Authors: Randy Shilts
April 14, 1985
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“Don Francis is a Nazi.”
The words passed confidently from one gay leader to another as they nodded in disgust at the CDC virologist who was participating in a panel on whether gay men should take the antibody test. The hallways outside the conference room were filling with 2,000 scientists and health authorities who were registering for the first International Conference on Acquired Immunodeficiency Syndrome. Although the conference was not slated to begin until the next day, gay participants had scheduled their own meeting for this Sunday afternoon to discuss issues geared toward their community. This included a panel on the preeminent issue—the Test.
Gay panel participants entertained the audience with different reasons as to why they should all agree to oppose the antibody test. And then Don Francis spoke, summing up his thinking with two lines and two circles.
The two lines fell across each other like the cross of St. Andrew. The line sloping downward represented the overall reduction in the number of sexual contacts that most gay men had accomplished as part of the dramatic sexual counterrevolution that had seized the gay community over the past two years. That development was hopeful. However, the upward slope of the second line, representing the dramatically increased prevalence of the virus among gay men, showed why this was not good enough to save homosexual men from biological obsolescence. Reducing sexual contacts by one-half, Francis explained, was not enough if the people with whom a gay man had sex were four times as likely to infect him with the AIDS virus. The person would still have twice the chance of getting infected that he had had two years before, Francis said. Gay men were playing the AIDS lottery less often, Francis said, but when they did play, they had a far greater chance of coming across a losing ticket.
Handing out pamphlets that advised gay men to reduce their partners was important, but it was not enough, Francis said. Data from the San Francisco hepatitis study showed that gay men were still out there getting infected with the AIDS virus. The gay community needed to start thinking about control.
Francis drew his two circles. One circle represented men infected with the AIDS virus; the other, men who weren’t. The point of AIDS control efforts, he said, should be to make sure that everybody knows into which circle they fit. They should be tested, he said. People who are infected with the AIDS virus should only go to bed with people who are infected; people who aren’t infected should only have sex with other people whom they know to be uninfected. He was not recommending mandatory testing, Francis stressed, and he believed civil rights guarantees needed to be in place to encourage people to be tested. Ultimately, however, the tough choice would have to be made. The two circles should be separate, Francis warned, or tens of thousands would die unnecessarily.
“I’ve seen a lot of viruses in my day, and I’ve come to develop a profound respect for this one,” Francis concluded. “There aren’t very many viruses in the history of man that kill one-tenth of the people they infect. We need to start thinking about controlling this one.”
Francis’s call to action stunned and outraged the gay audience. Nothing proved more unsettling than the word “control.” “Control, control, control,” muttered the AIDS writer for the
New York Native.
“It’s so fascistic, the idea of putting people in circles and talking about control.”
To some extent, the semantic aversion to this word reflected the gay community’s own ignorance of public health vocabulary, a shortcoming that had remained uncorrected throughout the course of the epidemic. For decades, control had been the operative word in the lexicon of epidemiologists whose job it was to eradicate diseases. It had rarely been invoked during the AIDS epidemic, however, because there were so tragically few tools of control. For Don Francis, the most important tool was being marketed now in beige plastic boxes to blood banks. He did not want it denied to him.
More than almost anyone in government, Francis knew that serious control efforts would not be mounted by federal health authorities in the coming years. Neither the money nor the motivation existed on the federal level. He believed the gay community itself would have to be enlisted if control efforts were to be made.
Gay leaders were instantly suspicious of Francis’s rhetoric. Already, they were aggravated at his criticism of bathhouses as “commercialized sex” businesses that had served as “amplification systems,” allowing the AIDS virus to spread throughout the gay community. And Don Francis was, after all, part of the federal government that had shown precious little concern over the wholesale demise of a generation of gay men. Why, suddenly, had control become such an important goal?
Moreover, the entire thrust of Francis’s proposal was entirely foreign to them. After spending four years listening to polite public health officials chatter in the intransitive lingo of AIDSpeak, AIDS activists were unaccustomed to hearing people suggest that they might actually have to do something. So far, most gay action against the disease had consisted of holding sophisticated AIDS education forums in Manhattan auditoriums and handing out condoms at the San Francisco Gay Freedom Day Parade. Faced with the challenge that this was not enough, most of the gay participants on the panel did to Francis what they had spent the past four years doing to gays with whom they disagreed on AIDS issues. They called him names.
While Jim Curran watched nervously from the back of the room, speaker after speaker denounced Francis as a Nazi and a brownshirt who wanted to put homosexuals into concentration camps. Dr. David Ostrow, panel moderator, disagreed with Francis, but he had known Francis since the hepatitis study in the late 1970s and understood his intentions. He pleaded with people who disagreed to hold off on the personal attacks, but the animus of a people wronged was such that it proved impossible.
Privately, Jim Curran agreed with Don Francis. He had recently heard of three San Francisco gay men in the hepatitis study who, to their amazement, had only recently developed antibodies to HTLV-III. They told doctors that they had been completely monogamous in recent years; it didn’t make sense. The three men’s lovers, it turned out, were infected. These three monogamous men would have been saved, Curran knew, had they known their lovers’ antibody status. That was the answer, he thought, but the sight of the hostile audience unnerved him.
“Don Francis does not speak for the CDC,” Curran anxiously told any reporter who asked. “He’s only speaking for himself.”
Yet, in that room on that Sunday afternoon, there was an awakening among these people. To a large extent, the public health issues of the AIDS epidemic had lain in their hands during the first phase of the scourge. Although the gay AIDS activists were fond of lecturing people that “AIDS is not a gay disease,” they had in fact treated the epidemic almost solely as a gay disease, the private property of a community that would base public health policy on its own political terms. Now there were other people with other ideas, and perhaps they might stop treating AIDS as a gay affliction. Jim Curran’s skittishness indicated that this moment was not at hand, but the debate over antibody testing clearly informed many people for the first time that the day might come.
For many people, the three-day international AIDS conference, co-sponsored by the U.S. Department of Health and Human Services and the World Health Organization, marked a time of awakening.
That Night
Marc Conant was leaving the Westin Peachtree Plaza Hotel when he ran into the president of the Bay Area Physicians for Human Rights.
“Don Francis says that gay men should take the antibody test and that antibody-negative people should never have sex with antibody-positive people,” the doctor said sneeringly. “Can you believe it?”
“I agree with that,” said Conant. “Makes sense to me.” At the welcoming reception, gay doctors buzzed about Francis’s fascism while CDC staffers talked about his petition to transfer to the Bay Area, reportedly after telling Walt Dowdle that “the Centers for Disease Control has never controlled a disease in its history.”
Conant caught up with Francis. He was relieved to find somebody who spoke sensibly about the antibody test. Conant agreed with Francis that the test would inevitably find wide use throughout society. The question was only how much suffering and death was necessary to convince people, homosexual and heterosexual alike, of its exigency. Events, thought Conant, would force the issue.
Francis was upbeat about his personal future.
“If there’s any chance of stopping this disease, it will happen in San Francisco,” Francis said, his enthusiasm already building for the move.
Conant was excited. At last, he had heard somebody in the federal government talk about stopping this disease. Later, Conant heard that other CDC staffers were calling Francis’s transfer an “exile to Siberia.”
The Next Day
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“AIDS has already arrived in every major city in the developed world,” said Jim Curran in the opening presentation of the AIDS conference. Between 500,000 and 1 million Americans, he said, were infected with the AIDS virus. The infection was so endemic to the United States that a vaccine, when available, should become part of the standard inoculations administered to all children before they enter school. He suggested that clinics and physicians providing prenatal and premarital screening of people in high-risk groups should consider routinely screening their patients for HTLV-III antibodies.
Robert Gallo followed Curran’s talk with the observation that it was outrageously optimistic to be talking of a time when Americans could be vaccinated. Beyond the problems of a rapidly mutating virus that might defy attempts to create one all-effective vaccine, there was the problem of proving a vaccine was effective once it was developed. “Before you talk about a vaccine being used on the public, you have to have testing and trials—and I haven’t heard of anyone close to that point yet,” said Gallo.
The normal way to test a vaccine was to administer it to a group of people at high risk of getting a disease, and not administer it to another group. If the people who don’t get the vaccine get sick, and the vaccinated people don’t, you have an effective vaccine. This was a simple enough process with, say, hepatitis, because the people who got sick were likely to recover. Such tests for AIDS, however, created enormous ethical questions. Safe-sex instruction for all volunteers was ethically essential. This, however, would undermine the ability to assess the vaccine.
Beyond that, there were huge financial risks. What company would withstand the threat of liability lawsuits in order to develop a vaccine? The hepatitis B vaccine had become a commercial failure. Enthusiasm for vaccines had dropped considerably since then.
This was only the beginning of the bad news. The scientific observations that emerged from the 392 presentations in the following days did little to cheer up conferees. The medical insights on AIDS ran the gamut from depressing to dismal.
The virus, scientists said, was the nastiest microbe humanity had encountered in centuries, if not in all of human history. The presence of antibodies presented “presumptive evidence” of continued infection with the virus. Once infected, people carried the virus and were capable of infecting others for the rest of their lives. The virus infected brain cells and the central nervous system, creating a host of neurological disorders beyond the immune deficiency caused by infection of the T-4 lymphocytes. As Bob Gallo told the crowd, “We
do
know what the antibody test means. Antibody positivity means virus infective. I don’t think there’s going to be a better assay [for AIDS] than the antibody detection.”
Any hopes that the virus would select many as carriers but few as AIDS victims were subverted by data from James Goedert, who had been monitoring cohorts of New York and Washington gay men since 1982. Of gay Manhattan men infected with the AIDS virus, 20 percent now had AIDS and another 25 percent had serious immune problems that Goedert called lesser AIDS. Only about one-half were healthy. Of the Washington sample, 12 percent had AIDS and 11 percent had lesser AIDS. Eight percent of the Danish gay men that Bill Biggar had tested now had AIDS. Goedert suspected that the differences in AIDS rates among the cohorts only reflected the differing times at which they were infected. The virus appeared to arrive in New York first, giving the Manhattan men more time to incubate the disease. Infections in Washington followed the New Yorkers’, and the spread of the virus in Denmark came later.
Goedert felt strongly that the CDC was understating the risk posed by the virus. He was appalled when he heard people using the term “exposed” instead of “infected.” According to his reasoning, the AIDS virus needed only one cofactor to produce the fatal disease—time. The virus plus time, given enough of it, would probably kill far more than the 5 to 20 percent being optimistically projected.
Questions about the role of time in the epidemic were dramatically resolved by the incubation studies presented by the CDC’s Dale Lawrence. Although Lawrence had arrived at his conclusions in late 1983, they had only been cleared for public disclosure at this international conference one year and four months later. Pencils dropped and jaws gaped throughout the auditorium as Lawrence calmly laid out his projection that the mean incubation period for the AIDS virus was 5.5 years. Some people, he added, would not get AIDS until 14 years after their infection. These figures meant that the typical person diagnosed with AIDS in April 1985 was infected in October 1979. The huge number of people infected with the virus in 1982, 1983, and 1984, when the virus was far more prevalent, would not show AIDS symptoms until the late 1980s. Some people getting infected at the time of the conference, meanwhile, would not come down with the disease until the turn of the next century.