And the Band Played On

by Randy Shilts

  Ed Brandt would have preferred not to be in his office that day. The Oklahoma City native had planned to stay only two years on the job, after being pulled from his post as assistant chancellor for health affairs at the University of Texas to join the Reagan administration. He figured he owed it to himself and his country to put to work finally all those less-government-is-better ideas he’d been espousing his whole career. He had talked about leaving when Reagan’s first HHS secretary, Richard Schweiker, resigned last year, but Schweiker had persuaded him to stay on and help the transition.

  At the start, Brandt had viewed AIDS as a minor problem. It would be poppers, the experts told him, so he hadn’t cared much. Now, the blood transfusion cases had instructed Brandt otherwise, and he figured it was his job to hold a steady course.

  Although a Baptist Sunday School teacher, Brandt wasn’t big on proselytizing other peoples’ morality, and he was too much a doctor to see AIDS as some curse from the Almighty. Already, however, some of the more conservative doctors in the administration, the religious ones who came on board with Reagan, were alluding to the God’s-curse theory and wondering whether too much money wasn’t going into AIDS research. There were letters too, like the one from the second-grade teacher who said her mom suffered from multiple sclerosis. “Why are these homosexuals getting all the research money and my mom with MS isn’t? Are they something special?”

  Ed Brandt saw it as his job to keep rational about this. Some mid-level White House types had tried to jump the AIDS bandwagon by writing legislation that would make it a crime for a person with AIDS to donate blood. Dr. Brandt had squashed that fast. There was no evidence that AIDS patients were streaming into blood banks, he noted. There was an element of meanness to the proposal that bruised the doctor’s midwestern sensibilities—like the White House guys enjoyed kicking a guy when he was down. That wasn’t American.

  Brandt was, however, a loyal follower of President Reagan, whom he truly respected. He had played the role for months now, holding back the line on health spending, the way he believed it should be held.

  Today, that was going to have to change. Brandt didn’t believe in throwing money at a problem, but he didn’t believe in starving science either, especially, when Americans were dying. AIDS, he now saw, was simply too important to have its funding scuttled from this or that program. He started writing his memo to the Assistant HHS Secretary of Management and Budget.

  “It has now reached the point where important AIDS work cannot be undertaken because of the lack of available resources,” he wrote. The CDC needed new money, not just the money that they were pirating from other budgets. He listed the “important prevention programs” that had been “postponed, delayed or severely curtailed” by the funding diversions. “…1984 will represent the third year in a row that we will be faced with major reallocation of resources to the AIDS program,” Brandt wrote. “Such long-term diversion of resources will have a detrimental effect on CDC’s important prevention programs.”

  The memo was written just four days after Dr. Brandt told a House subcommittee that a Public Health Emergency Fund was “unnecessary” because “existing budget and appropriations processes are effective in funding these [AIDS] activities.”

  Seeing catastrophe ahead, Dr. Dan William asked the owner of the St. Mark’s Baths, a four-story facility that advertised itself as the world’s largest bathhouse, to a restaurant for dinner. William laid out his plan. He was convinced that AIDS was caused by a new virus, being spread sexually. The overwhelming preponderance of his patients were people who went to the bathhouses. Obviously, bathhouses existed solely to provide the opportunity for the maximum number of sexual contacts. Nobody was saying the places should be closed down, William explained to the proprietor, but the bathhouses had a great opportunity to take the leadership role in promoting a new type of gay club.

  William was quite taken with his idea. “The New Safe St. Mark’s,” he said. The bathhouse could take the doors off the private rooms, turn up the lights to discourage orgies, and orient the sex more toward video eroticism in which gay men could masturbate with each other but avoid the exchange of semen that probably spread this thing.

  “People can do what they want to,” William recalled that the owner responded. “I have no right to direct their behavior.”

  On its multi-storied premises, the St. Mark’s Baths had put up two signs, measuring 28 by 11 inches, warning patrons that some doctors believed AIDS was sexually transmitted, and some time later the dormatory, where group sex was practiced, was closed.

  It was only later that the economic implications of his eager suggestions occurred to William. Of course the bathhouses would not want to emphasize that a sexually transmitted disease was loose, killing their patrons. It would destroy their business. William realized that he might have been around doctors too long. He couldn’t imagine anyone not wanting to act to save lives if they possibly could. The notion that some people might place personal profit above human life was utterly foreign to him.

  Fortunately, William had recently signed on as a member of the medical advisory board of the Gay Men’s Health Crisis. He hoped the new group would be able to start pressuring these businesses to see that their long-term survival depended on adaptation to new biological realities. The changes he had suggested were so obvious that he couldn’t imagine they would not be adopted before long.

  May 18

  CAPITOL, WASHINGTON. D.C.

  The letter from Dr. Brandt arrived minutes before the full House Appropriations Committee was to hold its final session on the last major supplemental appropriations bill for the current fiscal year. Even before the letter arrived, everybody on Capitol Hill knew that the committee would vote some increase for AIDS money. The question was how much they would approve. Proponents of more research were pulling numbers from the air. Brandt solved that problem.

  “You also asked whether additional resources could effectively be used in the current fiscal year,” Brandt wrote. “As with any situation as dynamic and critical as that of AIDS, funding requirements can change rapidly. Enclose 2 is a description of additional efforts which could be accomplished now and in future months.

  “While we are not requesting additional budget authority for these items, we would not oppose Congress giving the Secretary of Health and Human Services discretionary authority to transfer up to $12 million for AIDS activities across appropriations lines of HHS.”

  The words stunned administration supporters who had taken the health officials at their word when they said they had all the funds they needed for research. Although Brandt had tried to step delicately around the issue, even the administration’s most fervent supporters did not believe that the request stemmed from any “dynamic or critical” new developments in AIDS. No matter how “rapidly” the situation changed, no dramatic breakthroughs had occurred in the days since Brandt, Foege, Devita, and Krause testified against more funds.

  The Appropriations Committee refused Brandt’s request that money be diverted from other programs and quickly approved a bill for $12 million in new funds for the NIH and CDC. Word spread through the Hill that a number of congressional members, including some Republicans, were royally pissed at the dishonesty to which they had been subjected. This thing wasn’t over yet. The House would vote on the package the next week, and aides were betting that the whole sorry story would make it to the House floor.

  In the Senate, AIDS posed a different problem, requiring maneuvers to deny that body’s cadre of ultra-right-wing members, elected during the Reagan landslide of 1980, an opportunity to expound on AIDS. Although he was a conservative Mormon from Utah, Senator Orrin Hatch, chair of the Senate Committee on Labor and Human Resources, was committed to not letting health become a partisan issue, particularly in regard to AIDS. Hatch’s committee, however, included some of the looniest, raving New Right homophobes in the Senate—Jeremiah Denton from Alabama and John East from North Carolina. Thus, when Henry Waxman’s Public He
alth Emergency Act went to Hatch’s committee, he made the unusual parliamentary move of holding the bill at his desk and allowing it to go straight to the Senate floor without a hearing. Hatch figured that it was better to have no hearing, than one in which health issues would get mixed up with the fringe Moral Majority politics.

  These were the legislative acrobatics that AIDS would routinely demand on the Hill for years to come.

  May 20

  The National Cancer Institute and National Institute for Allergy and Infectious Diseases issued a request for scientists to apply for the $2 million in grant money that Bill Kraus and Tim Westmoreland had maneuvered through Congress last fall. The application deadline was August 1. Under new, expedited processes, the money might be available by the end of the year, although, privately, most scientists figured that the money would not actually get to research institutions until 1984. This $2 million in awards marked only the second call for research proposals issued by the NIH during the epidemic.

  May 24

  With the full House vote on AIDS funding due the next day, Dr. Edward Brandt assembled the top officials from the CDC and NIH for a news conference. There was much said about the promise of the HTLV lead and about people not panicking over blood transfusions, but only one sentence mattered.

  “It’s our number-one priority,” Brandt said. “I feel a great sense of urgency about AIDS.

  “I am aware of the fact that a number of people feel we have not been sensitive enough to the problem,” said Brandt. “Our response has had nothing to do with the membership of any high-risk group involved. These people are victims of an illness and we are going to do whatever we can to stop that problem.”

  With those words, Brandt stole the thunder that the House of Representatives had planned to unleash a day later and elevated AIDS to a new dimension of importance, even if the administration was not willing to spend any more money on the problem. From now on, whenever administration officials were pressed on the federal response to AIDS, they would reply: “This is the administration’s number-one health priority.” It certainly sounded sincere enough.

  By the day that Dr. Edward Brandt declared AIDS to be the administration’s top health priority, 1,450 Americans had contracted the disease and 558 had died.

  The Next Day

  U.S. HOUSE OF REPRESENTATIVES, CAPITOL

  Congressman William Natcher needed unanimous consent of the House to introduce his last-minute amendment for an additional $12 million for AIDS research. Congressional aides Tim Westmoreland and Michael Housh held their breath in the gallery, hoping no redneck would object and wreck everything. Nobody did. Natcher and Silvio Conte co-sponsored the measure. Upon its introduction, Natcher asked that the earlier testimony of Margaret Heckler and Ed Brandt against new AIDS funding be introduced into the record. The remarks, he felt, spoke for themselves.

  Congressman Conte was obviously angry as he rose to recall how he grilled the various chiefs of the CDC, NCI, and NIAID about the adequacy of funding. To make sure their duplicity was accurately recorded, Conte inserted the interrogations word for word into the Congressional Record.

  The House of Representatives passed the funds unanimously.

  Congressman Henry Waxman shuddered as he read all the news stories about the nation’s number-one health priority. If this was how they treated their number-one health priority, he wondered, what do they do with number two or three?

  30

  MEANWHILE

  AMA NEWS RELEASE FOR RELEASE FRIDAY, MAY 6. 1983

  EVIDENCE SUGGESTS HOUSEHOLD CONTACT MAY TRANSMIT AIDS

  CHICAGO—Evidence suggesting that Acquired Immune Deficiency Syndrome (AIDS) can be transmitted by routine household contact is presented in this week’s Journal of the American Medical Association.

  James Oleske, MD, MPH, and colleagues report eight cases of otherwise unexplained immune deficiency syndrome among children from the Newark, N.J., metropolitan area born into families with recognized risks for AIDS.

  “Four of these children have died,” the authors report. “Our experience suggests that children living in high-risk households are susceptible to AIDS and that sexual contact, drug abuse or exposure to blood products is not necessary for disease transmission.”

  Related articles by Arye Rubinstein, MD, and others, and Joseph Sonnabend, NB, MRCP, and colleagues suggest that AIDS can be transmitted to fetuses in the mother’s womb, and that the syndrome is acquired by male homosexuals as a result of life-style behavior that apparently overworks and ultimately virtually destroys the immune system….

  Commenting on the study in an accompanying editorial, Anthony S. Fauci, MD, of the National Institutes of Health, points out, “We are witnessing at the present time the evolution of a new disease process of unknown etiology with a mortality of at least 50 percent and possibly as high as 75 percent to 100 percent with a doubling of the number of patients afflicted every six months.”

  At first the disease appeared to be confined only to male homosexuals, he adds. Then it became clear that IV drug users also were susceptible, and after that the disease was found among Haitians and hemophiliacs, the latter apparently exposed through transfusion of blood products.

  “The finding of AIDS in infants and children who are household contacts of patients with AIDS or persons with risks for AIDS has enormous implications with regard to ultimate transmissibility of this syndrome,” Fauci says. “If routine close contact can spread the disease, AIDS takes on an entirely new dimension,” he adds.

  “Given the fact that incubation period for adults is believed to be longer than one year, the full impact of the syndrome among sexual contacts and recipients of potentially infective transfusions is uncertain at present. If we add to this the possibility that nonsexual, non-blood-borne transmission is possible, the scope of the syndrome may be enormous.”

  AIDS DISEASE COULD ENDANGER GENERAL POPULATION

  CHICAGO (AP)—A study showing children may catch the deadly immune deficiency disease AIDS from their families could mean the general population is at greater risk from the illness than previously believed, a medical journal reported today.

  If “routine” personal contact among family members in a household is enough to spread the illness, “then AIDS takes on an entirely new dimension,” said Dr. Anthony Fauci of the National Institutes of Health in Bethesda, Maryland.

  Arye Rubinstein was astounded that Anthony Fauci could so much as even imply that household contact might have anything to do with spreading AIDS. Rubinstein had never been a great admirer of New Jersey’s Dr. Oleske; they had antithetical views of AIDS in children. To Rubinstein, the mode of transmission was fairly obvious and fit quite well with existing epidemiological data on AIDS. The mother obviously infected the child in her womb. The fetus and parent shared blood as surely as an intravenous drug user, hemophiliac, or blood transfusion recipient. The fact that none of the infants in Oleske’s study were over one year old reinforced this notion. In order to interpret this data to mean that “routine household contact” might spread AIDS, an entirely new paradigm for AIDS transmission was needed. Rubinstein’s paper explained it all very easily, though the Journal of the American Medical Association seemed more enamored with Oleske’s specious analysis. In fact, the journal at first returned Rubinstein’s paper with the section on intrauterine transmission crossed out. The paragraphs had only appeared because Rubinstein had insisted that they be retained.

  What was Fauci’s problem?

  Upon investigation, it turned out that Anthony Fauci had not been sent Rubinstein’s paper before writing the JAMA editorial. Instead, he read only Oleske’s conclusions before writing his editorial.

  As an AIDS clinician at the National Institutes of Health Hospital, Anthony Fauci was noted for his heroic efforts to save lives early in the epidemic. He had risen rapidly in the NIAID hierarchy and was deemed a major NIH expert on AIDS at the time the infamous JAMA editorial was published. Fauci quickly cast blame on a hysterical medi
a for taking his comments “out of context.” After all, he had said only that the possibility of household transmission might raise all these scientific implications. The lay public did not understand the language of science, he pleaded. Science always dealt with hypotheticals; this did not mean he was saying that AIDS actually was spread through household contact. Moreover, the chief villain, he would accurately note, was the press office of the American Medical Association, which had so shamefully sensationalized the medical journal articles in an effort to draw attention to a journal that always found itself playing second fiddle to Science and the New England Journal of Medicine.

  No matter who was to blame, the coverage afforded to the “routine household contact” press release set in motion a wave of hysteria that no disclaimer would prevent. At the San Francisco Chronicle, science editor David Perlman rewrote the story, focusing instead on Rubinstein’s interpretation of the data. After completing his revisions, Perlman proceeded to call the JAMA press office and deliver a loud dressing-down to the public relations director who had unleashed this mischief. Few other newspapers had writers as sensitive to the social fallout of AIDS stories. The New York Times and USA Today ran the flawed AP version of the press release, as did most newspapers in the United States.

  As it was, nervous health officials and reporters had spent months talking about AIDS being spread through “bodily fluids.” What they meant to say was semen and blood, but the term “semen” is one that polite people don’t use in conversation, and blood banks still objected to the use of the term “blood.” The media’s circumlocution salved sensibilities but not public fears. Saliva was a bodily fluid. Could AIDS be spread through coughing? It was a question already being asked of Selma Dritz with greater frequency. Moreover, the report created a lasting impression on the public that would raise the hysteria level around AIDS for years to come. Scientists just aren’t sure how AIDS is spread, the thinking went. Because of the long incubation period, possible transmission routes existed that might not reveal themselves until later—until it was too late. Anthony Fauci had said as much in his ill-considered editorial.