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FATAL EXTRACTION: The Story Behind the Florida Dentist Accused of Infecting His Patients with HIV and Poisoning Public Health, by Mark Carl Rom

by Caitlin Burke

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Dr. David Acer, a dentist practicing in Florida, was diagnosed with AIDS in 1987. He continued to practice dentistry, receiving his medical care in a community some distance from where he practiced. In 1989, a patient of his, Kimberly Bergalis, was diagnosed with AIDS. Denying sexual intercourse, IV drug use, or a history of blood transfusion, Bergalis reported treatment by a dentist whom she believed to have AIDS. Subsequently, several other patients in Acer's practice were found to be infected with HIV, and genetic sequencing showed that the viruses they carried were exceptionally closely related -- more or less confirming that Acer was the source of infection. The Bergalis family went on to wage a bitter and very public battle for mandatory testing for all health care workers, arguing that every patient had a right to know his or her doctor's HIV status.

Mark Carl Rom was the principal investigator for the General Accounting Office's investigation of the Centers for Disease Control's handling of this case, and in Fatal Extraction: The Story Behind the Florida Dentist Accused of Infecting His Patients with HIV and Poisoning Public Health, he revisits the case as an example of the creation of public health policy. His careful and thoughtful discussion of difficult and complex issues makes a highly accessible introduction to the often obscure activities of government regulatory agencies.

Although many dozens of health care workers have been infected with HIV in the course of caring for infected patients, there is no documented case of transmission from a health care worker to a patient other than the Acer case. The risk of provider-to-patient transmission of infectious diseases remains relevant, of course; hepatitis is highly transmissible, for example, and waiting for the next provider-to-patient transmission of HIV risks confirming the Bergalis family's claims that the government "stood by not doing a damned thing" to protect patients from infected providers. Mark Rom's Fatal Extraction traces what the government did do, both before and after the Acer case -- the development of policies by numerous agencies, the variety of procedures by which they developed and distributed their rules, and the different levels of authority and enforcement the rules could expect.

Noting that there were excellent books about how courts and Congress make law, Rom originally sought to create materials for a class to discuss the way regulatory agencies arrive at rules. This project grew into a book that neatly connects with both popular and public health audiences. Introducing the scientific and medical issues in an easy, conversational style, Rom then offers a very focused analysis of the public policy issues that arose in the Acer case.

The questions are important and are fairly discussed. Does a patient's right to informed consent encompass knowledge of a health care worker's HIV status? Where does informed consent meet a health care worker's right to confidentiality of medical information? Who determines which procedures are "exposure-prone"? How can governments respond to patients' fears and prejudices without creating policies that are themselves based on fear and prejudice? Ultimately, Rom argues that this is a good time to assess the numerous and conflicting approaches that were put forward in response; it's long enough after the fact that some of the emotion has dissipated and more data and experience have accumulated -- and yet still before another such case has been documented.

Fatal Extraction is a surprisingly readable book. Although it serves up a healthy dose of terminal illness and media-enhanced scandal, its focus is on large-scale government-agency attempts to represent epidemiologic information fairly in public health rules. The style is sometimes a little too conversational, but the book is certainly easy to follow and careful in its navigation of bureaucracy and the political pressures on health issues. Fatal Extraction is a useful and appealing contribution both to the study of AIDS and to the study of public health in general.

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