"There have been as many plagues as wars in history; yet always plagues and wars take people equally by surprise." -- from "The Plague," by Albert Camus

As the local AIDS case-count shot past 1,000 last winter, District Public Health Commissioner Reed Tuckson decided it was time once again to read Camus' classic 1947 novel about an Algerian town's struggle against the bubonic plague.

The book's lesson, Tuckson said, is that while life goes on even in the face of calamity, "all issues come to be discussed in the context of the plague."

It will be the same with AIDS, he said, for the rest of the century.

"No other issue presents us with more challenges that get at the very heart of what kind of people we are," said Tuckson. "When the history books are written, AIDS will define this era." ::

It is here in the nation's capital that policy regarding AIDS will be shaped for the next decade. And at the same time, this city faces the epidemic on a much more personal level, as the virus continues its march through the city's people and its neighborhoods.

On any given day now, there are about 30 patients with AIDS in George Washington University Hospital, up from 20 a year ago.

In one recent evening, Georgetown University Med- ical Center's outpatient AIDS clinic saw 26 patients -- the sick along with the "worried well" -- more than in the entire month of last July.

Five babies a month are born at Howard University and D.C. General hospitals to mothers known to be infected with the AIDS virus.

Judy Pollatsek, an AIDS counselor for the St. Francis Center, a counseling organization that helps people deal with grief, was stunned recently to find herself thinking of 1983 as "the good old days." There was a time, she said, "when I knew almost every AIDS patient in the District. I can't come close to saying that anymore."

The Washington Blade, a weekly gay-oriented newspaper in the District, never used to run obituaries. But since the end of 1984, said publisher Don Michaels, not an issue has been printed without at least one obit.

This week, more than 6,000 scientists from around the world are gathering in Washington at the Third International Conference on AIDS. Among the key questions they are addressing are these: How catastrophic is the epidemic? What can be done? How will society respond to AIDS philosophically? Politically?

A deadly human retrovirus that was identified just four years ago is terrorizing at-risk populations, altering medical education and the nation's health care system, and redefining the sexual revolution. It has made "condom" a household word. It is crowding urban

hospitals, overwhelming already strained public health budgets, worsening the federal deficit. In some cities it threatens to decimate whole neighborhoods. In New York and San Francisco it already has.

By every estimate, the worst is yet to come.

At least 1.5 million Americans are already infected with the virus. The Public Health Service predicts a cumulative total of 270,000 cases and 179,000 deaths by the end of 1991. In that year alone, an estimated 145,000 Americans will be sick with AIDS and 54,000 will die -- nearly as many as were killed in the Vietnam war.

By 1991, AIDS patients will occupy 16,000 hospital beds, more than 1 percent of the nation's total, health economist Anne Scitovsky predicted recently. In New York it could reach 5 percent, in San Francisco 12 percent.

AIDS will surpass the medical cost of either breast cancer or lung cancer by 1991, Scitovsky said. Total costs, including medical care and lost productivity due to disability and premature death, will exceed $66 billion a year by then -- more than double the entire current Medicaid budget.

The rising count of cases -- now doubling every 12 to 15 months -- is "a reminder to all of us that the mathematical power of 2 is powerful indeed," Dr. June E. Osborn, dean of

the University of Michigan School of Public Health, has written.

"It is possible to say with unusual assurance now," Osborn said, "that AIDS will always be with us; that at least one quarter of a million will have sickened and died of it within the next five or six years, and that clinical medicine will be changed in many ways that demand quick, clever anticipatory planning of a sort for which we are terribly ill-prepared." 'Second Wave'

The D.C. Hospital Association recently appointed a task force to assess the AIDS crisis and prepare for the next five years. Another task force, organized by the Fairfax Hospital Association, is focusing on Northern Virginia. Every major hospital in the area is examining its policies, case load and bottom line in light of AIDS.

About 90 percent of the almost 700 cases within the District have been in gay or bisexual men. But now doctors are bracing for a "second wave" of AIDS cases involving intravenous drug abusers, prison inmates and prostitutes, who are harder to reach through preventive education and much more likely to lack health insurance and access to care.

"Our experience at GW has been largely with patients from the gay community, who tend to be well insured," said administrator Michael Barch, who chairs the D.C. Hospital Association task force. "Now, that's going to change. This will tax us to the max."

Nationally, AIDS strikes minorities disproportionately; blacks and Hispanics account for about 39 percent of the cases nationally, about double their portion of the population. In the District, about 50 percent of the reported cases are in blacks, 47 percent in whites and 3 percent in Hispanics.

Though most of the AIDS inpatients treated at Howard University Hospital are gay or bisexual men, said Dr. Wayne Greaves, chief of infectious diseases, a majority of the outpatients -- people who test positive for the virus but as yet have relatively mild symptoms -- are intravenous drug abusers.

Most of the people who will develop AIDS in the next five years already are infected with the virus, and most of those don't know it. Because the virus is present in semen and blood, it can be spread by having sex or sharing intravenous needles.

Even if an effective AIDS vaccine becomes available within a decade -- which many scientists regard as unlikely -- it would not help the millions of Americans infected by then.

"If we stopped everybody from making love and using intravenous needles today," said District Health Commissioner Tuckson, "there would still be hundreds and hundreds of people dying of this disease in this city in five years. We're fighting for the next five years after that."

In metropolitan Washington, 1,155 cases of AIDS have been reported since 1982, including 693 in the District, 223 in the Northern Virginia suburbs and 239 in the Maryland suburbs. More than half have died.

Among U.S. cities, Washington ranks ninth in the percentage of AIDS cases, and fifth in the actual number of cases -- behind New York, San Francisco, Los Angeles and Houston.

District health officials expect between 400 and 600 new cases of AIDS this year and between 500 and 900 in 1988. In addition, there will be between 7,000 and 14,000 cases of AIDS-related complex, a milder form of the illness that often progresses to full-blown AIDS.

"Even if the numbers remain as low as we could possibly hope for," said Dr. Charles Levy, chief of the infectious disease section at Washington Hospital Center, "the impact on this city and these hospitals and this community will be staggering. We can't do enough to be prepared for what's coming."

"It's like living in a small town, part of which is dying," said Jim Graham, director of the Whitman-Walker Clinic in the District. "If you don't know people, you know of people."

Most of all, AIDS is a stealer of young lives. A 34-year-old man who tests positive for the AIDS virus is 26 times more likely to die during the next seven years than the average American male of the same age, said Richard Schweiker, president of the American Council of Life Insurance.

"AIDS reverses the natural order of things," said Ronald Bayer, associate for policy studies at the Hastings Center, a New York think tank specializing in medical issues. "You have parents taking care of dying children. In a way it's the pattern of death that exists in wartime, when the young men go off to die." High Costs, New Demands

Medical care of AIDS patients is difficult and expensive. The AIDS virus destroys the immune system and leaves its victims vulnerable to a variety of otherwise harmless infections, most commonly rare pneumonias and cancers, which require many hospitalizations. The estimated average cost of medical care ranges from $50,000 to $150,000 per patient. Differing rates of hospitalization -- at daily charges of up to $1,000 or more -- account for most of the variation.

The Health Insurance Association of America estimates that the nation's medical bill for AIDS -- not counting the cost of the new AIDS drug AZT or the care of AIDS-related illnesses -- will total $40.5 billion between now and 1991. Of that, 35 percent will be paid by Medicaid and Medicare, 22 percent by commercial insurers, 19 percent by Blue Cross and Blue Shield plans and 24 percent by individuals.

AZT itself, the only drug approved for treatment of AIDS, is expected to raise the cost of AIDS care in the long run by keeping patients alive longer. The drug costs an average of $10,000 per year and, because of frequent side effects, its patients require additional lab tests and blood transfusions.

"We're diagnosing patients earlier and treating them longer," said Dr. Richard DiGioia, a District internist who has treated 150 AIDS patients. "That's great, but the ultimate costs are going to be higher."

About 40 percent of AIDS patients are covered by Medicaid because they are poor or have been impoverished by the cost of their own treatment. Only 1 percent of AIDS patients are enrolled in Medicare, which covers people who are 65 or older or have been disabled for at least two years.

Of the 23 AIDS patients in Howard University Hospital last month, only one had private health insurance. Fifteen were covered by Medicaid, two by Medicare, and five had no insurance at all.

Medicaid coverage of AIDS care will total between $400 million and $800 million this year, not counting the cost of AZT, and some say the Medicaid bill for AIDS could reach $10 billion by the mid-1990s.

"That's a staggering figure in the Gramm-Rudman era," said Michael Bromberg, executive director of the Federation of American Health Systems, an association of for-profit hospitals.

"It's very easy for a politician to call for education, even when it's controversial," Bromberg said, "but when it comes time to say who's going to foot the bill for $10 billion, they run away. No politician in this town wants to talk about new money."

Already, the rising number of AIDS patients is stressing many hospitals.

"Our hospital is full every day," said the Washington Hospital Center's Levy. "There are just no beds available at the end of the day. We can't provide much more care for AIDS patients without making it more difficult for other patients to get in."

The outpatient AIDS clinic at Johns Hopkins University Medical Center in Baltimore has "reached the saturation point" of more than 600 patients and is now turning people away for lack of space, money and personnel, said Andrew Sorensen, associate dean of the Hopkins School of Public Health.

Among District hospitals, George Washington and the Washington Hospital Center have seen by far the most AIDS cases -- more than 200 at GW and more than 100 at the Hospital Center, not counting patients from the suburbs.

Unlike public hospitals in most cities hard hit by AIDS, Washington's D.C. General has cared for only a small fraction of the patients -- about 8 percent. But as the cases mount, particularly in intravenous drug users and other largely uninsured groups, so will the burden on D.C. General.

"It's a powderkeg situation for us," said Dr. Larry Johnson, medical director of D.C. General, where the average length of stay for AIDS patients is 30 days, compared with eight days for others.

"Eventually," Johnson said, "the financial burden on the hospital will increase, and we'll have to take resources and funds from other things we're doing to take care of these patients. No metropolitan area has the resources to pay for this."

Area hospitals were unwilling or unable to disclose projected AIDS cases for 1991.

"No hospital wants to be identified as the AIDS hospital," said the Rev. Harold Burris, director of housing at Whitman-Walker. But some hospitals that once looked at cancer the same way, he pointed out, now showcase their cancer units.

"I like to remind the hospital people that NIH has not lost its prestige just because its 11th floor is primarily dedicated to AIDS patients," Burris said. "And San Francisco General Hospital has become perhaps the outstanding public hospital in the nation not because it ran away from AIDS patients but because it embraced them."

But the financial risk is high. The nation's only hospital exclusively for AIDS patients opened in Houston last September with a pledge from its for-profit owner, American Medical International, to accept 30 percent nonpaying patients. Seven months later, the hospital announced it had lost $2 million in uncompensated care of AIDS patients and

could no longer accept poor, uninsured patients.

The 150-bed hospital has about 20 inpatients and 700 outpatients and faces losses of $5.5 million from uncompensated care by year's end, said Jean Settlemyre, a group vice president of AMI.

With hospital costs so high, health officials are searching for alternative ways to care for AIDS patients -- at home, in nursing facilities and in hospices for the terminally ill.

Hospice of Northern Virginia, the area's largest, had 19 AIDS patients last year and expects to care for up to 35 percent of the Northern Virginia residents who die of AIDS in the future. That would be 100 patients in 1991 alone, said Cheryl Girard, education coordinator.

About 13 percent of the AIDS patients at Hospice of Northern Virginia had no insurance, compared with only 1 percent of non-AIDS patients, Girard said. Another 17 percent were covered by Medicaid, which fails to cover the full cost of care. The average cost of hospice care for an AIDS patient -- including both inpatient and at-home care -- is 50 percent higher than for other hospice patients but still far below the alternative of hospitalization.

A lot of chronically ill AIDS patients end up in the hospital for lack of home care services, said Anne Towne, director of Hospice Care of D.C. The key is finding enough home health aides, personal care aides and chore aides to provide "front-line personal care" to an AIDS patient at home.

Housing is another problem. The Whitman-Walker clinic runs six houses accommodating up to 37 people who are displaced from their homes, in economic need and willing to live in a group setting, said housing director Burris. The homes, at undisclosed locations in the District, have a current waiting list of about five or six.

The District's major need now, Burris and others agreed, is for an intermediate nursing facility for chronically ill AIDS patients who don't need to be in a hospital but need nursing attention and can no longer care for themselves at home or in a group home.

Health experts hope the AIDS epidemic, by sheer catastrophe, will call public attention to serious shortcomings in American health care -- the 80 million uninsured or underinsured, discrimination against minorities and gays, the need for education and prevention, the lack of home care and help for chronically ill.

"This disease is highlighting all the deficiencies of the health care system," said Dr. Jack Killen, medical director at Whitman-Walker.

And some believe that AIDS will force the issue of national health insurance back onto the political agenda after a layaway of 20 years.

"Because AIDS is so stark, it's an acute shock to the system," said the Hastings Center's Bayer.

During the first six years of the epidemic, care of AIDS patients has relied "to an enormous degree" on volunteerism, particularly from within the gay community, which Bayer called "one of the most ennobling expressions of what American society is capable of." But that volunteer effort, which in Washington has been led by the Whitman-Walker clinic, may be nearly stretched to its limit.

"It took us five years to get get to 35,000 cases," Bayer said. "Now we're going to double that in 14 or 15 months. Suddenly the capacity of a voluntary system of care is going to crumble. We had better develop publicly funded systems of care to take up the slack." Doctors and Patients

AIDS is changing traditional patterns of medical education and medical practice. Already, some young pediatricians and internists are beginning to shy away from urban teaching hospitals whose intensive care units are overwhelmed with AIDS patients. Educators are concerned that such hospitals won't give young physicians the broad medical training they need.

One of Dr. Jeffrey Akman's fourth-year medical students at GW told him excitedly last month that she had finally seen her first patient with diabetes. Already, she had seen five patients with AIDS.

AIDS meanwhile has utterly transformed the field of infectious disease. "If you're in infectious disease," said Dr. Phillip Pierce, director of the Georgetown AIDS clinic, "AIDS is what you're going to be doing."

Like every physician who took up that specialty before 1982, Pierce senses the irony:

"You looked at infectious disease doctors and you said, 'They cure people.' You looked at the oncologists {cancer specialists} and said, 'Boy, what a depressing set of diseases they have to treat.'

"Now I'm doing what the oncologists were doing back then. My patients' survival rate is lower than theirs."

He doesn't regret the move. "You don't get those kinds of choices in medicine or in life. It's a learning experience," he said.

"You share the most intimate details with your patients. You share the intimacy of death. You grow."

One day last year, counselor Pollatsek of St. Francis Center went to say goodbye to one of her patients in the hospital, a young man dying of AIDS. The two of them knew this would be their last meeting, and the man said he wanted to thank Pollatsek for all she had done.

"Thank you," Pollatsek replied.

The man on his death bed looked at her, taken aback at her gratitude. "But you're the expert," he protested.

"And who do you think is my teacher?" she said.

There was a pause, and then "this wonderful smile came over his face," Pollatsek recalled. And then he answered:

"Us." Beyond Numbers

Numbers alone cannot tell the impact of AIDS on a city like Washington. Though no neighborhood and no industry is exempt, the toll has been particularly devastating in walks of life where gays are especially well represented, such as the fashion industry and the arts community.

"It's an ongoing kind of cloud that hangs over the heads of our industry," said Neal Fox, president of Raleighs Corp. "In addition to the Willi Smiths and the Perry Ellises, there are a lot of other lesser known people who have died. of AIDS. It's had a definitive impact on our talent pool of creative individuals."

"I'm scared to death," said T.J. Edwards, 29-year-old playwright and actor who plays a man whose lover dies of AIDS in "As Is," now at the Studio Theater. "I'm afraid for my friends. My girlfriend is scared. I face it every night, going through that vicarious experience on stage."

"The theater community here is small," Edwards worries, "and it's not going to take much to devastate it."

Martin Feinstein, director of the Washington Opera, says that every time he meets or talks with colleagues from opera companies in other cities, he hears about another diagnosis, another illness or another death. His own company has already lost at least three members to AIDS.

"I've quit counting," said B.J. Stiles, 54, a former vice president of the Council on Foundations who now is a private consultant to AIDS-related organizations.

"It surprises me when a week goes by and I don't get a call from someone who has been diagnosed or whose lover or friend or relative has been diagnosed," Stiles said. "A good week is a week I don't get that phone call." 'Snuck Up on Us'

Doctors asked to predict the future of AIDS are daunted by the knowledge that no one five years ago could have foreseen the extent of today's crisis. Just five years ago, AIDS was still commonly referred to as GRID (gay-related immune disease) and was not among the diseases doctors were required to report.

Though studies suggest that many gay men have adopted safe sex practices to reduce the risk of AIDS, health officials worry that the danger is still underestimated by most Americans.

"I'm terribly afraid that where the gay community was three years ago -- 'it's not going to happen to me' -- is where the rest of the population is today," said Whitman-Walker's Killen.

"We've constantly underestimated the epidemic," said Dr. David Werdegar, health commissioner of San Francisco, where infection rates among gay men in some neighborhoods have reached as high as 50 percent.

"The concept of risk groups has blunted society's response to this epidemic," said Dr. Sheldon Landesman, an infectious disease specialist at Downstate Medical Center in Brooklyn. "It has enabled people to see it as somebody else's problem. It has allowed AIDS to be seen as a problem for the population of 'them.' "

In 1980 a group of doctors from Georgetown presented a puzzling case to a monthly meeting of infectious disease specialists from area hospitals. A young man had died of a rare type of pneumonia, without any of the known exposures that could cause it. The Georgetown doctors asked their colleagues if anyone had ever seen such a case.

"In that room there were hundreds of years of medical experience, and no one had ever heard of it," recalled the Hospital Center's Levy.

"It's gone from being so rare that no one in the field could believe a case to being one of the most common illnesses that young physicians in training see in the hospital," Levy said.

"It sort of snuck up on us," said Dr. Donald Poretz, an infectious disease specialist and chief of the medical staff at Fairfax Hospital.

Poretz' medical group has treated about 100 cases. They include a prominent politician, a Catholic priest and a couple of 16-year-old high school students. One patient, having learned his diagnosis of AIDS, went home and killed himself with a drug overdose that very night. Another, a 26-year-old woman who got the virus from a blood transfusion during childbirth several years ago, now suffers from ARC and is afraid to have sex with her husband or even kiss her two children.

Another, a 50-year-old woman, donated a unit of her own blood to herself before undergoing a routine hysterectomy -- only to discover the blood tested positive for the AIDS virus. The woman had no symptoms but she had been in a recent sexual relationship with a man who, unbeknownst to her or himself, was carrying the virus.

Said Poretz: "We're going to see more and more cases like that."