EDINBURGH, Scotland -- Drug abuse, prostitution, HIV and AIDS fall outside the tourist vision of a Scotland of kilts and bagpipes, shepherds and crofters, Harris tweeds and plaid woolens, fine whisky and golf at St. Andrews.
Edinburgh, Scotland's capital, is a stately city of gray and red stone, pinnacles and turrets and crenelations. It is a cultured city renowned for its theater festival.
It is not the sort of place you'd expect to find a rampant AIDS problem and some of the world's most progressive programs for the prevention and treatment of AIDS.
But with about 750,000 residents, Edinburgh and the Lothian governmental region that surrounds it account for 52 percent to 58 percent of Scotland's 2,000 infections of human immunodeficiency virus.
Scotland is about three times as large as Maryland, but has a comparable population of about 4.9 million. (Maryland's is 4.8 million.
The latest figures from the end of March show that in Edinburgh and its Lothian suburbs, 1,099 people were HIV positive, 206 had AIDS, 127 had died. The figures are small compared with Maryland and Baltimore, where the numbers in each category are about 15 times as high.
In Edinburgh, city and regional health authorities recognized the AIDS danger early and moved quickly. Inventive ideas flourished and resulted in a range of far-reaching HIV/AIDS programs virtually unmatched in Europe and often rare in the United States.
Edinburgh provides services for people with HIV or AIDS literally from infection to the grave.
The programs start with preventive innovations like the C-Card. Just put down your date of birth and your neighborhood and you've got your credit card good at any participating pharmacy for a virtually unlimited supply of condoms. About 4,000 residents of the area are carry C-Cards.
Needle exchange programs for drug users, just now struggling to get under way in Baltimore and still rare in the United States, have been operating here since 1986. Shared needle use among intravenous drug users had been by far the leading source of HIV infection, followed by homosexual and then by heterosexual partners. There were, of course, other causes.
Needles, syringes and condoms in a wide variety of sizes, shapes and strengths are displayed like household gadgets in a hardware store at the Spittal Street Centre here.
Edinburgh seems to be able to provide such HIV and AIDS services without undue fuss, ostentation, sensation or self-congratulation. Practically everyone working with HIV/AIDS people seems remarkably non-judgmental.
"We don't tell people not to use drugs," says Frank Gough, a 30-year-old member of the center's Harm Reduction Team. "Our main thing is to try to get a clean set of works [injection paraphernalia] to the clients who are using."
At the center, users can get up to 10 sets a visit. About 300 dropped in for their works last month. The center also sends a bus out to neighborhoods with heavy drug use. And it provides a "prescription" form users can take to 20 pharmacies, which will then provide syringes and needles.
"We encourage users to return their old works," Mr. Gough says. His voice is as soft and low as his demeanor is gentle. "Some don't. We don't insist. But if someone continues to not bring back works, we do get pretty strong about it."
Unhappily, the AIDS epidemic and widespread drug use by injection, mostly of heroin, arrived more or less simultaneously in the early 1980s in Scotland, most severely in Edinburgh.
"The Scots went straight to injecting," says Roger Lewis, director of the city's HIV/AIDS and drug study center.
Testing blood samples from drug users in the mid-1980s, researchers found one-third to one-half were HIV positive.
"Overnight Edinburgh acquired itself an HIV problem," says Dr. George Bath, AIDS coordinator for Edinburgh and its outlying region.
But preventive measures such as the needle exchange and condom programs are credited with helping to reduce the high HIV infection rate substantially among injecting drug users.
"In terms of new people coming to drug treatment services, well below 50 percent have ever injected," Mr. Lewis says. "Very, very small numbers have shared over the last six months. It's gone down like that."
Trouble with sex
Bringing about change in sexual patterns has been more intractable.
"If we talk about sexual transmission," says Dr. Bath, "the risk is ahead."
In one area of sexual activity, the Scottish Prostitutes Education Project (ScotPEP), a 4-year-old self-help group, encourages safer sex and safer drug use by men and women working in "the sex industry."
According to Ruth Morgan-Jones, the ex-prostitute and university-trained social scientist who is a director of ScotPEP, 500 to 700 women and 150 to 200 men work in Edinburgh's sex industry.
ScotPEP provides information and advice, education and support services -- and distributes thousands and thousands of condoms.
Ms. Morgan-Jones says nearly all Edinburgh prostitutes provide their customers with condoms. She says local prostitutes have become skillful negotiators for safer sex and will sometimes turn down recalcitrant customers.
It's a serious issue. Ms. Morgan-Jones estimates there are 250,000 to 400,000 "commercial sexual contacts" a year in Edinburgh. The last study, done five years ago, turned up 17 prostitutes with HIV infections.
And ScotPEP does not shrink from extremely sensitive issues: "We have a policy of not refusing to work with somebody under the age of consent," Ms. Morgan-Jones says.
"If we find a young boy of 14 who is working, we will give him condoms and we will give him information on how to protect himself.
"Our role is to prevent HIV within the sex industry," she says. "And we see that being only possible if we're prepared to accept the people who work."
End of the cycle
At the end of the cycle, the extraordinary Milestone House provides the only hospice in Scotland for people with AIDS and HIV. Milestone House aims to help residents and their families and friends and children approach death with as little pain and as much comfort and dignity as possible.
Designed specifically as an HIV/AIDS hospice and opened in 1991, Milestone House provides 20 beds in four handsome bungalows joined by two bright and airy conservatories to a central service block. Built of honey-colored brick and light wood and lots of glass, Milestone House is warm and light-filled, and the rooms are as cheerful and comfortable as they can be in a place where death is often the only way out.
Dr. Linda MacCallum, the buoyant, unprepossessing general practitioner who has been at Milestone House since it opened, says 230 people have come for 830 admissions.
Some come to give their care-givers a few days or weeks of respite, some for convalescence after treatment. Some come to die.
Dr. MacCallum has seen 37 of her patients die at Milestone.
"We're very lucky," she says. "Of the group we look after, the majority of them do have family about. Classically, if we have somebody dying, we've had 20 or 30 members of the family here, and 10 or 12 sleeping in the building as well."
There's a guest room in each bungalow and a lounge, and nobody minds if the family sacks out in sleeping bags on the floor. The average age at death is 32. There are often lots of young children. The lounge at the end of one bungalow has been turned into a kindergarten with dolls and a giant stuffed hippo and all manner of playthings.
And Milestone House doesn't immediately shove the dead into a plastic bag to be whisked away like contaminated trash.
"We have our own mortuary here," Dr. MacCallum says. "We do allow the viewing in the rooms.
"Patients will come in here. They will stay here. They will die here. They will have their service here. And they will leave by the front door."