HIST 234: Epidemics in Western Society Since 1600
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Epidemics in Western Society Since 1600
HIST 234 - Lecture 23 - AIDS (II)
Chapter 1. Dr. Margaret Craven Discusses AIDS [00:00:00]
Professor Frank Snowden: This morning we’re going to do something a little bit different, which is I thought that everyone was ready for a break. So, we’re going to have a guest lecturer this morning. I thought it was particularly important that at some point we give you a perspective from the clinical point of view, and so I’m introducing to you Dr. Margaret Craven, and I’ll just say a couple of things about her. She’s an OB/GYN, and so for about thirty years she was involved in the trenches in the war against HIV/AIDS. And she’s going to talk to us this morning about HIV/AIDS in this country, as I said last time. And that’s about all I wanted to say; except one other detail, which is that she’s also my wife.
Dr. Margaret Craven: AIDS is fundamentally different than any other emerging global pandemic preceding it, because of the high velocity of its spread around the world, and of the race to understand and control it. I have given you a handout, which is a copy of the 1981 MMWR, which stands for Morbidity and Mortality Weekly Report, of the Centers for Disease Control in Atlanta. The CDC was founded in 1946 to control malaria, and is now part of the Department of Health and Human Services. The MMWR is their fast-track method of publishing a medical article. This is basically so that clinicians can be up to speed on things.
One report is from Los Angeles about cases of pneumocystis pneumonias in gay men. In the same issue there was also a report from New York City about a rare cancer called Kaposi’s sarcoma in gay men. Imagine that you’re working in the field of public health and are reading this. The front page describes five cases of men between the ages of twenty-nine and thirty-six. All of them are gay and all have a rare lung infection called pneumocystis pneumonia. The back page of the report has an editorial note explaining what it is, as it is so rare that nobody would ever have heard of it. The article was the starting gun for a sprint on the part of the medical community.
Within three years of this publication by the CDC, the human immunodeficiency virus was identified as the cause of AIDS, the emerging epidemic of our times. It is even more fragile, fastidious and miniscule than the bacteria that cause syphilis or gonorrhea. But it is spread the same way, through the intimate exchange of bodily fluids. How did HIV become such a powerful and widespread killer in such a short time, causing the present worldwide pandemic of around 33 million infected individuals? How has it left more than 25 million of us dead, and 14 million children orphaned? Why did it still infect about 2.7 million of us in the year 2007, and kill 2 million people that year?
Certain historical background conditions made this tragedy possible: globalization; invasive medical technology, especially blood transfusions; and migration and concentration of gay men. Globalization is a phenomenon that’s been gathering momentum ever since Christopher Columbus linked the two hemispheres. I think you’ve heard about the Columbian Exchange. Many thinkers have written about it. I quote one of them:
“The need of a constantly expanding market for its products chases the bourgeoisie over the whole surface of the globe. It must nestle everywhere, settle everywhere, establish connections everywhere. The bourgeoisie has, through its exploitation of the world market, given a cosmopolitan character to production and consumption in every country. To the great chagrin of reactionists, it has drawn from under the feet of industry the national ground on which it stood, while old, established national industries have been destroyed, or are daily being destroyed. They are dislodged by new industries, whose introduction becomes a life and death question for all civilized nations; by industries that no longer work up indigenous raw material, but raw material drawn from the remotest zones.”
You may have recently heard about the tanker on the Australian Reef that was going to China. “Industries whose products are consumed not only at home, but in every quarter of the globe. In place of the old wants satisfied by the productions of the country, we find new wants, requiring for their satisfaction the products of distant lands and climes. In place of the old local and national seclusion and self-sufficiency, we have intercourse in every direction, universal interdependence of nations.”
Who do you think wrote this? Could it be Tom Friedman, who frequently contributes to the New York Times and writes extensively on globalization? How about Adam Smith or Karl Marx, both very famous political economists of earlier centuries? Or is it José Bové, a French farmer who organized a peaceful removal of McDonald’s from his town in France?
I quote once more. “The bourgeoisie, during its rule of scarce one-hundred years, has created more massive and more colossal productive forces than have all preceding generations together: subjection of nature’s forces to man and machinery; application of chemistry to industry and agriculture; steam navigation; railways; electric telegraphs; clearing of whole continents for cultivation; canalization of rivers; whole populations conjured out of the ground. What earlier century had even a presentment that such productive forces slumbered in the lack of social labor? Modern bourgeois society, with its relations of production, of exchange and of property; a society that has conjured up such gigantic means of production and of exchange is like the sorcerer who is no longer able to control the powers of the netherworld, whom he has called up by his spells.”
It sounds like this prophet, Karl Marx, speaking from the mid-nineteenth century, would not have been surprised to learn that an even faster mode of transportation, air travel, has been invented. It now links all the continents of the globe, so that we can wake up in Africa and go to bed in Canada. This enabled one good-looking French Canadian, gay and very promiscuous airline steward, so-called Patient Zero, to be instrumental in spreading the AIDS epidemic throughout North America. These same forces also gave birth to a growing science and technology that formed the underpinnings of modern biomedical research and Western medicine.
Chapter 2. Beginnings of the Epidemic: Globalization [00:07:42]
Let’s reminisce about the good-old days in the 1970s, pre-AIDS. I was an OB/GYN resident and remember that the medical profession was full of optimism and hope. A positive, rather complacent attitude was instilled in us medical students about what hardworking, well-trained doctors would be able to accomplish. We would be able to fix the body’s mechanical defects with needles, tubes, surgeries and blood products. Syphilis, TB, cholera and the other bacteria diseases would be eliminated with antibiotics. Vaccinations could cure a long list of awful diseases, like smallpox, polio, diphtheria, tetanus, and on and on. Globalization of medicine in the World Health Organization would make eradication of these diseases from the entire globe possible.
Here’s the World Health Organization’s optimistic definition of health, back in those days. Ambitious scientists and doctors were busy competing for grants, positions at prestigious laboratories, and prizes like the Nobel Prize. The Surgeon General of the United States announced rather arrogantly in 1976: “We have turned the page on infectious diseases.” This smug medical attitude suddenly disappeared in the 1980s, when our community was confronted with a totally new and mysterious emerging pandemic. Where did it come from? How did it start?
I highly recommend to you a book named The River, written by an Englishman, Edward Hooper, who tries to answer these very questions. The author’s avowed role model is Dr. John Snow, the first modern epidemiologist. He wrote a book about tracking down the source of cholera through the London water supply in 1849; you probably covered that in the course. Like Snow, Hooper has done an exhaustive investigation of every available source of knowledge relating to the emergence of the AIDS epidemic. Instead of one city, however, he has had to trace the epidemic to three continents. His story starts in the United States, with the first reported cases from the CDC that you have there, and traces the chain of infection backwards in time.
Hooper agrees with Randy Shilts, who wrote the AIDS classic And the Band Played On. Both think that the beginning of the epidemic here was probably July 4th, 1976. To celebrate the bicentennial of our nation, New York City hosted the Tall Ships. Huge sailing ships came from all over the world, and there was a lot of international partying going on in the Big Apple. Retrospectively, studies revealed that the first American babies who were HIV-positive were born in New York City a year later; 1977.
Hooper’s story then moves to Haiti. The refugees seeking asylum here seemed to have a horrifyingly high incidence of HIV, and as a result many Americans went through a phase of scapegoating Haitian refugees as the source of AIDS. “Papa Doc” had a brutal regime that ruled Haiti from 1957 to 1971, by means of violent death squads called the Tonton Macoutes. Therefore, when the Belgium Congo in Africa became independent from Belgium in 1960, thousands of French-speaking professionals escaped their oppressive government by taking jobs in the Congo. In addition, to help solve his economic problems in Haiti, “Papa Doc” promoted his capital as a tourist attraction for gay men from North America and Germany.
Haiti was not the only country linking the chain of infection back to the Belgium colonies in Africa. The epicenter of the disease is found where Congo, Rwanda, Burundi and Uganda come together by standard epidemiologic detective work. This is a picture of a refugee camp that is right in that area where AIDS originated. How it started is a much more controversial issue. Hooper finds extremely compelling the hypothesis that an oral polio vaccine, tested in Africa in 1958, in the very place that is now the epicenter of the disease, may have enabled the simian immunosuppressive virus to cross species from chimps to humans. This hypothesis is one among several about how the simian immune virus could have mutated into a human disease. Of course, there’s no ethical way of proving any of them, so we will never actually know what happened.
Chapter 3. Modern Invasive Medical Technology [00:12:53]
Anyhow, back to what we know for sure. Another background condition responsible for the rapid spread of AIDS are the tools of modern western medicine: hypodermic needles, blood banking and invasive surgical techniques. One of the first cases of recognized AIDS occurred in a Danish surgeon named Grethe Rask, who had gone to work in the Congo in 1964. She worked for three years in a rural hospital that often had no surgical gloves, doing her surgery barehanded. She fell ill in 1976, eventually having to fly back to Denmark under emergency conditions, and died there in 1977. As we saw from the CDC Report, the pneumocystis pneumonia that she had was a rare opportunistic infection that only occurs in people with severe compromise of their immune systems. According to close friends, she had no other possible route of infection than performing surgery, because she was celibate and basically spent her whole life working.
Hemophiliacs also were one of the first groups noted to have this new disease, because they needed to use pooled factor VIII to prevent bleeding. At that time, factor VIII was used from concentrated pooled serum from many units of donated blood, and by 1984 fifty percent of hemophiliacs were HIV-positive. And of course the tools of medicine don’t stay locked in offices and hospitals. Needles made their way onto the street for shooting the heroin that globalized Mafia was making available. IV drug use also preceded the arrival of HIV in New York at the Fourth of July celebration in 1976. IVDUs — that stands for intravenous drug users — soon became one of the high-risk groups for AIDS, along with hemophiliacs. Let’s take off that ugly picture.
Chapter 4. Homosexuality [00:14:54]
The fourth factor in the rapid spread of the epidemic was the migration and concentration of gay men in certain locations. How and why did this happen? Let’s go back in time to the middle of the twentieth century. The Nazi regime in Germany revealed to the world how bigotry, intolerance, racism and super-nationalism can grow into a grotesque, violent, terrifying political machine of ostracism, slavery and extermination. In Hitler’s Germany, homosexuals were forced to wear a pink triangle on their clothes, and were sent to concentration camps, along with Jews, Communists, disabled people and gypsies. I’m sorry to say that the Nazis are not the first and last people in the world to be bigoted, intolerant and racist.
When American fighting men came back home from World War II, blacks went back to the segregated South, Jews were excluded from social clubs, and not long afterward Senator Joe McCarthy and FBI Director J. Edgar Hoover took on Communists and homosexuals. The police in many large cities entrapped men in bathrooms by propositioning them and immediately arresting them if they responded. The usual punishment was not jail, but notification of the employer and public humiliation. Alan Turing, a mathematical genius who had cracked the Nazi’s submarine code, was arrested, tried and convicted under Britain’s Anti-Homosexual Statutes in 1952. He committed suicide in the summer of 1954 by taking a bite of a cyanide-laced apple in his laboratory.
What do people do when they’re living a life of harassment and persecution? They look for a place to go where they’ll be accepted, cared for and left alone. Thus ghettos form, even without state decree. After the war, people who were ostracized and harassed back in their hometowns began to seek the anonymity of big cities. A gay community sprang up in Greenwich Village in New York. Another developed as a summer vacation spot on Fire Island. In the ’60s, it was illegal to serve openly gay men at a bar. Radical gay power and liberation was launched with the Stonewall Inn Riot, the last weekend of June 1969, when a gay bar was raided by the NYPD and drag queens fought back.
However, the apogee of political success for gays was achieved not in New York but in San Francisco. Harvey Milk was elected as a supervisor, the first openly gay elected official in the nation. And some of you may have seen the recent movie, the film that was named Milk, which is about his story. In 1978, right in City Hall, Harvey Milk and the liberal mayor, George Moscone, were shot by another member of the Board of Supervisors, the anti-gay politician Dan White. Instantly, Harvey Milk became a martyr, galvanizing gay solidarity.
By 1980, the then governor of California, Edmund Brown, declared the last week in June Gay Freedom Week. This is the week of Gay Freedom Day parades all over the world, commemorating the Stonewall Riot. As a result, San Francisco became a Mecca for gay people who streamed there in great numbers. I quote Randy Shilts in And the Band Played On:
“The promise of freedom had fueled the greatest exodus of immigrants to San Francisco since the Gold Rush. Between 1969 and 1973, at least 9,000 gay men moved to San Francisco, followed by 20,000 between 1974 and 1978. By 1980, about 5,000 homosexual men were moving to the Golden Gate every year. The immigration now made for a city in which two in five adult males were openly gay.”
This group was very politically coherent. They were thrilled to come out of the closet and participate openly. Gay people started their own churches and choirs. As a result, local charities, like the Red Cross, were happy to exploit their civic mindedness. In 1980, five to seven percent of the donated blood in San Francisco was given by gay men who did not know that they were HIV-positive. Of course, immigrant groups always have their seamier side of organized crime and commercial sex. Gay men, in particular, were accustomed to covert and anonymous expression of their sexuality, and participation in the bathhouse culture was more mainstream for them. Remember, many of these young men had been repressing and hiding their sexuality for most of their lives, and when society denies people healthy ways of expressing their sexuality, all kinds of strange things begin to happen. Many of the strange things that happened in the bathhouses are perfect methods of transmitting every kind of infection; especially Hepatitis B, giardia, salmonella, and something brand new, HIV.
And if you don’t know what the bathhouses are, I would recommend that you read Randy Shilt’s book and find out. So, this is the background of AIDS: globalization, modern invasive medical technology, and ghettoizing of gay people.
Chapter 5. Uncovering the Medical Basis [00:20:36]
Okay, let’s return to 1981 and the first report in the medical literature, that you all have in your hands. Western doctors who read it were oblivious to the fact that while everyone was celebrating the World Health Organization’s successful program to eradicate smallpox in 1978, a stealthy brand new germ had spread from Central Africa, via professionals who had worked there, to both Haiti and Europe. It had been introduced to centers of commercialized gay sex, once it had spread into the blood banks and hospitals of every nation, into intravenous drug users and into their partners and babies.
Of course, when the first horrible deaths from weird infections occurred in the late ’70s and early ’80s, doctors had no idea that the cause of this mysterious immunological deficiency was a retrovirus, that it was a slow virus and had been contracted up to ten years before. The first characteristic of the disease observant doctors noticed was its typical STD pattern. It affected exactly the same high-risk groups that syphilis and Hepatitis B affect: gay men, prostitutes of both sexes, intravenous drug users, and hemophiliacs. This epidemiological pattern caused instant recognition in the minds of the knowledgeable. They immediately knew that this was an infectious disease caused by a virus and bodily fluids. That’s why the first reports submitted in 1981 were published immediately in the MMWR.
Take another look at the paper yourselves. Imagine reading it and instantly predicting the awful future. Luckily for all of us, Dr. Don Francis, the man in the sweater, did just that. He was a thirty-eight-year-old epidemiologist who was at the time working with the gay community on developing a Hepatitis B vaccine. His Ph.D. project and lab work had been on retroviruses. On hearing about these two reports, he instantly put two and two together, to predict that this was a virus responsible for immunosuppressant and to predisposing to cancers, as well as opportunistic infections. Why, just the year before, in 1980, Dr. Robert Gallo of the National Cancer Institute had shown that a retrovirus he called HTLV caused a type of leukemia common in Japan. It was contagious and had a frighteningly long incubation period.
Dr. Francis at the CDC understood immediately, in 1981, what sort of a disaster was in the making, and so right away he began trying to move heaven and earth, to get money for research for virus labs to isolate the virus and get a diagnostic test. But his pleas fell mostly on deaf ears. A few did eventually pay attention to him, luckily, and a year later Dr. Gallo, at the NCI was finally convinced that Dr. Francis was right, and dedicated a portion of his lab to the research.
Meanwhile in France, Professor Luc Montagnier of the Pasteur Institute, and in San Francisco Jay Levy, were also working on trying to isolate the virus. The French isolated it first, and soon afterwards applied to the Patent Office in the United States for blood tests. Gallo’s lab announced in 1884 that they had discovered the AIDS infectious agent, applied also for a patent, and tried to take all the credit for the discovery. This led to an unpleasant and embarrassing squabble between France and the U.S. We always seem to be getting into little squabbles with them. Finally after lawsuits, congressional investigations and public apologies, everyone agreed on a way to share. A settlement negotiated in 1987 named Montagnier and Gallo as co-discoverers, and divided the royalties from the blood test between an AIDS foundation, the NIH and the Pasteur Institute.
The 2008 Nobel Prize in Medicine went to Dr. Montagnier for his discovery. As you can see, it is he who is smiling, not Dr. Gallo. Montagnier’s and Gallo’s efforts had produced a diagnostic, at least a blood test, by 1984. This had enormous implications, of course, for the blood banking industry. It also meant that populations could be screened to find out who was infected. Naturally, epidemiologists wanted to screen the high-risk populations to find out the actual extent of the epidemic. They wanted to do what epidemiologists always do; try to contain the disaster by identifying carriers and their contacts, and by preventing the spread of the infection. Unfortunately, they knew that trying to work with the two high-risk groups, MSMs — that’s men who have sex with men — and IVDUs was not going to be easy.
As an example, gay Gaëtan Dugas, the Canadian airline steward who is known as Patient Zero, estimated he had approximately 250 sexual partners per year, and carried on like that for longer than ten years. Busy guy. The hotline at the Kaposi’s Sarcoma Foundation began receiving repeated calls from people who had had sex in a sex parlor with a Frenchman, and he then calmly told them that he had gay cancer, or Kaposi’s sarcoma. This is Gaëtan Dugas. And this is what one of the signs of Kaposi’s sarcoma. As a result, a director of the San Francisco Public Health Department had to confront him of the consequences of his behavior. His pithy response to her was, “It’s none of your god-damned business. It’s my right to do what I want to do with my own body.” If I was totally cool, I would say that with a French accent, but I’m not.
Next, the exact mechanisms of pathogenesis were worked out. HIV was shown to be transmitted by sexual contract from exposure to infected blood, or from an infected mother to her fetus or breastfed infant; although the paranoid public thought that you could get it from doorknobs and toilet seats. Once the virus gained access to the new host, it would target lymphocytes in the blood with the CD4 surface molecule. After gaining entry to these important cells in the immune system, since the virus is cytopathic and cell killing it would replicate, kill the cell, and release into the bloodstream, causing a viremia of billions of particles.
Researchers discovered that they could follow the course of the disease by counting CD4 cells. More recently, the ability to measure viral loads directly has also become possible, and so this is presently a routine means of monitoring the course of disease and impactive treatments. In healthy people, CD4 counts are over 500 cells per millimeter cubed, and when the count drops under 200 the person experiences significant immunodeficiency, so that their body cannot fight off opportunistic infections like TB, pneumocystis pneumonia — or PCP as it’s called — toxoplasmosis and cryptococcal meningitis.
Here’s a chart showing the most common presenting complaints in a Haitian clinic, leading to a diagnosis of AIDS. You can see that fifty-four percent presented with TB. Sorry, yes, extra pulmonary and pulmonary TB. Ten percent were diagnosed as part of pregnancy screening. And the third largest group had what was called “slim disease”; which is basically wasting away.
Chapter 6. Treatment [00:28:51]
Once the pathogenesis was understood, strategies for treatment could be developed. This has consisted of three prongs of attack: 1, Aggressive treatment and prevention of the opportunistic infections that ravaged the bodies of immuno-compromised people; 2, antiretrovirals, and more recently, protease inhibitors. That’s lots of pills.
The invention of antiretroviral agents began with AZT, introduced in 1987. Since then, more than fourteen have been approved by the FDA, the Food and Drug Administration, which is incredibly fast approval. Usually the FDA is very slow and deliberate about approving new drugs. However, because of intense pressure from gay activists, like ACT UP, the rules were changed for AIDS medications. In 1994, the Pediatric AIDS Clinical Trial Group protocols showed that AZT, taken during pregnancy, could significantly reduce the vertical transmission of HIV from mother to baby. There’s also firm evidence now that drugs given after exposure, for medical workers, rape victims, or other unprotected sex, offers a good hope of prevention. This is called post-exposure prophylaxis. And the most recent discovery is that circumcision offers some protection to men.
In the space of seven years, from the first reported cases in 1981 of agonizing deaths in young gay men, the scientific medical establishment was able to unravel the mystery of the disease and start treating it. However, because of globalization, and because of cultural attitudes towards sex — that we’ll talk about — HIV/AIDS had already spread around the entire world, within those seven years, and was decimating Sub-Saharan Africa.
Since 1987, tremendous strides have been made in wealthy countries in treating the disease with complicated and expensive multiple drug regimens. Recommendations from a CDC panel in 2002 state: “Antiretroviral regimens are complex, have serious side effects, pose difficulty with adherence, and carry serious potential consequences from the development of viral resistance because of non-adherence to the drug regimen, or suboptimal levels of antiretroviral agents. Haitian involvement in therapeutic decisions is critical.” It’s a full-time job, being HIV-positive, just keeping track of your medications. These treatments cost well over fifteen hundred dollars a month, and turn AIDS into a chronic illness.
Most of the people in the world, however, are too poor to have access to these expensive drugs and complex healthcare interactions. The majority of people with AIDS waste away, and die, between the ages of twenty-five and forty-four, without the benefit of any medical care. Despite millions of dollars, and years of trying, all attempts at developing a vaccine have been dismal failures so far. But this is basically an STD, isn’t it? What about prevention? We all know that STDs are potentially preventable. So, why wasn’t something done at the beginning of the epidemic? Why did the world wait around for science to be worked out before going into action to do something about the disaster?
You can bet that all smart medical personnel, like this lovely nurse, instantly put on gloves, gowns and masks, and instituted universal precautions; which is the modern day quarantine. Why didn’t everybody else put on their condoms? Our culture greeted the news of this frightening new disease with the same old counterproductive reactions of the past — scapegoating, mass hysteria — and the public was given a front row seat by modern mass media to the confrontation between the Religious Right, led by people like Reverend Jerry Falwell and his Moral Majority, and organized gays like ACT UP. It was even more exciting than professional wrestling.
Chapter 7. Public Health Challenges [00:33:26]
When the media and the public realized, however, that unsuspecting patients were being infected by the blood supply, people with AIDS were ostracized.
Hemophiliac children were prevented from attending school. Haitian immigrants were excluded from the country. People were afraid to donate blood. They associated walking into a blood bank with catching the disease. But when Rock Hudson, a movie star icon of male charisma at the time, announced he had AIDS, and died of it in 1985, the American media and its adoring public finally decided we’d better get serious about all of this. Old religious ideas about sexuality took on fresh meaning. Suddenly everyone began talking about celibacy, monogamy and abstinence. The sixties and seventies had been a time of liberalization of old sexual mores in Western civilizations. With the invention of the birth control pill, legalized abortion and effective treatments for STDs, many religious fundamentalists had been very unhappy. Now they could climb into their pulpits and preach fire and brimstone.
Jerry Falwell, a Baptist minister pronounced: “AIDS is not just God’s punishment for homosexuals, it is God’s punishment for the society that tolerates homosexuals.” The Roman Catholic Church, ruled by the Pope from the Holy See at the Vatican as an absolute monarch, made a response through its Global Government of Bishops and Parish Priests. The Catholic Church also condemned homosexuality. And since the Catholic Church is opposed to all birth control, the use of condoms was also condemned.
Now, the gay community has a particular interest in the Catholic Church. They suspect that many who have taken a vow of celibacy may actually be closet homosexuals. As a result, a decision was made by the gay community to hold their annual World Pride Celebration in Rome in the Year 2000. This was especially maddening because the late Pope John Paul II and the Vatican had mobilized tremendous resources to celebrate the 2000 Years of Christianity, the Jubilee. The church tried pressuring the Italian government to remove its support for the Gay Pride demonstration.
The pope appeared to make the following statement: “In the name of the Church of Rome, I must express sadness for the affront to the Grand Jubilee of the Year 2000, and for the offense to the Christian values of the city that is so dear to the hearts of the Catholics of the world. Homosexual acts are against Nature’s laws. The church cannot silence the truth, because this would not help discern what is good from what is evil.” Before AIDS emerged in the United States, right-wing religious groups had organized politically around anti-abortion agendas. This group, which uses the buzzwords “right to life” and “family values,” was already up and running, with big clout on the Republican Party’s platform. They had helped to elect the conservative California governor, President Ronald Reagan in 1980. He was in the White House, busy slashing the healthcare budget when the AIDS tragedy unfolded. A disease of gay men and drug users was not a priority for him.
At a time that called for strong leadership to contain a major emerging epidemic, our president chose to remain oblivious to the insistent demands of the CDC and gay rights groups to be proactive about preventing the spread of suffering. In addition, he had instituted the gag rule, which effectively defunded the United Nations Population Fund, the largest backer in the world of women’s reproductive health, the clinics where poor people get condoms. When President Reagan nominated Dr. C. Everett Koop to be his surgeon general, feminists, gays and pro-choice groups were worried because this pediatric surgeon from Philadelphia had a reputation for an anti-choice agenda. Finally, five years into the epidemic, President Reagan responded to mounting pressure by asking Dr. Koop to prepare a report on AIDS.
Dr. Koop is a great guy. He’s a good, hard-working doctor, and he got busy for the next nine months doing a thorough and honest job investigating the epidemic. He ended up writing a lot of the report by himself. To the medical profession’s delight, the report was explicit, non-judgmental, controversial and popular. It contributed significantly to providing accurate, comprehensive information to the public. Koop also personally penned “Understanding AIDS,” the public health brochure. He made the decision to send the brochure to all 107 million U.S. households in 1988, the largest public health mailing ever. And rumor had it at the time that President Reagan didn’t find out about it until after — after he got his in the mail, I guess.
Aside from Dr. Koop, however, the Reagan administration had two political agendas that could not have been more inimical to containing the epidemic. The statistics speak for themselves. Instead of providing more funding to the government’s health agencies to deal with the problem, the administration was slashing budgets. In addition, they blocked efforts of sex educators worldwide, around STD prevention, the so-called gag rule. The large groups of people who believe in preventive medicine began lobbying hard for good sex education and PR for condom use. But Republicans and the religious right have consistently tried to block providing this education in public schools and on TV, while legislating abstinence-only education, to which billions of dollars have been given.
The gay community, of course, educated themselves about safer sex, but they blocked the closing down of the bathhouses for an unconscionable amount of time. Another preventive strategy that can tremendously slow the spread of HIV is needle exchange programs. IVDUs — intravenous drug users — reuse dirty needles. In countries that provide sterile needles in exchange for dirty ones, the spread of disease among this group slows dramatically. However, in the United States, these programs have been blocked by the religious right. One of the most depressingly shortsighted responses to the epidemic was that of the blood banking industry. The Food and Drug Administration is the federal agency that regulates them, but politics prevented them from doing the right thing.
Dr. Don Francis and the CDC were desperately trying to convince the FDA, the Red Cross, the American Association of Blood Banks, the National Hemophilia Foundation, to institute screening of blood for Hepatitis B, even before the blood test for HIV had been invented. Because gay men had cooperated in the research for a vaccine against Hepatitis B, it was clear to everyone that the same people at risk for one disease were at risk for the other. But the gay groups were absolutely paranoid about screening of any kind. They feared the stigma of positive blood tests would affect their — would make them lose their job and their insurance, and the blood banking industry was very happy to go along with the gay lobby because it would be so expensive and such a big deal for them to screen the blood. Therefore, even though Don Francis was openly accusing them of negligent homicide, the Red Cross did nothing until 1985, when the screening test for HIV became available. Prior to this, babies needing transfusions, grandmothers needing hip replacements, hemophiliacs, their wives, and many others had died premature, prolonged and painful deaths, from the contaminated blood supply.
Once blood testing became routine, politically organized gay groups successively got irrationally stringent confidentiality laws passed around the screening test, and those regulations have had a negative impact on collecting accurate statistics ever since. Luckily, not all reactions to the AIDS crisis were based on intolerance, political expediency, financial shortsightedness and self-interest. Many nurses, doctors, families and friends of victims, ministers and rabbis, rallied around to provide support, to organize fundraising, to apply political pressure, and countless acts of compassion and charity.
A heartrending and beautiful reminder of this is the AIDS Quilt, which is part of the Names Project. Their stated goals are to provide a creative means for remembrance and healing; to illustrate the enormity of the AIDS epidemic; to increase public awareness of AIDS; to assist with HIV prevention education; and to raise funds for community-based AIDS service organizations. Anyone can commemorate someone who died of AIDS by making a panel of the quilt, which is the size of a gravestone, three feet by six feet, with the name, the dates, and any memorabilia on it. A documentary about the project called Common Threads won an Academy Award in 1990 and is available for you to watch. In October of 1996, the AIDS Quilt was unfurled in Washington, DC. It was a mile long, extending from the Washington Monument to Capitol Hill. I just want to say it’s a little different living through an epidemic than reading about it.
Chapter 8. Future Directions [00:44:10]
Many thoughtful religious people were jolted into reexamining their proper role in this crisis, with regards to human sexuality and health. The Episcopal Bishop of Newark, New Jersey, John Shelby Spong, became famous with the press in the 1980s because of his active role in ordaining gay priests, and his work against homophobia. He, along with others, formed a taskforce on changing patterns in sexuality and family life, to examine changes in modern society, and to make recommendations for study for the National Episcopal Convention in 1987. The taskforce recommended, in relation to premarital sexual activity, “that all relationships are to be assessed in terms of their capacity to manifest marks of the realm of God; healing, reconciliation, compassion, mutuality and concern for others, both within and beyond one’s immediate circle of intimacy.” With regard to issues of committed homosexual relationships, the report suggested that “ideally homosexual couples would find within the community of the faithful, the congregation, the same recognition and affirmation which nurtures and sustains heterosexual couples and their relationships; including, where appropriate, liturgies which recognize and bless such relationships.”
Many religious people were eager to become a source of encouragement and healing, instead of guilt and shame, for the myriad of people who do not fit into narrowly defined, unrealistic sexual roles. Reactions to the AIDS epidemic has caused ongoing struggles within traditional religions around the issue of gay relationships and premarital sex education, and this continued into the new millennium. Three days after the tragedy of 9/11, the Reverend Jerry Falwell pronounced on the 700 Club, the Christian TV show: “I really believe that the pagans and the abortionists, and the feminists and the gays and the lesbians that are actively trying to make an alternative lifestyle, the ACLU, People for the American Way, all of them, who have tried to secularize America, I point the finger in their face and say, ‘You helped this happen.’”
CNN sat up and took notice of this, and gave the executive director of the National Gay and Lesbian Taskforce an opportunity to respond. She answered by saying, “The terrible tragedy that has befallen our nation, and indeed the entire global community, is the sad byproduct of fanaticism. It has its roots in the same fanaticism that enables people like Jerry Falwell to preach hate against those who do not think, live, or love in the exact same way he does. The tragedies that have occurred this week did not occur because someone made God mad, as Dr. Falwell asserts. They occurred because of hate, pure and simple. It’s time to move beyond a place of hate and to a place of healing. We hope that Mr. Falwell will apologize to the U.S. and world communities.”
The sad fact is that any one of us can get AIDS, in the same way that anyone can be the victim of a terrorist. You don’t have to do anything to deserve it. All you have to do is be in the wrong place at the wrong time. Whether we like it or not, in this twenty-first century, we are one overgrown human family of more than 6.7 billion individuals, packed into a global village. The thirty-three million among us who live with HIV/AIDS are a huge reservoir for all sorts of opportunistic infections, because of immune compromise. As a result, syphilis and TB have made a comeback. Multiple-drug-resistant TB is becoming a growing problem.
At present, our best hopes for prevention of HIV/AIDS in the future lies in unfettering the gags on the sex education community; providing condoms; supporting and promoting monogamy, regardless of sexual preference; needle exchange programs; universal access to family planning and prenatal care; and in funding viral research. Wherever the next killer epidemic starts, like AIDS did in Africa, it won’t take long to infect the whole earth if governments insist on playing politics with the medical profession and public health institutions.
Evidence-based medicine, not religious revelation, should be the basis of decision making when it comes to containing epidemics. Our future relies on clever, energetic young people, like yourselves, deciding that you’re not afraid of the hard work and complicated, unpopular truths that are an integral part of maintaining public health. Here’s a list of questions to get you started thinking and talking about sexually transmitted diseases and public policy. And I think you’re going to email that to them, right? So, you don’t have to copy it down. Good luck.
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