The Coming Plague

by Laurie Garrett

  In 1975 the U.S. government spent $360 million on drug treatment and prevention programs, and $320 million on law enforcement aimed at narcotics control. By 1980 those figures had shifted to $410 million for treatment and prevention, half a billion dollars for law enforcement. By 1989 those figures would have soared to $1.2 billion for treatment and prevention efforts and $2.66 billion for law enforcement. Institute of Medicine, Treating Drug Problems, Vol. 1 (Washington, D.C.: National Academy of Sciences, 1990).

  47 New Jersey Department of Health, “Statistical Perspectives on Drug Abuse Treatment in New Jersey, 1985,” CN 362, Office of Data Analysis and Epidemiology, Trenton, NJ, 1986.

  48 C. E. Cherubin, “Infectious Disease Problems of Narcotic Addicts,” Archives of Internal Medicine 128 (1971): 309–13.

  49 D. P. Levine and J. D. Sobel, Infections in Intravenous Drug Abusers (Oxford, Eng.: Oxford University Press, 1991).

  50 Ibid.

  51 E. Drouhet, B. Dupont, C. Lapresle, and P. Ravisse, “Nouvelle Pathologie: Candidose Folliculaire et Nodulaire avec les Localisations Ostéo-Articulaires et Oculaires au Cours des Septicemies à Candida albicans chez les Héroïn Omanes, Mono et Polythérapic Antifongue,” Bulletin de la Société Française Mycologique Médecin 10 (1981): 179–83.

  52 J. Mills and D. Drew, “Serratia marcescens Endocarditis: A Regional Illness Associated with Intravenous Drug Abuse,” Annals of Internal Medicine 84 (1976): 29–35.

  53 Bacterial subtypes 29/52/80/95 in Detroit; 29/77/83A/85 in Boston. See L. R. Crane, D. P. Levine, M. J. Zervos, and G. Cummings, “Bacteremia in Narcotic Addicts at the Detroit Medical Center: I. Microbiology, Epidemiology, Risk Factors, and Empiric Therapy,” Review of Infectious Diseases 8 (1986): 364–73; and D. E. Craven, A. I. Rixinger, T. A. Goularte, and W. R. McCabe, “Methicillin-Resistant Staphylococcus aureus Bacteremia Linked to Intravenous Drug Abusers Using a ‘Shooting Gallery,’” American Journal of Medicine 80 (1986): 770–76.

  54 L. B. Reichman, C. P. Felton, and J. R. Edsall, “Drug Dependence: A Possible New Risk Factor for Tuberculosis Disease,” Annals of Internal Medicine 139 (1979): 337–39.

  55 The exceptions, of course, were the middle- and upper-class cocaine addicts. By 1985 a multimillion-dollar industry for treatment of such individuals would flourish worldwide. One would even bear the imprimatur of the wife of a former U.S. President, Betty Ford.

  11. Hatari

  1 Centers for Disease Control, “Pneumocystis Pneumonia—Los Angeles,” Morbidity and Mortality Weekly Report 30 (1981): 250–52.

  2 Centers for Disease Control, “Kaposi’s Sarcoma and Pneumocystis Pneumonia Among Homosexual Men—New York City and California,” Morbidity and Mortality Weekly Report 30 (1981): 305–8.

  3 The often-cited first popularly published account of these cases was written by Lawrence Altman: “Cancer Outbreak in Homosexuals,” New York Times, July 3, 1981: 20. In point of fact, the first published account of a mysterious new ailment in the gay community was authored by Dr. Lawrence Mass and appeared on May 18, 1981, in the New York Native.

  4 Many details of the first days of the AIDS epidemic, particularly in the United States, can be found in D. Black, The Plague Years (New York: Simon & Schuster, 1986); S. Connor and S. Kingman, The Search for the Virus (London: Penguin, 1988); M. Daly, “AIDS Anxiety,” New York, June 20, 1983: 23–29; L. Kramer, The Normal Heart (New York: New American Library, 1985); R. Shilts, And the Band Played On (New York: St. Martin’s Press, 1987); and F. P. Siegal and M. Siegal, AIDS: The Medical Mystery (New York: Grove Press, 1983).

  5 By 1990 the CDC’s budget was $1 billion. The nearly fourfold increase was largely related to AIDS surveillance, state health department support for HIV work, and AIDS education campaigns.

  6 S. E. Follansbee, D. F. Busch, C. B. Wofsy, et al., “An Outbreak of Pneumocystis carinii Pneumonia in Homosexual Men,” Annals of Internal Medicine 96 (1982): 705–13.

  7 S. K. Dritz, “Medical Aspects of Homosexuality,” New England Journal of Medicine 302 (1980): 463–64.

  8 Centers for Disease Control, “Acquired Immune Deficiency Syndrome (AIDS): Precautions for Clinical and Laboratory Staffs,” Morbidity and Mortality Weekly Report 31 (1982): 577–80.

  9 Larry Kramer, Joseph Sonnabend, Michael Callen, and Richard Berkowitz penned dire warnings to the gay community that appeared in the New York Native, then the city’s leading gay newspaper. Sadly, the most outspoken leaders of the gay community at the time, and the Native itself, roundly denounced Kramer and Callen. The pair were reviled as homosexuals filled with self-loathing; antisex gays who wanted their fellow travelers to return to the quiet, closeted days before Stonewall. Kramer, in particular, was called everything from a homophobe to a hateful fearmonger. The campaign against Callen would start slowly, but would snowball until, in 1983, false rumors would spread that the gay activist was secretly a Christian fundamentalist, working for the Reverend Sun Myung Moon.

  10 K. B. Hymes, J. B. Greene, A. Marcus, et al., “Kaposi’s Sarcoma in Homosexual Men: A Report of Eight Cases,” Lancet II (1981): 598–600.

  11 M. S. Gottlieb, R. Schroff, H. M. Schanker, et al., “Pneumocystis carinii Pneumonia and Mucosal Candidiasis in Previously Healthy Homosexual Men: Evidence of a New Acquired Cellular Immunodeficiency,” New England Journal of Medicine 305 (1981): 1425–31; H. Masur, M. A. Michelis, J. B. Greene, et al., “An Outbreak of Community Acquired Pneumocystis carinii Pneumonia: Initial Manifestation of Cellular Immune Dysfunction,” New England Jonrnal of Medicine 305 (1981): 1431–38; and F. P. Siegal, C. Lopez, G. S. Hammer, et al., “Severe Acquired Immunodeficiency in Male Homosexuals, Manifested by Chronic Perianal Ulcerative Herpes Simplex Lesions,” New England Journal of Medicine 305 (1981): 1439–44.

  12 W. L. Drew, L. Mintz, R. C. Miner, et al., “Prevalence of Cytomegalovirus Infection in Homosexual Men,” Journal of Infectiouis Diseases 143 (1981): 188–92.

  13 H. Masur, M. A. Michelis, J. B. Greene, et al., “An Outbreak of Community-Acquired Pneumocystis carinii Pneumonia,” New England Journal of Medicine 305 (1981): 1431–38.

  14 W. W. Darrow, D. Barrett, K. Jay, et al., “The Gay Report on Sexually Transmitted Diseases,” American Journal of Public Health 71 (1981): 1004–11.

  15 Gottlieb, Schroff, Schanker, et al. (1981), op. cit.

  16 Siegal and Siegal (1983), op. cit.

  17 W. Rozenbaum, J. P. Coulaid, A. G. Saimot, et al., “Multiple Opportunistic Infection in a Male Homosexual in France,” Lancet I (1982): 572–73.

  18 Most budgetary information outlined in this chapter was drawn, unless noted otherwise, from U.S. Congress, Committee on Government Operations, “Federal Response to AIDS” (Washington, D.C.: Government Printing Office, November 30, 1983); and U.S. House of Representatives, Hearings Before a Subcommittee of the Committee on Government Operations, “Federal Response to AIDS,” August 2, 1983.

  19 No laboratory funds were specifically earmarked for the group, though lab research is generally the most expensive component of any scientific investigation.

  20 Original members included Drs. Willy Rozenbaum, Jacques Leibowitch, Serge Kernbaum, Jean-Claude Gluckman, David Klatzmann, Odile Picard, and Charles Mayaud, as well as Claude Villalonga and Jean-Baptiste Brunet. For a detailed description of French anti-AIDS efforts, see M. D. Grmek, History of AIDS: Emergence and Origin of a Modern Pandemic (Princeton, NJ: Princeton University Press, 1990).

  21 A. R. Moss, P. Bacchetti, M. Gorman, et al., “AIDS in the ‘Gay’ Areas of San Francisco,” Lancet I (1983): 923–24.

  22 A good synopsis of the early San Francisco Cohort findings can be found in the CDC’s Morbidity and Mortality Weekl
y Report 34 (1985): 573–75, entitled “Update: Acquired Immunodeficiency Syndrome in the San Francisco Cohort Study, 1978–1985.”

  23 In his revealing book, Koop: The Memories of a Family Physician (New York: Random House, 1991), former Surgeon General C. Everett Koop described in detail his struggles over AIDS. He asserted, “Within the politics of AIDS lay one enduring, central conflict: AIDS pitted the politics of the gay revolution of the seventies against the politics of the Reagan revolution of the eighties.”

  24 E. N. Brandt, “Implications of the Acquired Immunodeficiency Syndrome for Health Policy,” Annals of Internal Medicine 103 (1985): 771–73.

  25 According to the U.S. Public Health Service, AIDS-related actual spending in FY 1982 and 1983 broke down as follows:

  (In thousands)

  Agency FY 1982 FY 1983

  ADAMHA (Alcohol, Drug Abuse, and Mental Health Administration) $ 0 $ 516

  CDC (Centers for Disease Control) $2,050 6,202

  FDA (Food and Drug Administration) 150 350

  NIH (National Institutes of Health):

  NCI (Nat‘l Cancer Institute) 2,400 9,790

  NHLBI (Nat’l Heart, Lung and Blood Institute) 5 1,202

  NIDR (Nat‘l Institute of Dental Research) 25 25

  NINCDS (Nat’l Institute of Neurological, Coronary Disease and Stroke) 31 684

  NIAID (Nat‘l Institute of Allergy and Infectious Diseases) 297 9,223

  NEI (Nat’l Eye Institute) 33 45

  DRR (Department of Research Resources) 564 699

  National Institutes of Health Totals $3,355 $21,668

  Grand Total Public Health Service Spending $5,555 $28,736

  26 Memorandum, Dr. James Wyngaarden, Director, National Institutes of Health, to Board of Institute Directors, July 13, 1982.

  27 G. Bosker, “Gays and Cancer—Blaming the Victims?” In These Times, August 25—September 7, 1982: 2.

  28 The events are described in D. M. Auerbach, W. W. Darrow, H. W. Jaffe, and J. W. Curran, “Cluster of Cases of the Acquired Immune Deficiency Syndrome,” American Journal of Medicine 76 (1984): 487–92; W. W. Darrow, “AIDS: Socioepidemiologic Responses to an Epidemic,” in R. Ulak and W. F. Skinner, eds., AIDS and the Social Science: Common Threads (Lexington: University Press of Kentucky, 1991), 82–99; and Centers for Disease Control, “A Cluster of Kaposi’s Sarcoma and Pneumocystis carinii Pneumonia Among Homosexual Male Residents of Los Angeles and Orange Counties, California,” Morbidity and Mortality Weekly Report 31 (1982): 305–7.

  29 R. Shilts, “Patient Zero: The Man Who Brought the AIDS Epidemic to California,” California, October 1987: 96–99, 149–60; and R. M. Henig, A Dancing Matrix (New York: Alfred A. Knopf, 1993).

  30 The early AIDS gay clusters looked like this:

  Sources: D. M. Auerbach, W. W. Darrow, H. W. Jaffe, and J. W. Curran, “Clusters of Cases of the Acquired Immune Deficiency Syndrome,” American Journal of Medicine 76 (1984): 487–92; W. W. Darrow, “AIDS: Socioepidemiologic Responses to an Epidemic,” in R. Ulack and W. F. Skinner, eds., AIDS and the Social Sciences (Lexington: University Press of Kentucky, 1991), 82–99; and W. W. Darrow, M. E. Gorman, and B. P. Glick, “The Social Origins of AIDS: Social Change, Sexual Behavior, and Disease Trends,” in D. A. Feldman and T. M. Johnson, eds., The Social Dimensions of AIDS: Method and Theory (New York: Praeger, 1986), 95–107.

  31 In Auerbach, Darrow, Jaffe, and Curran (1984), op. cit., the question of latency was depicted as follows:

  32 L. Corey, “The Diagnosis and Treatment of Genital Herpes,” Journal of the American Medical Association 248 (1982): 1041–49.

  33 Centers for Disease Control, “Update on Kaposi’s Sarcoma and Opportunistic Infections in Previously Healthy People in the United States,” Morbidity and Mortality Weekly Report 3 (1982): 294–301.

  34 Centers for Disease Control, “Opportunistic Infections and Kaposi’s Sarcoma Among Haitians in the United States,” Morbidity and Mortality Weekly Report 31 (1982): 353–61.

  35 For a detailed account of Haiti’s AIDS epidemic and its political dimensions in the United States, see P. Farmer, AIDS and Accusation: Haiti and the Geography of Blame (Berkeley: University of California Press, 1992).

  36 R. Altema and L. Bright, “Only Homosexual Haitians, Not All Haitians,” Annals of Internal Medicine 99 (1983): 877.

  37 Jaffe’s rough pictograph of the epidemic appeared as follows:

  Source: H. W. Jaffe, D. J. Bregman, and R. M. Selik, “Acquired Immune Deficiency Syndrome in the United States: The First 1,000 Cases,” Journal of Infectious Diseases 148 (1983): 339–45.

  38 Centers for Disease Control, “Pneumocystis carinii Pneumonia Among Persons with Hemophilia A,” Morbidity and Mortality Weekly Report 31 (1982): 365–67.

  39 Centers for Disease Control, “Possible Transfusion-Associated Acquired Immune Deficiency Syndrome (AIDS)—California,” Morbidity and Mortality Weekly Report 31 (1982): 652–54.

  40 Centers for Disease Control, “Unexplained Immunodeficiency and Opportunistic Infections in Infants—New York, New Jersey, California,” Morbidity and Mortality Weekly Report 31 (1982): 665–67.

  41 B. D. Colen, “Epidemic Baffles U.S. Experts,” Newsday, September 12, 1982: 14, 27.

  42 H. W. Jaffe, D. J. Bregman, and R. M. Selik, “Acquired Immune Deficiency Syndrome in the United States: The First 1,000 Cases,” Journal of Infectious Diseases 148 (1983): 339–45.

  43 In defense of the lassitude of government responses vis-à -vis the blood supplies of the United States, Canada, and Western European countries, it would later be argued that such surveys were impossible until the etiologic agent of AIDS was discovered. However, in the absence of a viral screening test, much could have been done to study those individuals listed as “hemophiliacs” or “unknown risk factor” cases on government AIDS rosters to identify contaminated units of blood. Requests for funding of such research in the United States were consistently denied until mid-1984.

  44 T. Beardsley, “British AIDS: Whose Blood Can Now Be Safe?” Nature 303 (1983): 102.

  45 In 1983 blood was collected in the United States by 180 regional centers and 1,800 hospitals, all members of the American Association of Blood Banks. In addition, some 3,800 smaller hospitals not members of the AABB collected and transfused blood. See D. M. Surgenor, E. L. Wallace, S. H. S. Hao, and R. H. Chapman, “Collection and Transfusion of Blood in the United States, 1982— 1988,” New England Journal of Medicine 322 (1990): 1646–51.

  46 The series for which Gilbert Gaul won the Pulitzer Prize ran over several days in the Philadelphia Inquirer in September 1989.

  47 In 1980, about 11,600 of the people with hemophilia had a genetic deficiency related to Factor VIII; about 3,000 had a Factor IX deficiency. Both products were available for treatment use.

  48 It would later be shown that at least 10 percent of the injecting drug users of New Haven, Connecticut, were already infected with the AIDS virus by 1982. Since other areas have proven to have even greater numbers per capita of AIDS cases among drug users, it is assumed that far more than 10 percent of the users of East Brooklyn, Harlem, the South Bronx, and Newark were infected in 1982. See R. D‘Aquila, A. B. Williams, H. D. Kleber, and A. E. Williams, “Prevalence of HTLV-III Infection Among New Haven, Connecticut, Parenteral Drug Abusers in 1982–1983,” New England Journal of Medicine 314 (1986): 117.

  49 There were some laboratories that pooled plasma from over 30,000 donors to make a batch of Factor VIII. See P. H. Levine, “HIV Infection in Hemophilia,” Journal of Clinical Apheresis 8 (1993): 120–25.

  50 D. L. Aronson, “Infection of Hemophiliacs with HIV,” Jou
rnal of Clinical Apheresis 8 (1993): 117–19.

  51 These figures were calculated by the author based on 1980 STD data, plus hemophilia blooduse data found in L. M. Aledort, “Current Concepts in Diagnosis and Management of Hemophilia,” Hospital Practice. October 1982: 77–92; and National Institutes of Health, “Pilot Study of Hemophilia Treatment in the U.S.,” report to the Department of Health, Education, and Welfare, June 30, 1972.

  52 In lawsuits against the blood bank industry in 1992–94, Francis so testified.

  53 With the advantage of hindsight, there were other courses of action open to the FDA and the blood industry in 1983. Without knowing the cause of AIDS, they could have lowered the danger of the blood supply through:

  • Closing all plasma and blood-for-money sites. This would only be done for blood years later in the United States, following rising pressure from the voluntary donor segment of the industry. It would never be done for plasma. By 1994, however, most European, Asian, and Latin American countries would still allow commercial blood banks to pay donors. In some countries (such as Brazil and India), most blood would be purchased, and rates of HIV and hepatitis contamination would, as a result, be very high.