Holocaust Image : AIDS Toll in S.F.: City Under Siege
In keeping with his position as executive director of the San Francisco Chamber of Commerce, John H. Jacobs is by nature an optimist.
But ask him about the future of the AIDS epidemic and the professional booster turns somber. About 4% of the city’s residents--including a staggering 50% of the estimated 42,500 to 69,100 gay men--are infected with the AIDS-causing human immunodeficiency virus. Barring a cure or effective treatment, all can expect to die, most within 10 years.
“Nearly one person in 20,” Jacobs said, shaking his head in horror. “I was in World War II. You could do better than that in a city under attack.”
Present, Future Toll
A city under attack. A war. A natural disaster. A holocaust. These are the images leaders in business, politics, medicine, labor and the arts conjure when reflecting on the present and future toll of AIDS upon this city of 750,000. Already, with more than 5,000 diagnosed cases, 3,000 deaths and an estimated 30,000 people infected with the virus but not yet ill, no facet of life--from the tourist trade to apartment vacancies--is untouched.
“When a member of the family gets hurt . . .,” Mayor Art Agnos said, “the whole family is aware of it and tries to deal with it. San Francisco is a family sized city, where what happens in one part of it is felt by every part of it.”
The past is bleak enough, with more San Franciscans dead of AIDS than from all the wars in this century, combined and doubled. AIDS already has claimed more lives than the great earthquake and fire of 1906, which killed 2,010 of the city’s estimated 450,000 inhabitants. But seven years after the first recorded AIDS death here, a painful realization is seeping in: This is only the beginning.
Labor Shortage Possible
Businesses are braced for skyrocketing medical expenses and potential labor shortages. Some, including Bank of America, have put grief counselors on call to comfort survivors. Health coverage has become a major element in labor negotiations. Political analysts suspect gay political influence will wane as more gay men succumb.
“All the mechanisms we’ve used to keep the awful truth at bay are breaking down,” said Dr. James W. Dilley, executive director of the AIDS Health Project.
He echoed the fear of many who believe the city is ill prepared for “the overload of grief” it will face as the AIDS death rate doubles, to six people a day, by 1993.
Even today, “no one ever finishes mourning because they know the next loss is coming,” said Rabbi Yoel H. Kahn, who ministers to the largely gay Congregation Sha’ar Zahav.
“I don’t think there will be a pall cast over the city,” Agnos insisted, convinced of the resilience of his constituents. “But it will certainly be something that all of us feel and carry with us because it is going to be the biggest human tragedy in the modern history of this city.”
By 1993, 12,349 to 17,022 San Franciscans will either have AIDS or be dead from it, the Public Health Department said in a report issued in March. The range reflects uncertainties over treatment advances.
No other big city approaches San Francisco’s per-capita rate of infection. San Francisco has about three times more AIDS cases per capita than New York and 10 times as many as Los Angeles.
Los Angeles County, with a population of more than 8 million, has had 5,230 diagnosed cases of AIDS, and there have been more than 15,000 cases among New York’s 7.2 million people. Neither city has a firm grasp on the number of people who are infected but not yet ill, though health officials in both places peg the number between 100,000 and more than 200,000.
San Francisco officials, on the other hand, have a high level of confidence in their estimate of 30,000 infected people because of data gathered in various health studies and surveys involving gay men during the last decade.
The grim projections assume that there will be no dramatic breakthroughs in the treatment of AIDS and HIV over the next five years. While many here pin their hopes on better treatments, city health officials say they accounted for anticipated advances in calculating the number of people who will succumb.
Doctors and scientists say the gains will likely be small and incremental.
Gearing Up for Worst
“I came back from (the International AIDS Conference) in Stockholm (in June) even more depressed about the short-term outlook for treatment,” said Dr. Mervyn Silverman, president of the American Foundation for AIDS Research and former head of the San Francisco Health Department.
As a result, city health planners are gearing up for the worst. The $90 million spent in the fiscal year just ended in government and private money to care for people with the disease could rise to $376 million a year by 1993. Where AIDS patients require roughly 140 hospital beds now on any given day, as many as 440 beds a day will be needed in five years, the Department of Public Health predicts.
The city is angling for $10 million to $25 million in federal money to turn a shuttered hospital into a 300-bed regional treatment center that should relieve the pressure on hospitals and hospices.
Gay men account for 97% of the San Francisco AIDS cases, and their prominence and numbers here magnify the loss. More than in any other city, gays are part of the fabric of life in San Francisco. Nearly 60% have college degrees and professional or management jobs and earn at least $25,000 a year, according to a demographic report done for the San Francisco AIDS Foundation.
But while the effects are more apparent, so is the response. As officials in Los Angeles debate opening an AIDS ward at County-USC Medical Center, this city is expanding its 5-year-old ward to 28 beds from 20. With free or low-cost counseling, housing, food delivery and other services, San Francisco has been held up as a model of compassionate, cost-effective care.
The city’s heralded educational program promoting safe sex has reduced the number of new infections among gay men to about 200 a year, according to the city Health Department. But because epidemiologists here find the onset of the disease is, on average, 10.8 years after infection and most infections occurred between 1982 and 1983, the number of AIDS diagnoses will not peak until 1994. The epidemic will extend well into the the 21st Century, regardless of whether a vaccine is developed.
“The clock is ticking,” said Dr. David Werdegar, San Francisco Health Department chief. “I have the feeling that the public forgets that there is a time dimension--that a great many people got infected in the early ‘80s and (the time when they will become sick) is getting closer.”
‘Conveyor Belt to Death’
For Hank Wilson, who has lived with an AIDS diagnosis for a year and buried many friends, the time line is even shorter. “We have a sense we’re on a conveyor belt to death, and we hear the motor running,” said the 36-year-old hotel manager, who is agitating for stepped-up delivery of experimental drugs to people with AIDS.
Health Department forecasts tell only part of the sad tale. How does a city quantify the loss of an Andrew Meltzer, the rising young conductor of the San Francisco Opera who died of AIDS at age 40 this year?
“Anyone who heard him conduct last year’s ‘La Traviata’ cannot help but feel the tragedy,” said Anthony Turney, administrative director of the opera.
Indeed, many people find it difficult to look unflinchingly into the future. “It is very hard to speak rationally about how it will feel,” said Supervisor Harry Britt, who is gay.
Britt avoids funerals and did not even attend the local showing of the Names Project AIDS Quilt, which commemorates the dead. “There are a lot of people I haven’t seen for several years, and I just don’t want to know,” he explained.
Some predict an outbreak of civil disobedience as anger grows over what gays view as the maddeningly slow research effort. At a recent statewide strategy session of gay leaders, “civil disobedience was at the top of the agenda,” Supervisor Britt said. “Before 1993, there are going to be some major eruptions,” added Tim Wolfred, president of the San Francisco AIDS Foundation and a member of the Community College Board.
If there is a paradox to this unfolding catastrophe, it is that it is nearly invisible. A casual visitor would find little evidence of sickness, other than subway station billboards promoting AIDS volunteerism and safe sex and a vigil by AIDS patients in a cluster of tents outside a federal building.
The Castro district, a hub of gay life since the major influx of gays in the 1970s, bustles still. Despite the dying, San Francisco remains a unique refuge from hostility for many gay people, and they seem determined to continue to build their lives here.
Although the bathhouses, which are believed to have contributed to the rapid spread of the virus, are long gone, gay dance clubs are once again packed after a lull of a few years. This year’s Gay Pride Parade drew 275,000, the biggest crowd ever. Gay sports organizations, political clubs and theater groups continue to thrive. Those with AIDS who are healthy enough forcefully demand access to experimental drugs and reject the label of “victim.”
To Kahn of Congregation Sha’ar Zahav in the Castro, this determination to go on represents not so much denial as resistance against a virulent enemy that blinds, disfigures, dements and kills. For the community to succumb to despair would be to concede defeat.
‘Like the Holocaust’
“This is like the Holocaust, (when) the Jewish response among the people in the camps was spiritual resistance--to go on developing (their) lives and culture as if (the suffering) didn’t exist,” said the rabbi. Indeed, unlike some other hard-hit locales, San Francisco is resisting the plague at all levels--from City Hall to the financial district, from churches to cultural institutions--in part because of the political strength of gays.
Since the 1970s, gays have played pivotal roles in local elections. With their numbers and integration into the political system, they got the attention of elected officials even before the disease had a name.
Nothing in voter turnout suggests a loss in numbers of gay voters, perhaps because those gays who survive are more motivated to vote than ever. But citing inescapable calculations, political analysts anticipate a loss of gay political strength.
More than 20,000 gays could die here by the time the first wave of the epidemic is over--and that will translate into “a loss in political power,” said David Binder of the San Francisco Poll.
A less tangible reason for an impending decline is that several rising political stars of the ‘70s and early ‘80s have died or have devoted themselves to helping people who have become ill.
Some of the decrease in numbers will be made up by younger gays who continue to move here, and lesbians are filling leadership roles once held by men. Still, migration to San Francisco has slowed and the gay population is aging, according to the demographic report for the San Francisco AIDS Foundation.
For those who survive, the life-or-death AIDS issue is taking precedence over such questions as full civil rights for gays or benefit packages that include provisions for unmarried couples. “There is nothing else on the agenda,” said Dick Pabich, a gay political strategist.
Local officials responded by spending $24 million last year--including $10 million directly from local tax revenue--for AIDS-related service. But while City Hall has had enough to pay its AIDS-related bill, the epidemic will strain city coffers and, said Health Commissioner Jim Foster, confront policy-makers with “terrible choices” in allocating scarce dollars.
“People who are dying or are desperately ill claim a higher priority. There is going to be resentment. That is inevitable,” Supervisor Bill Maher said.
Need for Federal Bailout
Without a federal bailout, the city cannot handle the cost. “You can shut down the entire library system or the Police Department, and you still don’t have the money,” Britt said.
Government costs have been kept down by volunteer care worth millions. But an extraordinary outpouring of support--most from gays--is reaching its limit. While caseloads grow, volunteers and donors are themselves becoming sick.
“It’s going to get harder,” said Chris Sandoval, an administrator of the Shanti Project, which provides practical and emotional support to people with AIDS. “We are getting into populations that are not glamour populations--IV drug users in the Tenderloin, people who have no sense of community.”
Feeding and housing impoverished people with AIDS could require a sixfold increase to as much as $5.5 million by 1993, the city’s five-year plan said. Day care of mentally ill people with the disease, an item not counted in the figures today, could cost $9.4 million.
Without stepped-up funds, “people will be dying in the street,” said Geoffrey Froner of the Haight Ashbury Free Clinic, who estimated that today 400 people with AIDS are homeless in San Francisco.
“Every single person with AIDS we deal with has credit problems. It will continue to grow exponentially,” said Clint Hockenberry, administrator of a legal aid group for people with AIDS. More and more of the roughly 1,900 clients who consult with his attorneys are declaring bankruptcy.
Impact on Economy
With rising numbers of bankruptcies, stretched health trust funds and lost productivity, the epidemic will hurt the city’s economy for years to come.
Analysts who track tourism, San Francisco’s No. 1 industry, say they see no signs that tourists are staying away out of fear, even though hotel occupancy rates dipped about 5% in the first six months of 1988, a year that many people in the trade expected to be buoyant.
While professional analysts and executives in the tourist trade blame part of the decline on the construction of two new luxury hotels, tourist-class and budget hotels are also feeling the pinch.
“Of course AIDS is a factor,” confided the general manager of a posh downtown hotel. “The attitude in the business is that you can’t turn it into a positive, that this is something we shouldn’t talk about.”
The epidemic has already discouraged some businesses from locating here by “reinforcing the perception of San Francisco as an expensive place to do business,” said John Harrington, a partner with Price Waterhouse & Co.
“The financial impact goes far beyond the cost of drugs and hospitalization,” added Dr. Ralph Alexander, medical director for Pacific Bell, where one in five employee deaths is due to AIDS. “There are also frequent absences, as well as training and replacement costs.”
In the early 1980s, Bay Area employers were among the first in the nation to establish compassionate policies for the stricken. Co-workers were taught that AIDS cannot be casually transmitted, and people with AIDS were encouraged to remain on the job as long as they were able.
Now, employers must grapple with what Chris Loker, a personnel representative for Bank of America, called “the second wave of the AIDS epidemic:” an epidemic of grief from the loss of loved ones. “We are seeing the result of that loss in the work setting,” Loker said.
Two months ago, the bank’s 28 personnel representatives received special training to identify grievers and direct them to counselors.
Big companies are also moving to cut costs. Most have adopted a practice called “case management” for AIDS in which consultants work with patients and care givers to save money and enhance quality of life, often substituting in-home care and stays in nursing homes for costly hospitalization.
‘Can Be Managed’
“AIDS can be managed,” said Clark E. Kerr, vice president of corporate health programs at B of A. “You don’t have to have workplace panic. You don’t have to have uncontrolled costs.” At B of A, which has had more than 50 AIDS deaths, cases cost a relatively modest $25,000 in medical expenses last year.
But if large companies believe they can weather the storm, small businesses have cause to worry. Businesses owned by and catering to gay people have been especially hard hit. “Every month, I cross two or three members off our list,” said Robert Barnes, president of the Golden Gate Business Assn., a gay Chamber of Commerce.
In labor negotiations, health and welfare benefits account for “probably the biggest” issue, in part because of AIDS, said Walter Johnson, head of the San Francisco Labor Council. Managers of benefits and trust funds for several unions say their funds are strained or will be soon as claims continue.
“It’s like Noah building the ark. I think a lot of people thought this was going to be a drizzle,” Johnson said. ". . . With a small company, it can take apart the (health benefits) plan.”
In a recent strike by 1,700 workers against seven San Francisco-area hospitals, the disease emerged as an issue. The hospitals had wanted to eliminate short-term sick leave, double deductibles for doctor and hospital visits and require employees to pay part of their health insurance.
The strike was settled after the hospitals agreed to continue providing free care through health maintenance organizations, while requiring employees to pick up a bigger part of the tab if they continue to go to their own doctors.
John Mehring, a psychiatric ward technician who has AIDS-related complex and estimated that half of his co-workers are gay, was among those who carried picket signs out of fear that he would lose health benefits.
“We see these benefits as literally a life-and-death issue,” he said. " . . . We know what happens to people when they don’t have adequate health-care insurance.”
PROJECTED AIDS CASES IN SAN FRANCISCO
This chart represents a worst-case scenario as envisioned by San Francisco public health experts, who expect between 12,349 and 17,022 diagnosed cases by 1993. Anticipated advances in treatment were taken into consideration in the prediction. The current population is 750,000.
ESTIMATES OF SERVICE COSTS
The cost of the AIDS epidemic is counted not just in hospital care but in dollars spent on mental health, housing and other care for the chronically ill, education, research and administration. The chart represents high-end cost estimates. Low-end cost estimates are $160 million by 1993.
Based on current service utilization patterns and currently anticipated adjustments in future years.
million dollars l987-'88: $89,264,525 ’88-'89: $161,857,372 ’89-'90: $200,881,045 ’90-'91: $248,205,229 ’91-'92: $306,158,854 ’92-'93: $376,401,529 Already the AIDS epidemic in San Francisco has been more deadly than war or natural disaster.
AIDS: 3,000 1906 earthquake*: 2,010 All 20th century wars**: 1,350 * San Francisco Archivist ** Mayor’s office and federal archives Source: San Francisco Department of Public Health