Prof: 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 Jos� Bov�,
a French farmer who organized a peaceful removal of McDonald’s
from his town in France? I quote once more.
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. 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 4^(th),
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.
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. 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. 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.
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.
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.
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.
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 Ga�tan 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 Ga�tan 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. 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. 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.
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.
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.
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
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. 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.