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Authors: Laurie Garrett

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Indeed, Reichman had great difficulty finding a medical journal willing to publish his 1979 findings, and the paper was rejected several times, not because of any inherent flaws in the study, but because the journals simply didn't consider a high level of active TB among junkies terribly important.
Reichman absolutely believed in 1979 that injecting drug users were passing TB infections to one another. Unfortunately, virtually all societies on the planet held injecting drug users in contempt, viewing them as dangerous criminals, pathetically weak individuals, filthy denizens of ghettos, perilously insane characters, or satanically inspired deviants. Microbial threats to such individuals were generally ignored. Nearly every legal system defined some or all drug-related activities as criminal offenses.
Injecting drug abusers were outcasts, at the bottom of the social totem poles of nearly every culture on earth.
Furthermore, physicians generally detested working with addicted patients because the individuals rarely told the truth about activities that might affect their health, often failed to follow doctors' orders, sold their prescription drugs on the streets, and, if given the opportunity, stole needles and drugs from the hospitals and clinics they visited. Physicians who chose to specialize in treating and researching the unique health problems of drug abusers often suffered denigration from their colleagues, and wealthy private hospitals wanted nothing to do with either the drug-using patients or the physicians who cared for them.
55
As a result, few professionals in the world in 1980 were in a position to notice what was going on in the heroin ecology.
One way drug users legally obtained money with which to buy narcotics was by selling their blood to hospitals and blood banks—a practice that would be outlawed in most industrialized countries by the mid-1980s but would continue in much of the developing world well into the 1990s. Most blood banks worldwide in 1980 didn't test their products for microbial contamination.
Toward the end of the 1970s a new set of players appeared on the international narcotics scene; South American cocaine cartels surfaced that converted the coca leaves of Bolivia, Colombia, and Peru into a potent white powder. Designed to be inhaled rather than injected, cocaine appealed to a different social class. It seemed “clean,” its high produced a surge of energy rather than opiated enervation. And it was very expensive.
By 1980 cocaine had supplanted vintage wine in some cities as the drug of choice for the upwardly mobile. Its popularity was so great that icons such as pop stars, society matrons, literary celebrities, and professional athletes were fairly candid about their using it. Stories of pop heroes running quickly through $20,000 to $100,000 to support a cocaine addiction filled the gossip columns.
Few microbes were able to exploit the powder cocaine ecology effectively. The powder was dry and acidic—an environment hostile to most organisms. And few addicts could afford the kinds of long-term habits seen in heroin users that allowed for the slow growth and mutation of microbes over several generations of bacterial, fungal, or viral time. But some people turned to cocaine injections, allowing the microbes to exploit a new ecology that offered most of the benefits of the heroin environment.
In 1980 Don Francis found himself in the midst of an outbreak of a new strain of hepatitis B, spread among injecting cocaine users in New Bern, North Carolina. It seemed to have begun among the teenage sons and daughters of the city's upper-crust families, who had started shooting cocaine as an adolescent fad. Soon their poorer peers were following suit, having discovered that the expensive drug went a lot further when injected, rather than snorted.
When Francis got called to New Bern to head up a CDC investigation, ten of the teenagers had died of fulminant hepatitis B infections of their livers, and many more were sick. The virus was spread, of course, through shared needles. What alarmed Francis was how rapidly these kids got sick and died. These otherwise healthy adolescents were “dropping like flies,” Francis told colleagues at the CDC. He suspected that it was what he called “a two-hit phenomenon”; some other bug was in the kids—possibly also passed by the needles—that acted in concert with the hepatitis virus to produce a disease more lethal than either could create on its own.
Francis injected hepatitis extracted from the blood of the infected New Bern teens into chimpanzees, but no disease occurred in the animals. For weeks he tried to make other test animals sick, with no result. In the end Francis was forced to give up. The New Bern teenagers stopped dying as soon as they ceased injecting cocaine, and there was no evidence that the mysterious microbes had found their way beyond the tight-knit cocaine ecology of the North Carolina city.
Not knowing what lurked out there, waiting for an ideal ecological opportunity to pounce, galled Francis no end.
Even as he closed the books on the New Bern case, another microbe was exploiting to its advantage the unique ecologies of cities on three continents.
Hatari: Vinidogodogo (Danger: A Very Little Thing)
THE ORIGINS OF AIDS
 
 
Everybody knows that pestilences have a way of recurring in the world; yet somehow we find it hard to believe in ones that crash down on our heads from a blue sky.
—Albert Camus,
The Plague
, 1948
 
And that was the day that we knew, oh! In the world there is a new disease called AIDS. I thought surely this will be the greatest war we have ever fought. Surely many will die. And surely we will be frustrated, unable to help. But I also thought the Americans will find a treatment soon. This will not be forever.
—Dr. Jayo Kidenya,
Bukoba
.,
Tanzania
, 1985
Greggory Howard stood across the street from the ugly brick building and watched as junkies went in and reformed addicts came out.
Howard had tried methadone before—who hadn't? It was easy enough to buy on the streets during tough times when the police were busting local dealers or the supply from wherever hadn't made its way to Newark.
But today he was going to walk in that door and sign up for the methadone maintenance program. Last night's hit was the last.
He'd said that before, of course, but this time Howard was fed up with beatings, arrests, and looking up at the stars from a filthy alley. He was sick and tired of being sick. He wanted to “feel good about Greggory again.”
Inside the Essex Substance Abuse Center, fluorescent light and iron bars greeted him, and Howard almost fled. But then he spotted the Dixie Cups. Methadone didn't come in Dixie Cups on the streets, but he had heard about this. It was almost impossible to steal a paper cup of neon-pink liquid and sell it on the streets. You had to drink it down right here, under glaring lights with the authorities watching.
Howard's body was trembling with the anticipation of that pink substitute high.
He stepped up to the iron-barred window and announced that he would like to quit his heroin habit.
Three thousand miles away in San Francisco, Bobbi Campbell stood adjusting his nun's habit. Campbell and friends from
Fruit Punch
, a gay men's radio talk show, had formed the Sisters of Perpetual Indulgence. The dozen or so Sisters would don their habits and carouse, given any good public forum. Handsome, black-haired Andy would shed his usual reserve and twirl a rosary while loudly declaring the beauty of gay love. Tall, thin Charlie would dance in circles singing “I Enjoy Being a Girl.” Fred, with scraggly beard and wire-rims poking out of his face-framing habit, created endless clever chants, plays on Catholic homilies.
Still in graduate school at U.C. Berkeley, Bobbi, already a nurse, was the baby-faced member of the group. He wanted being gay in 1981 to be playful and joyous. Never mind those serious-politico-homosexual-rights-types who were embarrassed by flamboyant queens. Nurse Campbell, “Soeur en Drag,” called himself Sister Florence Nightmare.
Everything about the full-time party that was San Francisco seemed fabulous to Campbell. True, everybody he knew seemed to have more than their share of one bizarre illness after another, but if it was all so joyous, who cared?
In Manhattan, Michael Callen was making music: disco dance tunes, gay love ballads, anthems. He, too, was thoroughly enjoying these days of liberation.
“Promiscuous” was a special word for twenty-six-year-old Callen. By the logic of the day, if it was liberating to openly declare one's right to have sex with a man, “it seemed to follow that
more
sex was
more
liberating,” Callen said.
Like many, if not most, of the members of Manhattan's exploding gay community, Callen had left small-town America to escape the claustrophobia of his native Ohio. Raised a strict Methodist, the slender, nonathletic youth sang in the church choir and tried to belong. But he clandestinely devoured literature on homosexuality, most of it written by straight male psychologists. And he reached two conclusions: if homosexuality was a sickness, then he had it; and the best place to be “sick” was New York.
At age seventeen he had arrived in Manhattan, and soon discovered the gay bathhouses and sex palaces. With the exception of a several-months-long affair with a gay police officer, Callen's life from 1972 to 1981 was an endless string of sexual trysts and anonymous encounters—well over a hundred per year.
Thousands of miles and as many cultural leaps away, along the shores of Lake Victoria, Noticia finally had a dignified job as secretary to a Bukoba businessman. True, his tiny business wasn't much and her pay, even by
Tanzanian standards, was rather modest, but the job was honest and covered her bills.
After a year in Mombasa and Nairobi working as a prostitute, secretarial work wasn't at all bad. She had left her village of Nganga in late 1979 when it became obvious that her family would never recover from the shame of her rape by occupying Ugandan soldiers. Now, no man would marry her.
Noticia could not have risen above outcast status unless she left Nganga. So she had followed the example of many other Mhaya women of Kagera province and made the long, difficult journey across Lake Victoria by steamship, then overland hundreds of miles to the turquoise Indian Ocean.
In the Kenyan seaside city of Mombasa, Noticia serviced the sexual needs of three or four men a day for very little money. Later, in the Sofia Town slums of Nairobi, she fared a bit better, making more money than she had in Mombasa. She saved enough money to return to Bukoba and start a new, independent life.
Noticia was a shy young woman, and her voice was as soft as silk. Her high cheekbones and dignified carriage attracted the men of Bukoba like bees to honey. They would beg her to go to the disco to dance, drink Safari beer, and listen to flattery.
Noticia felt hopeful about her future.
A thousand miles to the south, Dr. Subhash Hira and his staff at Lusaka University Teaching Hospital went over their medical records in a routine meeting. It was the usual daunting list of sexually transmitted diseases: syphilis, gonorrhea, chlamydia, chancroid, and the like. One of Hira's assistants pointed out that there was a woman on the ward suffering from an unusual case of herpes zoster: tough, perhaps a special kind of herpes.
Hira suggested that everybody keep an eye out for such things, and the meeting moved on.
In the fall of 1980, Dr. Michael Gottlieb was in his office at the University of California at Los Angeles Medical Center when a colleague asked if he would look at a particularly unusual respiratory case. A short while later, a frail man of thirty-three waited in one of the outpatient clinic's private rooms.
Gottlieb was startled by the obvious severity of the man's ailment. He appraised the patient carefully: pale, almost ashen; extremely thin, bordering on classic anorexia; a mouth full of the white “cottage cheese” indicative of a fungal infection; coughing uncontrollably, and evincing severe lung pain. It looked like pneumonia, but it was exceedingly rare that Caucasians of this age developed such brutal illness in Los Angeles.
Gottlieb ordered a bronchoscopy, as well as scrapings from the mouth sores, and had the sputum samples sent to the lab. The results astonished
him:
Pneumocystis carinii
pneumonia, or PCP, filled the young man's lungs. Caused by a parasitic protozoa, PCP was almost exclusively seen among newborn infants in intensive care, terminally ill cancer victims, and/or elderly individuals living in nursing homes and other group settings. While nearly everyone had some
Pneumocystis
in his or her body, the organism was usually considered harmless because it was effectively kept in check by the immune system. What typical patients with PCP shared were exceptionally weak immune systems and concentrated exposure to other immune-deficient humans.
One thing was certain: it was rare, to the point of inconceivable, that this otherwise healthy man would have PCP.
“This is a red flag for something,” Gottlieb told colleagues at UCLA. “This patient has no prior history of illness that should predispose him to
Pneumocystis
. It makes no sense.”
The lab also reported that the white sores in the patient's mouth were caused by
Candida albicans
fungi, which could be sexually transmitted. And another sexually transmissible, usually harmless microbe was found in the patient's blood: cytomegalovirus.
Gottlieb took a careful history but learned little to explain his illness. True, the patient was a homosexual, and had had a few sexually transmitted diseases, but
Pneumocystis
wasn't spread sexually, and none of the three infectious agents ravaging him usually caused illness in healthy young adults. It just didn't make sense.
When Gottlieb ran blood tests the mystery deepened: the young man's antibody-producing capacity seemed intact, but his T-cell response was virtually nil. T, or thymus-derived, cells performed a range of crucial functions in response to infection, including identifying an invader and signaling the rest of the immune system to take defensive action against the microbe. Without an intact T-cell system no higher animal—be it mouse, dog, or
Homo sapiens
—could hope to halt the advance of even something as normally benign as
Pneumocystis.
By March the patient had to be hospitalized. Gottlieb and his UCLA staff tried a variety of experimental and long-shot drugs on him, including the antiparasitic drugs trimethoprim-sulfamethoxazole and pentamidine and the antiviral acyclovir. The patient died on May 3, 1981: the autopsy found
Pneumocystis
throughout his lungs.
The terse litany of a medical report could never capture the drama of this patient's illness and death. For Gottlieb it had been shattering to witness, with uncharacteristic impotence, the patient's entire body fail, one organ after another, seemingly overwhelmed by waves of infection.
Even if this had been Gottlieb's only such case he would have felt compelled to chronicle the mystery for scientific scrutiny in some obscure medical journal.
But it wasn't the only case.
A Los Angeles private practitioner with a sizable gay clientele had, since
late 1979, been spotting numerous cases of persistent long-term fatigue, reminiscent of mononucleosis, among his patients. Most of Dr. Joel Weisman's fatigued gay men were infected with the usually harmless cytomegalovirus.
In January 1981 one of Weisman's patients worsened significantly. In a few weeks, the thirty-year-old man's lymph nodes had swollen markedly, he'd lost more than thirty pounds, developed a pronounced
Candida
infection, and was running a daily fever of over 104°F.
By February, when it was clear the man wasn't improving with amphotericin B antifungal therapy, Weisman had him admitted to the UCLA Medical Center. Weisman and Gottlieb discussed the case, as well as other apparently odd infectious diseases seen among local homosexuals. When Weisman's patient also developed PCP in April, the doctors feared they were seeing a pattern.
By then Gottlieb had three other homosexual patients under treatment for PCP, none of whom was responding to treatment.
The similarities were striking: all five men were Caucasian, gay, aged between twenty-nine and thirty-six years at the time of PCP diagnosis, suffered PCP along with
Candida
and cytomegalovirus infections, had abnormal immune responses, reported multiple sex partners, and occasionally used amyl nitrite “poppers” as sexual stimulants.
One admitted to using injectable narcotics.
The “poppers” intrigued Weisman because he knew that use of the cardiovascular stimulants had recently become a fad all over the United States. Men believed the stimulants magnified the orgasmic rush of sex and enhanced their prowess.
Gottlieb wrote up a brief report and sent it to the CDC's Sexually Transmitted Diseases (STD) division, where Dr. Mary Guinan found it interesting enough to bring to Jim Curran's attention. They discussed the coincidences and, knowing that a number of STDs were epidemic in the gay community, speculated whether this might be due to any of several microbes then rampant in that population. Guinan pointed out that orders for pentamidine, an anti-PCP drug that physicians ordered through her office, had jumped from the usual fifteen requests a year to thirty in the first five months of 1981.
Curran decided to put the Gottlieb paper in the CDC's
Morbidity and Mortality Weekly Report
, and on June 5, 1981, U.S. physicians read for the first time of a curious new health problem in homosexual Americans.
The section written by Gottlieb and his Los Angeles colleagues was followed by an editorial, penned by Curran.
 
 
The occurrence of pneumocystis in these 5 previously healthy individuals without a clinically apparent underlying immunodeficiency is unsettling. The fact that these patients were all homosexuals suggests an association between some aspect
of a homosexual lifestyle or disease acquired through sexual contact and
Pneumocystis
pneumonia in this population … .
All of the above observations suggest the possibility of a cellular-immune dysfunction related to a common exposure that predisposes individuals to opportunistic infections such as pneumocystis and candidiasis.
1
 
 
On July 1, 1981, Dr. Paul Volberding opened San Francisco General Hospital's first designated cancer clinic. Not long out of residency, Volberding was pleased to be appointed acting chief of oncology for the city's primary public hospital, which also served as a teaching facility for the University of California at San Francisco Medical School. He selected as his nurse Gayling Gee, an experienced health provider whose staff record displayed a rare mix of administrative and patient care talents.
No sooner had the clinic officially opened than a nurse from another ward handed Gee the charts on an indigent cancer patient who had already been seen by several of the hospital's doctors. All of the physicians were baffled by the case. Gee looked at the diagnosis: Kaposi's sarcoma.
“Never heard of that one,” Gee said.
“Well, take a look,” the other nurse said. Soon, Gee and Volberding were examining a thin young man with pleading eyes. He had made the rounds of doctors, seen the befuddlement his case prompted, and was frightened.
Volberding studied the purplish-blue splotches on the man's body. These endotheliomas—out-of-control growths of the surface vascular networks on the skin—were a form of cancer extremely rare in the United States, though common in some parts of Africa.
“What do you do for a living?” Volberding asked, wondering if there might be some toxic chemical explanation for the tumors.
“I'm a hooker,” the man replied. “Can you help me?”
Volberding had no idea how to respond.
Four days later the CDC published a report linking Kaposi's sarcoma, PCP, and homosexuality.
2
It described twenty-six cases of gay men in California and New York City who, though averaging just thirty-nine years of age, had all contracted the rare skin cancer usually seen in the United States only among elderly men. Eight of the men had died of either the cancers or other infections, most succumbing within a year of diagnosis. All but one of the men were Caucasian; the one exception was black. All were gay; no information about possible injecting drug use was provided.
The CDC also reported that the numbers of PCP cases were up, from five in Gottlieb's report a month earlier to a total of fifteen, all in California.
Credit for seeing a link between the skin cancer and prior PCP reports went to New York City dermatologist Alvin Friedman-Kien, who had documented an additional fifteen Kaposi's sarcoma cases by the time the CDC's report was released. That meant that at least forty-one gay men had Kaposi's
sarcoma in New York, Los Angeles, and San Francisco, and some fifteen others had
Pneumocystis
pneumonia.
A review of the medical records at New York City's Bellevue Hospital showed that no men under fifty years of age had been diagnosed with Kaposi's sarcoma during the previous decade. Suddenly, there were thirty-three such cases in New York City.
3
San Francisco had two cases, though records at the city's five largest hospitals revealed no Kaposi's in men under sixty-five during the prior decade.
“Why, at this time, the disease would appear among gay men is unclear,” Dr. John Gullet of San Francisco's St. Francis Hospital said. “All over the country scientists are working on this with a sense of urgency. Maybe we have a new virulent strain of CMV [cytomegalovirus]. That would be the most plausible explanation.”
He added that the patient he had treated for Kaposi's “had no T cells. Zero. Zip.”
Curran, Guinan, and Harold Jaffe were convinced that something serious was going on, but they lacked the resources for a full-scale study. Curran appealed to CDC director Dr. Bill Foege, who was fighting a losing battle with the new budget-cutting administration of Ronald Reagan. Swept into power in November 1980 on the promise of slashing the federal bureaucracy, Reagan vowed to reduce spending in all areas other than the military, domestic law enforcement, the space shuttle program, and a handful of other sectors. He had also promised to cut taxes, and sent a bill for the largest tax reduction in U.S. history to Congress for approval.
When Curran asked for funds for a full-scale investigation of the mysterious outbreak among homosexual men, he was told that massive cuts in the CDC budget were expected. The White House was, at that moment, lobbying hard for its tax reduction plan, which would be passed on July 29. Reagan's budget-axer, David Stockman, was submitting daily memos to federal department directors pointing out areas of alleged fat and duplication in their budgets. Directors such as Foege were meant to take such memos seriously.
To protect Curran's budget Foege took the epidemiology group out of the STD division, which expected severe budget cuts, and hid it in his own discretionary budget under the name Task Force on Kaposi's Sarcoma and Opportunistic Infections. He told Curran that ought to protect the admittedly paltry funds from David Stockman's ax. Nobody in the White House would know what Kaposi's was until they researched it and learned it was a cancer of elderly men—Reagan's constituency.
Curran was discreetly named director of the quietly created task force, overseeing a budget of less than $200,000 and a staff of twenty, most on loan from other programs.
4
The entire CDC budget for 1981 was just $288 million
.
5
Meanwhile, Gayling Gee was having a terrible time dealing with her Kaposi's patient. Homeless, moving from one San Francisco crash pad to
another, the young prostitute would scrounge enough change every morning to buy a cup of coffee, a doughnut, and bus fare to the hospital.
“Help me, Gayling,” he would plead. “I don't know what to do.”
Too weak to work at any trade, he fell way outside the social services safety net of the day. Gee had no idea how to help.
In August, Volberding admitted him to the oncology ward: soon, he was dead.
There was little time to mourn. Volberding and Gee admitted three other gay men with the same strange cancer, and elsewhere in the hospital Dr. Constance Wofsy was handling an ever-increasing load of
Pneumocystis
cases.
6

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