programs that have powerful constituencies. As discussed in Chapter 3, advocacy for STD funding has been traditionally weak because many patients infected with STDs are unaware of the infection, and those who are rarely want to disclose their infection in public, let alone organize public support for STD funding.

Opponents of block grants are particularly concerned that socially conservative interest groups will prevail in lobbying against STD programs at the state level. Allowing states to set funding allocations would also increase the already wide variability in STD programs among the states, because some states may seriously neglect STD programs. In addition, consolidating STD funding into a block grant may also result in the dissolution of the relatively weak constituency groups fighting for STD funding. The Coalition to Fight STDs, an alliance of more than 40 groups organized by the American Social Health Association, monitors public sector efforts against STDs and advocates at the national level for funding for STD prevention, treatment, and research. STD coalitions at the state or local level are rare, although they are emerging in some states, such as North Carolina, to improve STD funding.

Lastly, opponents suggest that past experience with other block grants may portend the fate of STD programs in a consolidated state grants program. For example, in 1981, the categorical Lead-Based Paint Poisoning prevention program was folded into the newly created Preventive Health and Health Services block grant, and the Urban Rodent Control program was folded into the new Maternal and Child Health block grant. These efforts lost funds in virtually all states after the federal categorical programs that funded these services were folded into the block grants. Both of these programs were widely viewed as federal "big-city" programs that found little support in state legislatures dominated by rural representation. Programs that had state support before the advent of federal categorical programs fared better than those that previously had little or no state funding (U.S. General Accounting Office, 1984; Peterson et al., 1986; Elling and Robins, 1991).

Conclusions

Current STD prevention services comprise several disjointed components, including provision of clinical services, disease surveillance and information collection activities, training and education of health care professionals, and funding of activities and programs. Although these components are largely publicly sponsored programs, they involve all levels of government and the private sector.

Dedicated public STD clinics have been instrumental in public efforts against STDs since they were established several decades ago. The quality and effectiveness of services delivered in these settings, however, are extremely variable and clearly need significant improvement. Until universal health care coverage is implemented in the United States, the function of public clinics as providers of



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