AIDS: 1991

The following fictional scenario is based on what is known about acquired immune deficiency syndrome, AIDS. It is meant to summarize the latest information on the disease and to describe choices that could confront society if the virus continues to spread unchecked. The author has been a persistent advocate of increased government spending on education and prevention to help stop the spread of AIDS.

It is Sept. 17, 1991, and the White House has just announced that the vice president’s daughter and her 5-month-old son have AIDS. Shocked and declaring that “this brutal, uncontrolled epidemic must be stopped-- and stopped now,” the President appoints a blue-ribbon commission to find ways to quickly halt the spread of the disease in American society.

By any measure, it is an awesome task. Since June, 1986, when the U.S. Public Health Service predicted that the number of AIDS cases would jump tenfold in five years, to almost 270,000, millions more have become infected with the AIDS virus. Estimates now put the total at 3 million to 4 million--about one in every 70 Americans--and each is considered capable of spreading the disease to his or her sexual partners.

Researchers have a far better understanding of the AIDS virus than they did in 1986 and can blunt its attack on the immune system, the body’s natural defenses against disease. But five years later, there still is no vaccine to prevent new infections, no cure for the disease itself. Today, as in 1986, more than 80% of the patients diagnosed as having full-blown AIDS will die within two years as their weakened immune systems are overwhelmed by diseases healthy bodies can easily repel.

As federal health officials projected in 1986, more than 54,000 Americans will die from the disease this year--almost as many people who died in the entire 40 years of the polio epidemic. There are so many AIDS patients that acute-care services at many hospitals have been in chronically short supply for years now. Insurance companies have been bankrupted. Every American is paying higher medical bills and insurance premiums.

The signs of trouble have been apparent for years, even before actor Rock Hudson died of AIDS in 1985 and the press erupted with reports about the disease. “Not since syphilis among the Spanish, plague among the French, tuberculosis among the Eskimos and smallpox among the American Indians has there been the threat of such a scourge,” the prestigious Journal of the American Medical Assn. had warned that year.

But only this year, as the vice president’s daughter and grandson fall victim, and as the AIDS toll exceeds the annual slaughter on the nation’s highways, does the nation finally recognize that a health crisis of historic proportions is at hand.

The President’s Commission, headed by a retired Supreme Court justice, quickly gets down to business. It just as quickly discovers that its choices of recommendations are amazingly few. Despite years of increasingly dire warnings from public health officials, little has been accomplished to check the spread of the disease. The greatest efforts--and almost all of the money--have been aimed at producing a vaccine and drugs to treat the disease. Nothing suggests that the general public, after years of denying that this “gay plague” could affect them, knows enough to take the protective measures that would help to contain it.

Faced with this grim reality, the commission produces a set of drastic recommendations. The AIDS virus, the panel notes, is spread in three major ways: by sexual contact, by intravenous drug use, and from mother to child (during pregnancy or through breast feeding). Any approaches that don’t block these routes of transmission can’t be effective, and AIDS could be expected to spread indefinitely.

Nonetheless, the recommendations create a firestorm of controversy.

The report calls for mandatory AIDS virus testing of every U.S. resident. Everybody will have to carry a photo identification card describing his or her test results. Those who are infected will be barred by law from having sex with uninfected people. Anyone found to have spread the infection will be jailed. Sex outside of marriage will be outlawed. Sodomy laws will be reinstated. If an infected woman becomes pregnant, she will be forced to have an abortion. Everyone entering the country--businessmen, tourists and Americans living abroad--will be quarantined for two weeks and then tested for the virus. All Americans will be tested for intravenous drugs, and drug users will be forced into treatment programs or jailed.

To many, it seems that George Orwell’s dark vision of a pervasively monitored society has arrived seven years later than he predicted. It appears that the nation is quickly becoming a society at the mercy of AIDS, divided between those who are infected and those fearing infection. The whole world is beginning to consider the United States a diseased country.

As the President endorses the recommendations, Congress pauses to investigate how the situation could have gotten so far out of hand. How, it asks, could the country be left with so few--and, to a free society, such repulsive--options? The AIDS virus, after all, had been identified almost a decade ago. What went wrong?

The answer, congressional investigators find, can be traced at least to June 12, 1986, to the Public Health Service report that predicted a quarter of a million additional cases of full-blown AIDS within five years and that called for quick action to educate the public in ways to prevent it. “We must inform and educate both infected and uninfected people,” Donald Ian Macdonald, acting assistant secretary for health, said then. “Special efforts will be directed to pre-adolescents, adolescents, minorities, women and health-care providers, in addition to the people whose behavior puts them at risk for infection and AIDS.”

The report drew front-page headlines across the country. While the raw projections were startling, even more disquieting was the fact that they were based primarily on the number of Americans then thought to be infected with the AIDS virus--1 million to 1.5 million people. The report did not emphasize that the problem would grow even greater as Americans continued to become infected after 1986.

Moreover, there was evidence that even the figures the health service used were understated. Studies by the Centers for Disease Control indicated that accurately diagnosed cases of AIDS were being underreported on death certificates by 10%, apparently to spare survivors the stigma of the disease. A 1985 California Department of Health Services study put the problem at 17%.

But a Justice Department legal opinion quickly overshadowed the PHS report and enormously complicated the task of convincing infected men and women to practice the kind of sexual behavior that could keep the disease from spreading. On June 23, 1986, the department said that an employer could legally fire employees with AIDS simply if the employer feared or suspected--even without scientific evidence--that the virus could spread in the workplace. Companies quickly extended the idea to include individuals who had taken a blood test that detected antibodies to the AIDS virus (the only test available at that point)--people the Public Health Service said were infected with the virus and able to infect others, though not suffering from the disease itself.

To those in the groups at highest risk of contracting AIDS--gay and bisexual men, intravenous drug users, hemophiliacs, and the sexual partners of each--the implication was clear. Since 1985, a positive antibody test had meant trouble obtaining health and life insurance; now it also meant a real chance of being summarily fired.

Citing those fears, and the devastating emotional impact of a positive test result, leaders of the gay community rebuffed the Public Health Service’s call for all high-risk individuals to be tested. Consequently, thousands of Americans who otherwise might have taken the test, discovered whether they were infected and stopped practicing high-risk sexual behavior, didn’t do so. The disease spread virtually unchallenged.

For years to come, government efforts to respond to AIDS overwhelmingly emphasized medical research, not education and prevention. Just weeks after the PHS report was issued, for example, the Department of Health and Human Services said it would dole out $100 million over five years to 14 institutions--including five in California--to develop AIDS drugs. That was roughly four times the amount the federal government would spend that year on education and prevention programs. Yet the research money involved only 1,000 AIDS patients, while thousands more Americans were being infected each month. In the meantime, there was evidence, including a 1986 survey of Los Angeles homosexual and bisexual men, that showed that educational campaigns could be effective in persuading gay men to practice low-risk sexual behavior.

Even the bare-bones state and county educational programs were embroiled in controversy. Politicians--fearing they would be branded as pornographers and accused of encouraging homosexuality--refused to fund programs to distribute detailed, explicit educational pamphlets describing “safe” sex. Similarly, proposals to educate drug addicts and to supply them with sterile needles so they would not share them and spread the disease were politically unpalatable.

From then on, the congressional investigators concluded in retrospect, the move toward the commission’s recommendations seemed almost predictable--in fact, inevitable:

Nov. 4, 1986. The LaRouche AIDS Initiative, which suggested that people with AIDS and those infected with the virus might be subject to quarantine, narrowly fails in California. The balance in the election shifts when public health officials oppose the measure. They are concerned that high-risk people will be driven underground, and that letting the public vote on complex health-prevention measures sets a dangerous precedent; scientific validity and civil rights concerns are of secondary importance. (U.S. Rep. William E. Dannemeyer of Fullerton had sent a chill through them on July 2: “War is too important to be left to generals, and public health is too important to be left to public health officials.”) Even traditional foes of gay rights measures, worried about being identified with extremist Lyndon LaRouche, joined in opposition. Although the initiative fails, it raises the specter that those who test positive could one day find themselves forcibly isolated from the rest of society. Fewer people than ever want to be tested.

May, 1987. Scientists develop a blood test that detects the AIDS virus itself, not just antibodies to it. The new test, which replaces the one in use since 1985, lays to rest contentions that people with positive results on the antibody test have merely been exposed to the virus and may not be infected with it. Researchers now are able to show that most people who had AIDS antibodies in their blood in 1985 are carrying the virus two years later. The National Cancer Institute and the Centers for Disease Control had been saying as much since 1985.

October, 1987. Researchers, benefiting from ever larger infusions of federal AIDS research funding, produce drugs that make the AIDS virus disappear from the blood at least temporarily, delaying the development of many AIDS-associated illnesses. But the drugs can’t chase the virus from the brain, and cases of AIDS-caused dementia, which frequently require long-term hospitalization, rise. Ironically, because the new drugs prolong the lives of those infected, medical costs increase dramatically. And, as the Public Health Service report had predicted in 1986, some drug-resistant strains of the quickly mutating AIDS virus have emerged.

December, 1987. AIDS cases are soaring. Public hospitals around the country acknowledge there are so many AIDS patients that they are unable to provide proper medical care to all acutely ill individuals. The problem was apparent as early as February, 1986, when officials at the Manhattan Veterans Administration Medical Center in New York reported that 23 of the hospital’s 120 acute-care beds were filled by AIDS patients on any given day. “If the rate of patient influx increases, these hospitals may be stretched (to) where they can’t (treat AIDS patients) anymore,” one official predicted in Hospitals magazine. As the veterans hospitals stop accepting AIDS patients, the burden on state and county hospitals increases. Some areas raise taxes to cover the rising costs; others significantly cut outpatient services to cover the rise in inpatient expenses.

September, 1988. Congress reports that a majority of states, modeling their legislation on a plan first proposed in California in 1986, have agreed to pay the health-insurance premiums of AIDS patients who lose their jobs. By paying the insurance premiums, the states keep AIDS patients off public medical assistance and so avoid footing their huge medical bills--which even in 1986 ranged from $30,000 to $70,000 each. As a result, private insurance companies are forced to pay more benefits and raise their premiums for everyone. Many insurance companies had long ago begun screening applicants to weed out members of high-risk groups. In October, 1985, for instance, Transamerica Occidental Life Insurance Co. of Los Angeles announced that it would use blood tests on some applicants. Barred in California from testing for AIDS antibodies, the company instead used a test that checked the health of the body’s immune system.

November, 1988. Almost half of the states now require that doctors report the names of people who have a positive AIDS virus test. (Two years ago--in July, 1986--only six states had reporting requirements for the AIDS antibody test. Earlier that same year, California Health Director Kenneth Kizer had called for the power to require mandatory AIDS antibody testing when public health officials found it appropriate.) In California, consent had been required for the antibody test, which was developed not as a diagnostic tool but to safeguard the nation’s blood supply. The consent clause does not apply to the virus test. With fear of the test rising, people seek out doctors who will agree not to perform the test without consent.

March, 1989. A second-generation virus test is approved. It is far less expensive than the original AIDS antibody test--and thus can be used economically on millions of people. The test shows that when the AIDS virus is present in blood, it is nearly always present in semen as well. This characteristic makes the AIDS virus distinctly different from other persistent viruses, such as genital herpes, which only occasionally can be spread. Federal health officials had suspected as much since the early 1980s, when they had identified the AIDS virus as one of a class of viruses that incorporates itself in the genetic material of those it infects--which means it can last for a lifetime.

May, 1989. The federal government orders cuts in the Medicare program because Social Security disability payments to AIDS patients--they have routinely qualified for such payments since 1985--are putting an increasing burden on the entire Social Security system, which Medicare is part of. As in the past, the government turns to one of the few areas of flexibility in Medicare, and chops payments to physicians. Doctors are outraged.

It now seems likely that the Public Health Service was correct in 1986 when it projected that, within five years, the direct health-care costs of persons with AIDS would consume as much as 2.4% of the nation’s entire health-care budget. And although AIDS is becoming more evenly distributed geographically--as the PHS predicted it would--New York, Los Angeles, San Francisco and Miami, in that order, are still by far the hardest hit. Officials in those cities are especially worried, because at the time of the report, the PHS acknowledged that its estimate could be conservative by 10% to 15%.

Even more frightening, the Centers for Disease Control keeps raising its estimate of how many of those infected with the AIDS virus will eventually develop the disease. The first estimate--by Dr. James Curran of the CDC, in 1984--was 10%. (At the time, he predicted 30,000 AIDS cases by 1989--a number surpassed three years early.) By 1986, the disease-infection ratio was up to 20% to 30%. Now it’s 30% to 40%. With millions believed to be infected, the numbers seem calamitous.

June, 1989. The Centers for Disease Control report the first case of AIDS infection traced to blood that had tested negative for presence of the virus. (On June 20, 1986, a similar case involving the AIDS antibody test was reported by the CDC.) Other studies show it is possible to have the virus in the blood for up to two weeks at a level too low to cause a positive test, but at a level high enough to infect transfusion recipients. (This contrasts with the antibody test, which may not become positive for several months after infection.) Researchers compare the situation to the hepatitis B virus: Even though donated blood has been routinely tested for hepatitis B since 1971, infections through blood transfusions still occur.

October, 1989. Federal officials report the first full-blown AIDS case traced to blood that had tested antibody negative in 1986. Colorado, taking its cue from a measure proposed in 1986 by California state Sen. John Doolittle of Citrus Heights, makes it a felony for a homosexually active man to donate blood. The law is repealed when blood donations fall sharply.

February, 1990. An AIDS vaccine is ready for human trials. Although widespread use of a vaccine is years away, and though millions will remain infected and the vaccine will not help them, health officials finally have hope of stopping new infections.

When a hepatitis B vaccine was tested on humans, researchers asked the gay community for volunteers, since the disease was most prevalent among male homosexuals. But when asked to participate in AIDS vaccine trials, gays adamantly refuse.

Politicians, hoping to protect the heterosexual population and recognizing that the male homosexual population in some cities has been saturated with the virus for years, are outraged and perplexed. But gay community leaders cite a Catch-22 situation: The vaccine trials can only use men who are not already infected; thus, all potential participants must be tested for the virus; but those with positive results could lose their jobs and health insurance. In the growing climate of fear, gay community leaders scoff at promises of confidentiality.

May, 1990. An Illinois case clearly demonstrates the spread of the AIDS virus from an intravenous drug user to a female sexual partner, to another man with whom she had sex, to another woman, to another man. Like so many developments, this one had been expected by researchers since as early as 1986, when a study in Ohio reported the spread of AIDS from a man to a woman and to another man. (Also that year, at the international AIDS conference in Paris, the Centers for Disease Control had presented a study of men and women who had contracted AIDS from blood transfusions. The wives of seven of the 41 men in the study had begun to test positive for the AIDS antibody; so had the husband of one of the 16 women.)

Even then, evidence of heterosexual transmission of the AIDS virus had been around for years. AIDS had been rampant among heterosexual men and women in central Africa and Haiti. At the same Paris AIDS conference, studies showed that about 6.5% of all adults (8% of all pregnant women) in Kinshasa, the capital of Zaire, were infected with the AIDS virus. And in the United States, the 1986 Public Health Service report had predicted almost 7,000 heterosexually transmitted AIDS cases by 1991, or more than 9% of the total.

“In case you aren’t listening,” the CDC’s Curran said in Paris of heterosexual spread of the disease, “this means you, too, gang.”

But the study finally and convincingly indicates to the public that AIDS may be starting to spread through the entire sexually active population, gay and straight. Women no longer feel safe by avoiding gays and drug users; they at last realize that they must know not only the AIDS risk of their current sexual partner, but the risk of all his prior sexual contacts as well.

January, 1991. By now, 196,000 cases of AIDS have been diagnosed. Another 74,000 will be diagnosed by year’s end. More than 125,000 Americans already have died from AIDS; 54,000 more will succumb by the end of the year. The numbers are difficult for the average citizen to comprehend, as they were when the PHS made its initial projections in 1986. But AIDS is now the No. 2 cause of death nationwide, exceeded only by heart disease. More people will die from AIDS this year than die from either cancer or accidents. And still the disease is spreading.

March, 1991. Several insurance companies have gone out of business because of losses due to AIDS. To salvage the industry, Congress permits all remaining life-insurance companies to refuse to cover anyone with a positive AIDS virus test.

Heterosexual men and women who are thinking of becoming intimate with each other flock to testing centers to determine whether either carries the virus, only to learn that the results aren’t valid unless they refrain from any sexual contact for two weeks before being tested. And, to their shock, the 1986 Public Health Service projections hold true: in about one in 108 heterosexual couples, one of the partners tests positive. Suddenly, even heterosexuals do not want to be tested.

July, 1991. The daughter of the vice president of the United States is ill. Rumors that she has AIDS persist. Although married for three years, she had one prior sexual relationship, in 1987. Attempts have been made to locate her former boyfriend, but he cannot be found. Her baby is not gaining weight and has remained hospitalized since birth.

Sept. 17, 1991. The President announces the grim diagnosis and appoints the commission, dubbed CRASH: the Commission to Reassess American Safety and Health. “Society cannot afford the continued spread of this virus,” he says in a televised speech. “It can touch anyone--even innocent women and children. No option can be overlooked.”

Nov. 23, 1991. The report is released. It reads:

“We have a crisis that requires drastic measures. Failure to follow these recommendations will undoubtedly lead to a need for even more drastic measures in the future.

“Health officials estimate that 3 million to 4 million Americans are now infected with the AIDS virus. Since 30% to 40% of them are likely to develop AIDS by 1998, we can expect 900,000 to 1.6 million cases of AIDS by that year. Most important, if we do not prevent those 3 million to 4 million Americans from infecting others, the number of AIDS cases will rise indefinitely.

“A major financial commitment--one that should have been made long ago--is needed. But the money must be accompanied by important legislation that addresses the known routes of transmission: sexual activity, drug use, from mother to child.

“SPREAD BY SEXUAL CONTACT. While gay and bisexual men still represent more than 50% of AIDS cases, an increasing percentage of cases is due to heterosexual spread of the virus. Therefore we must prevent sexual behavior that can spread the virus. Thus, all sexual contact outside of marriage must be illegal, including oral and anal sex (both homosexual and heterosexual) and vaginal sex. In addition, in marriages where one partner is infected, the couple must not engage in sexual contact.

“We believe that Americans are law-abiding citizens. Voluntary compliance is anticipated in large measure.

“Nevertheless, how can compliance possibly be monitored? We urge a crash program to test every man, woman and child in this country for the AIDS virus. For those who are negative, repeat testing will be done every three months. All Americans will carry a photo identification card listing their AIDS virus status. The card must be carried at all times and will be checked routinely in all business transactions--from receiving a paycheck to applying for employment, a driver’s license, a bank account, a car loan or a passport.

“Anyone whose test shifts from negative to positive will be interviewed, and their sexual partners will be tested to determine the source of the infection. It will constitute a felony for any infected individual to have sex with an uninfected individual, with mandatory jail sentences if the partner becomes infected.

“The commission considered quarantining all individuals who test positive for the AIDS virus. But the cost of quarantining 3 million to 4 million people could reach $100 billion per year, not including the cost of building new facilities. (In 1986, the average cost of guarding, housing and feeding a prisoner was about $25,000.) And because there is ample evidence that a person remains infected for years and perhaps a lifetime, long-term incarceration would be needed. That does not include the economic cost of removing these people from the workplace.

“In order for these policies to succeed, we must prevent the entry into this country of any person infected with the virus. We therefore must use the armed forces to close and fortify both our northern and southern borders. Foreign visitors will not be permitted to enter the country without certification that they are free of the virus. Even with such certification, because of the nature of the virus test, foreign visitors must undergo a two-week quarantine and repeat testing.

“INTRAVENOUS DRUG USE. We must institute a nationwide testing program for intravenous drug use. Drug and alcohol testing programs already in place in many companies and schools can easily be expanded. Drug users who do not have jobs must be apprehended. Those who test positive must enter drug programs and submit to weekly checks. Further use of drugs, or failure to stay in a program of drug prevention, will lead to jail sentences.

“MOTHER TO CHILD. All pregnant women must be tested and their fetuses aborted if they test positive. Any mother who is not tested before the sixth month of pregnancy, and who subsequently tests positive, will be jailed.

“This commission does not make these recommendations lightly. But the most compelling argument for mandatory abortion is a 1985 Centers for Disease Control report showing that an infected woman runs a greater risk of developing AIDS if she bears a child. Therefore, in addition to preventing the spread of the virus from mother to child, abortions will protect the health of the mother--a justification that even most abortion opponents have long recognized as valid.

“The recommendations are stringent, but necessary. The nation is under siege. While the commission does not wish to deal in moral issues and recognizes that it benefits from hindsight, we must make clear that this epidemic was made possible by the moral disintegration that has occurred in this country over the past four decades.”

fter brief public hearings, Congress passes the legislation, despite its own profound misgivings and legal challenges from an unusual coalition of civil liberties and anti-abortion groups. Some in Congress take their cue from public opinion polls, including Los Angeles Times polls in 1985 and 1986 showing that 51% of those surveyed would support making it a crime for an AIDS patient to have sex with another person, and that 48% would support issuing ID cards to those who tested positive for antibodies. Forty-six percent supported the idea of quarantining AIDS patients, and 15% even agreed that AIDS patients should be tattooed.

The measures are repugnant to many people, but until a vaccine or drugs that kill the AIDS virus are developed, there doesn’t seem much choice. And, as the Public Health Service predicted in 1986, even today a vaccine is still years away from being put into general use.

A congressional staff report accompanying the legislation predicts that the laws will cause severe societal and economic disruption, as well as the greatest assault on personal liberties since the Japanese-American internment during World War II. Nonetheless, the report predicts, the Supreme Court is likely to uphold the measures’ constitutionality, given the public health emergency.

Mexico, Canada and most other countries, which by now have major AIDS problems of their own, can be expected to retaliate by refusing entry to Americans who do not submit to quarantining, the study says. Saudi Arabia instituted such a policy in 1985, and as early as January, 1986, Brazilian health officials asked visitors to Rio de Janeiro’s carnival to fill out questionnaires about homosexuality and AIDS. In December, 1985, authorities in Peking, seeking to prevent “epidemic diseases from being introduced to China,” had even burned tons of secondhand clothing donated by foreigners. With its immigration “safety valve” closed in the southwest United States, Mexico--already irritated by U.S. policy in Latin America--might sever its diplomatic ties and align itself with the Soviet Union.

Within the United States, deep divisions that cut across racial and economic lines can be expected. Those who are infected with the AIDS virus will be pitted against those who are not. Suspicion will focus first on single individuals, straight and gay, whether they test negative or positive. But stress will also devastate couples--gay or straight--in which one member tests negative and one tests positive, since if the uninfected partner becomes infected, the other would go to jail.

Within months, the congressional report predicts, such couples, along with many single Americans who test positive, will try to leave the country rather than be branded as pariahs at virtually every turn in their lives. In short, the country may witness an amplified version of the Vietnam exodus, in which young men of draft age fled to Canada, Sweden and other sympathetic countries rather than fight in the armed forces. This time, with the borders sealed in both directions and with passports denied to those who test positive, some of those leaving will try to depart by boat--either to Latin America or Canada. But no country will be willing to offer asylum to carriers of “the U.S. disease,” and their navies will attempt to intercept the American “boat people.”

The trauma will be indiscriminate: Politicians, judges, sports heroes, clergymen, skilled professionals and company presidents will be among those testing positive. In 1986, most of those heterosexuals infected were drug users; after five years of uncontrolled spread, that is no longer true.

Already, the congressional staff report notes, economic dislocation is apparent. Hundreds of thousands of Americans began slipping across the border as soon as the CRASH report was released, disrupting the workplace and causing a sudden shortage of skilled labor. Economists are predicting a severe recession, and stock values have dropped sharply. Foreign countries have removed billions of dollars in assets from U.S. banks, threatening their survival. The travel industry is languishing. Foreign trade has dried up. Thousands of foreign businessmen have left the country to avoid forcible testing, devastating the real estate market, especially in California and New York.

The shame of it, the congressional report says in summary, is that the U.S. Public Health Service report in 1986 also called for appointment of a blue-ribbon commission to deal with the epidemic. But the choices available to it then would have been far greater, far less repressive than those the CRASH panel faced in 1991. Then, in fact, the best option was still available: development of major educational and prevention programs to deal realistically and effectively with slowing the spread of the AIDS virus.

“Despite the best efforts of the scientific community, biomedical research cannot eliminate the problem of AIDS in the short term,” Harvey V. Fineberg, dean of the Harvard School of Public Health, wrote in the New York Times that year. “The fact is, however, that we require no new technological breakthroughs to limit the spread of the AIDS virus.” The Journal of the American Medical Assn. agreed. “Individuals,” it said, “have the power to protect themselves more than science currently can.”

In 1986, it had not been too late.