Alone . . . With AIDS : Health: In rural Vermont, clinics and support groups are few and far between. The lack of care and companionship takes its toll on patients.

BURLINGTON, Vt. —  This is the land of the cow on the hillside, the cow on the T-shirt, the cow on the Ben & Jerry’s ice cream container. It is the land of sweet air and town-owned forests, of covered bridges and meadows lush with wildflowers.

Life just feels healthy here. People walk down the street in Birkenstock sandals. They windsurf in the summer and ski in the winter. Vermonters frown on plastic shopping bags. They think globally but act locally. “Save the World,” one poster of dancing Holsteins proclaims. “Vermont first.”

“I think even here in this state, there is the mythology that the Green Mountains somehow protect us from the rest of the world,” said Deborah Kutzko, a nurse who is head of the infectious disease unit of the Vermont Health Department.

“Unfortunately, that is not true.”

Kutzko oversees all the AIDS cases in Vermont, which is home to about 563,000 people. To date, “all” means 83 confirmed cases--including about 50 fatalities--of the disease since the state’s first known case in 1982. Between 500 and 800 residents are thought to be carrying the human immuno-deficiency virus that causes AIDS.

Compared to a state such as California (with more than 29 million people), where 23,775 have died of AIDS since 1981, the numbers seem relatively small. But AIDS in Vermont has its own “vastly different” face, Kutzko says.

That face is marked by the loneliness and isolation that come with rural life, when you must drive hundreds of miles to an AIDS clinic or AIDS support group. When you are the only person in your village who suffers from the disease.

Vermont is the most rural state in the nation; about two-thirds of its residents live in rural areas. There is only one AIDS clinic--in Burlington--and only eight AIDS support groups scattered around the state.

“Nobody else here has what I have. Nobody is sick like I am,” said Shawn, a 21-year-old gay man who has a number of AIDS-related illnesses, and who is confined to his home in Rutland. “There ain’t other ones around.”

Although AIDS is usually associated with urban areas, the profile of rural AIDS is expected to become increasingly significant. “Even though AIDS cases are heavily concentrated in the largest cities, the epidemic is increasingly affecting smaller communities,” concluded a 1990 report from the Centers for Disease Control in Atlanta.

And those smaller communities may not be prepared.

“The problem is tiny, but the resources are proportionately tiny,” said Dr. Chris Grace, an immunologist at the University of Vermont who runs the AIDS clinic. “We are a microcosm of the rest of the epidemic.”

Towns in Vermont are scattered in mountains and valleys and may be hours from Burlington, the only semi-metropolitan area. In the harsh winter, driving can be treacherous.

“The good news is that the health care system is not overloaded,” said Kutzko. The bad news is that it may be far away and hard to get to in an emergency.

Support may be just as difficult to come by. “If you are in a city like Boston, you can go down the street and find treatment and a support group,” said Grace. But that’s not the case in Vermont.

And the support organizations “walk the tightrope between confidentiality and trying to help people hook up with each other,” said Lauren Corbett, executive director of Vermont CARES (Committee for AIDS Resources, Education and Services).

In small towns, tongues may wag and fingers may point. In a village of 400 people, a prescription for AZT, the most widely used AIDS drug, will not for long remain a secret.

“There’s a sense of privacy, but you also have that small-town atmosphere, and a communication system that far exceeds Ma Bell,” said Lorraine Wargo, a nurse who has worked with AIDS patients here. “People with AIDS are afraid the word will get out and everybody will know. I think that people with AIDS are still in the closet in Vermont.”

What’s more, if there is no one in a rural town to offer the kind of empathy and camaraderie an AIDS patient needs, the trip to a formal support group in Burlington may be daunting or even impossible.

In Rutland, Shawn said he is too financially strapped to own a car--and even if he did, he is too sick to drive. Most of his family members shun him, he said. An AIDS caseworker for Vermont CARES sometimes makes the drive from Burlington, about two hours away. Only a few old friends stop by the shabby apartment Shawn shares with his mother and an adult, retarded brother.

“There’s no one to talk to about what I got,” said Shawn, who in healthier days did maintenance work at Killington, a nearby ski resort. “I feel like I’m getting sick of suffering.”

And there may be other roadblocks to finding kindred souls with AIDS in rural areas. Doris, a 31-year-old carpenter and recovering drug addict in Burlington, learned she is HIV-positive about a year ago. The one AIDS and HIV support group she found was made up of gay men. Other than the disease, they had little in common, Doris said.

“In Massachusetts, where I’m from, there are a lot of support groups for people with HIV,” said Doris. “Here, I only know one other woman who is HIV-positive. It’s a very lonely disease here. Very lonely.”

The absence of an emotional safety net may exacerbate the course of AIDS, said Dr. Calvin Cohen, a clinical instructor at Harvard Medical School and the director of an AIDS research program in Boston.

“Several studies have shown that when we look at longtime survivors of HIV, one of the aspects that they have in common is the emotional support,” Cohen said.

Some Vermont doctors are concerned about the availability of up-to-the-minute medical knowledge. In a rural setting, said Grace, “the number of physicians who are comfortable and familiar with AIDS treatment is relatively small. Any one physician may see only one AIDS patient--or maybe no AIDS patients.”

AIDS, Grace added, “is an incredibly complicated disease that is always changing. There are things about AIDS that you never see as a general-practice physician.” Because many patients in rural locales do not have medical insurance, “for the doctors, this is basically charity work,” Grace said. “Our clinic is losing money hand over fist.”

Physicians treating AIDS in rural areas may also lack access to experimental drugs and protocols, Cohen said. “Getting involved in real clinical trials for AIDS is much harder in rural areas,” he said.

On the other hand, said Kutzko, an avowed optimist, “In a rural state, we’ve had the opportunity to watch the larger states make mistakes (primarily, hospital overcrowding). We can take the good parts from other states.”

But Kutzko is also a realist: “I think there is a problem with a lack of reality about AIDS,” she said. “People don’t protect themselves as well here as they should. It’s very hard to believe that AIDS is real here, so it’s hard to believe that (protection) is necessary.”

As if to underscore that theme, a goldfish bowl full of condoms sits by the front door of Vermont CARES, like after-dinner mints. Nearby hangs a sign. “No matter who you are, you can get AIDS in Vermont,” it reads. “But you don’t have to.”