual power, but his recommendations (as well as the predictable conservative chorus in opposition to them) led Reagan and his advisers to appoint the commission with Executive Order 12601 in the summer of 1987. The president’s choice for chair was Watkins, who later admitted to knowing nothing about HIV-AIDS before his appointment. Most of the rest of the commission’s members consisted of scientists and physicians involved in AIDS research and treatment, with a few ideologues thrown in to appease cultural conservatives worried about Koop’s embrace of the use of condoms. Presidential commissions usually are convenient vehicles to table issues until after a term in office has ended, and they rarely lead to radical changes. The Watkins Commission, as this body would come to be known, started out similarly and predictably, and its initial composition offered little comfort to HIV-AIDS activists clamoring for a real, comprehensive effort. The independent and no-nonsense personality of the commission’s chair, nevertheless, came back to haunt those in the administration hoping to prolong the era of malign neglect.
Before issuing its final report on June 27, 1988, the Watkins Commission actually did its homework. It held many hearings and site visits, allowing ordinary people as well as experts to speak truth to power. The commission uncovered frequent instances of irrational discrimination against those who were HIV-positive, discrimination the administration had earlier dismissed. The commission concluded that both ignorance and indifference had accelerated and prolonged the spread of HIV-AIDS. Based upon its investigation of the grassroots, the commission recommended nearly six hundred overdue, specific ways to combat HIV-AIDS, steps that included the establishment of what came to be called the National Commission on AIDS, which was to carry on the presidential commission’s work into the next decade; produce national antidiscrimination legislation; expand drug treatment programs; mandate a “cleaner” national blood supply; and earmark more money for case management and preventive education.
Reagan rejected most of these recommendations in early August of 1988, opting instead for his own scaled-down plan of action. He refused to consider a national antidiscrimination law to protect people with HIV-AIDS. Instead, he ordered that federal employees should not fire or harass other federal employees who had HIV-AIDS but still were able to work. To Reagan, if HIV-positive federal employees could not work, they could be terminated with cause. Private businesses, trade unions, and public schools were asked to follow his functional example voluntarily so that no new federal intrusion into the marketplace would be necessary.
Similarly, Reagan refused to increase funding for drug treatment as recommended by the commission. Reflecting the contempt of social conservatives for what they viewed as a permissive society, Reagan was much more interested in punishing addicts and users in his “war on drugs” than in expanding the drug treatment programs that he believed were “coddling” the offenders. Worried about the “innocent victims” of the epidemic rather than the dreaded higher-risk groups, the president called for better screening of blood and blood products, encouraging people to think about donating their own blood before elective surgery or to have blood available for emergency surgery.
Reagan, and then his successor, Bush, did acquiesce in the formation of a National Commission on AIDS
The commission’s final report, AIDS: An Expanding Tragedy
While the national commission was frequently critical of his policies, George H. W. Bush, however, was more sympathetic toward people with HIV-AIDS than was Reagan at any time. The epitome of noblesse oblige, he endorsed a “kinder, gentler” approach to governing that would be recycled by his son as “compassionate conservatism” ten years later. Unlike his son, fortunately, he would not be held hostage by the tenets of evangelical Christianity. Accordingly, the Bush administration that followed Reagan would construct the basic outlines of AIDS policies that Bill Clinton and George W. Bush would follow, piecemeal compromises that tried to address the still-expanding tragedy without being fully underwritten or increased when necessary.
Most significant was George H. W. Bush’s signing in 1990 of two landmark pieces of legislation that promised to help people with HIV-AIDS: the Americans with Disabilities Act
The Ryan White Act provided federal funds for case management and any FDA-approved drug that patients with HIV-AIDS might require to improve or extend their lives. With Bush’s guidance, Congress then appropriated $220.5 million for the Ryan White programs in its first year, a sum that only scratched the surface in meeting the needs of the many local AIDS service organizations that spent and distributed the money.
Clinton would greatly increase funding for the Ryan White programs, but it would never be enough to keep up with the “expanding tragedy.” As more effective drugs prolonged the lives of those infected after 1996, the emergency nature of the epidemic passed only to reemerge as a chronic sea of poverty that required even more money than the fiscally prudent Clinton was willing to spend.
Also, George H. W. Bush in 1991 signed what would be the groundwork for presidential AIDS policies in two other areas: the Housing Opportunities for Persons with AIDS Act
During the 1990’s, HOPWA funding would wax and eventually wane, but the quick-fix nature of the program was not designed to fix the long-term cultural roots of poverty and their impact on the spread of the epidemic. The Social Security rules allowed HIV-positive individuals without AIDS to qualify for disability benefits. Yet, as the epidemic affected increasingly poor and young members of ethnic and racial minority groups in the 1990’s, those benefits designed for middle-class workers remained elusive or inadequate for the majority of those newly infected.
Presidential AIDS policy on the domestic side really has not gone beyond the reforms of 1990 and 1991. Clinton may have postured to feel the pain better than Reagan and the Bushes, but he left little more than dashed hopes about a more coordinated and comprehensive federal effort. Excitement about new cocktails of drugs in 1996 and 1997 gave way to a resigned sense of complacency by 2000, stymieing any large-scale “Manhattan Project” response to HIV-AIDS long called for by activists and patients. Clinton’s scandals jeopardized any domestic reforms, let alone those that appealed to the poor and marginal.
Finally, international, not domestic, AIDS concerns became preeminent in Clinton’s second term and then under George W. Bush. AIDS was declared a national security threat in 2000, but that failed to generate any more attention to the unresolved crisis in the United States. Indeed, as the costs for the Iraq war mounted in 2004, the first programs to be cut were Ryan White and HOPWA. On the international front, one might hope that enlightened self-interest will continue to increase U.S. funding of HIV-AIDS treatment and prevention in Africa, the Caribbean, and Asia, funding that did increase substantially under Clinton and his successor. Yet given the fitful and incomplete track record of the U.S. government at home in reference to HIV-AIDS, no one should hold their breath.
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Behrman, Greg. The Invisible People: How the U.S. Has Slept Through the Global AIDS Pandemic, the Greatest Humanitarian Catastrophe of Our Time. New York: Free Press, 2004. -
Kaiser Foundation. Kaiser Daily HIV-AIDS Report: AIDS at 20 (June 4-8, 2001). http://www .kaisernetwork.org/dailyreports/aidsat20.cfm. -
Koop, C. Everett. Koop: The Memoirs of America’s Family Doctor. New York: Random House, 1991. -
National Institutes of Health, Archives and Modern Manuscripts Program, History of Medicine Division. Complete listing of the presidential and national commissions’ archival records (Collection no. MS C 544). http://www.nlm.nih.gov/hmd/manuscripts/ead/ncaids544.html#series1. -
Shilts, Randy. And the Band Played On: Politics, People, and the AIDS Epidemic. New York: St. Martin’s Press, 1987. -
Smith, Raymond A., ed. Encyclopedia of AIDS: A Social, Political, Cultural, and Scientific Record of the HIV Epidemic. New York: Penguin Books, 2001. -
Willinger, Barbara L., and Alan Rice, eds. A History of AIDS Social Work in Hospitals: A Daring Response to an Epidemic. Binghamton, N.Y.: Haworth Press, 2003.
June 5 and July 3, 1981: Reports of Rare Diseases Mark Beginning of AIDS Epidemic
July, 1982: Gay-Related Immunodeficiency Is Renamed AIDS
Spring, 1984: AIDS Virus Is Discovered
July 25, 1985: Actor Hudson Announces He Has AIDS
September, 1986: AZT Treats People with AIDS
March, 1987: Radical AIDS Activist Group ACT UP Is Founded
December 1, 1988: First World AIDS Day
July 26, 1990: Americans with Disabilities Act Becomes Law
June 25, 1993: Clinton Appoints First AIDS Czar