The D.C. Commission on Public Health is responsible for a wide range of services from cancer prevention and prenatal care to drug abuse clinics and childhood vaccination programs. Now AIDS has become a major priority. Dr. Reed Tuckson, 36, who became director of the department in February, describes the world's newest epidemic and how it is likely to affect the District for years to come. He is interviewed by Washington Post staff writer Larry Thompson.

Q. Is there anything special about Washington that puts city residents at a higher risk for AIDS than other cities? Are we now at high risk?

A. Yes, we're at high risk. And the reasons that we are at high risk are, one, we have a large number of practicing homosexuals; two, we have a large number of black and minority homosexual and bisexual persons who, because of a variety of reasons, don't want to confront that and live lives that are very much underground and suppressed. Number three, we have a large number of i.v. drug abusers, an unacceptably high number of i.v. drug abusers in our community.

Number four, we have far too many young adolescents who define their masculinity by their heterosexual conquests and therefore are reluctant to stop engaging in casual sex and are reluctant to use condoms because they think that also somehow diminishes their masculinity.

And we've got a lot of people who are already chronically ill from other diseases . . . their immune system is already compromised. They would be more vulnerable to a virus and to exhibiting more profound manifestations of that disease.

Q. How bad is the problem in the District?

A. I don't know the answer. We have 763 cases as of today. I think . . . there are incredible numbers who have this virus in our community. Five years from now, we're going to have lots of people with AIDS. A lot of people are going to need very intense health care resources.

{In the District, so far,} 7 percent of the cases of AIDS are from i.v. drug abuse. Then there's another 6 percent that's homosexual/bisexual and i.v. drug abuse. {The rest are homosexual males.}

Q. So the AIDS virus primarily spreads sexually in Washington?

A. Right. All the proportions seem fixed. I know 7 percent is i.v. drug abuse. Six percent is a combination of homosexuality and i.v. drug abuse. All the prostitutes with this disease have gotten it from i.v. drug abuse, not from sexual activity.

I know it's 1 percent for heterosexuals, and it's holding. I don't know why. Now in the black community across the country, it's 11 percent. For the black community in D.C., it is 1 percent.

Q. What are you doing to stop the spread?

A. We've got to get our message to the people that need it the most: how to protect yourself and what risk you're at, and the risk of the people that you are around. For the i.v. drug abusers, we know that while commercials on television and public service announcements are one thing, they don't hear them because they are in shooting galleries. The thing that we've got to do is start to talk about getting at these populations.

Q. To make a difference, do you have to send public health workers into the shooting galleries. How many people can you put in the field at one time?

A. Well I don't know, to be honest. I don't know how many I'll be able to field. I do know that it is possible to go in and talk to them. I've done it. I know what drug abusers will say: 'No, I don't share needles because I don't want to get that AIDS.'

Q. You went in a shooting gallery to talk with the drug addicts?

A. Oh yes. I did. The narcotics division will take me into the shooting galleries with them on the drug busts. I'm talking to them while they're being carted off to jail. And it was very instructive.

We're in dungeons and basements and there's a styrofoam cup sitting in the middle of a table with six needles stuck in it. You know if a guy has the heroin and there's nothing around, he is going to reach in that {cup for a needle} and do it.

Q. So are you going to give them a box of 100 needles so they don't have to share and use dirty needles?

A. No. I certainly considered giving out free needles as a possibility. But then, the more we learned about the etiquette of drug abuse, we learned that the clean needle we give out will be a dirty needle once used. It won't be thrown away. So that doesn't solve the problem.

Another reason I didn't want to give out free needles is that it will send a double message to the drug abusers. We're saying don't do drugs, but here's a needle to do drugs with. And I'm fundamentally and totally in a war against drug abuse in this city.

Q. How can you tell what kind of impact you're having with programs today? You're not going to be able to see any effects of those programs for some time down the road.

A. That's a good point. To be honest with you, it's going to be very difficult. I think it is important to do {AIDS blood tests}.

Another way is to look for other markers. We would want to look at how our sexually transmitted diseases {syphilis, gonorrhea, herpes} in general are going. The unfortunate reality is that they don't seem to be decreasing.

Q. In the District?

A. In the District, or anywhere in the country, they seem to be holding steady. You would expect that if people were using condoms and were decreasing their promiscuousness you'd see a decrease in sexually transmitted diseases.

Q. Since there is no cure or vaccine, are you focusing mainly on prevention?

A. Most of my focus must be on prevention, but increasingly I'm becoming occupied with the consequences of the disease. I'm going to wind up being responsible for organizing, or assuring that there is, a system of care for persons who have the disease.

When you realize that a person with AIDS will require housing support, food support, medical support, a buddy, home nursing support -- it's an array of services that have to be coordinated somehow. Not only provided and accessible, but coordinated. And that's going to wind up being, again, a public health function.

Q. Those are the same services needed by people with other chronic diseases. Historically, the system hasn't worked all that well in providing them, has it?

A. Well, it hasn't worked as well as we'd want it to work.

Q. AIDS is going to stress it even more.

A. AIDS is certainly going to tax us. But I have a relationship with the Commissioner of Social Services and the Commissioner of Mental Health now to bring this {AIDS} plan that we've developed into existence. I'm sure it will lead us to significant organizational change that will help us. So, for example, we now have expedited Medicaid eligibility, expedited general public assistance, and Social Security. If you want to apply for Social Security benefits now and you have AIDS, that happens pretty quickly.

Q. If you have AIDS, do the doors open more quickly than if you have some other chronic disease?

A. Exactly. The system is greased a bit because of the urgency of this disease.

Q. Many people with AIDS are going to get sick with nasty diseases and are going to end up in the hospital. Yet about 40 percent of the people with AIDS already in the city are on Medicaid. What kind of economic burden is that going to put on the hospital system in this community?

A. You've got 100,000 people without health insurance in D.C. right now. You've got a hospital industry that last year absorbed over $100 million in free care.

The Medicaid budget is the fastest growing part of the D.C. government budget, and there are limits on how fast and how far it can grow. Yet we're faced with the absolute certainty that we're going to have incredible demands on the Medicaid budget from AIDS. We're going to have hospitals that are going to need support because they're going to get bombarded with admissions five years from now. It is inevitable that the hospital industry is going to be seriously affected.

Q. Could a significant increase in AIDS cases threaten to collapse the city's health-care system?

A. Too soon for me to make that statement responsibly. I don't know the answer. I don't think it's time for that degree of panic. But it certainly is fair to say that it will have a significant economic impact on our hospitals.

Q. Are you getting enough financial support from the city council to do what you need to do to stop this disease?

A. Yes. The city council added money to the budget this year. {In fiscal year 1986, $175,000 was allocated for AIDS. In 1987, that amount jumped more than 10-fold to $1.86 million. For fiscal year 1988, which starts Oct. 1, $3.78 million of the commission's total budget of $124.6 million will be spent on AIDS.}

Q. Enough?

A. Enough for this year, they did. I have no complaints at all with city council.

Q. There are a number of chronic diseases, sometimes referred to as the big six -- cancer, heart disease, substance abuse, accidents and homocides, premature births and diabetes -- that strike poor minority groups more often than whites. What kind of impact is AIDS having on the fight against these diseases?

A. There's a danger, a real danger, that we will not focus on other diseases and that we won't have the budget resources.

There's only so much money that you can get, and we have to decide how much money we're going give to the Department of Human Services. It is inevitable that AIDS is going to get most of the new money that is going to come into the system, which means that there's less money to fight infant mortality and less money to fight the war on cancer.

I don't like the choices I have to make.

Q. How does Reed Tuckson, human being, commissioner of public health, think we're doing?

A. Reed Tuckson needs to be a better historian, and I need to spend more time -- which I don't have -- reading history.

Q. Why?

A. Because I am 36 years old and I haven't seen enough.

I think that we are doing pretty well but certainly not as well as I would want us to do. {AIDS} is presenting us as difficult a set of issues as can be resolved in a pluralistic, democratic way. What I am happy about is that I do see the process working. I think resources are being made available and people are exercising those responsibilities; those are things I think we've done well.

The true test is coming because the amount of resources that is going to be needed to take care of and to continue the prevention efforts to do all the other things that will be required as we go forward is going to be incredible.

Q. All this seems to put you pretty much in the hot seat. Are you being criticized for the choices you make?

A. First of all, you can always criticize. I mean there's always things we can do better. And I have to be thick-skinned. I can't be afraid of ideas or criticism. If somebody says 'Look, you're not reaching us,' then I need to; the stakes are too high.

Q. Public health commissioners tend not to last too long in this town, does that add to the pressure?

A. I've always told my people, realize this is very transient. We've got to get everything we're going to get done, now, quick. Get it done. Get it in place. Get the ideas out because I may not be here long. Nobody's lasted more than two years in a while. So hurry up. Hurry up. Hurry up.

People got really concerned about my intensity, and they think I'm frenetic.

Q. Are you?

A. Oh yes, no question, because I know I probably only have two years, and so I've got to get it in. I got to get all the ideas in place, all the things moving, everything ready and then hoping that every day you get you get an extra day.