Not long ago, AIDS Project Los Angeles took an unusual step in its campaign to prevent people in the county from becoming infected with the human immunodeficiency virus.
The agency asked government funders to reduce its allocation for educational efforts by $100,000--and to redirect the money to agencies that tailor their educational programs specifically for black and Latino gay and bisexual men.
“That’s the top priority in terms of primary prevention,” explained Stephen Bennett, chief executive officer of APLA, which is rooted in the Anglo gay community.
The group’s decision to spread its money around is a hopeful sign that the attempt to forge a countywide partnership among local AIDS organizations and county health officials, launched earlier this year amid great skepticism, is beginning to bear fruit.
Another promising indicator is that county health officials, after months of input from community-based organizations, are putting the finishing touches on a plan that is designed to plug the gaps in the county’s response to the HIV epidemic for the 1990s.
The plan urges expanded educational efforts among minority gays; new programs to prevent the spread of the virus among needle-sharing addicts; better outpatient care at county facilities, and a drive to provide early medical intervention for the already-infected to delay the onset of full-blown AIDS, which without treatment develops an average of 11 years after infection.
“It is a shared vision,” said Torie Osborn, director of the Gay and Lesbian Community Services Center, the county’s second-largest AIDS-services organization. “In order for things to work, we have got to work together,” added John Schunhoff, assistant director of the Department of Health Service’s AIDS Program Office.
The new atmosphere couldn’t be more timely, for health experts say that Los Angeles is at a turning point. The decisions its leaders make in coming months will help determine whether the county’s path in the 1990s resembles San Francisco’s, a model of comprehensive prevention efforts and compassionate, cost-effective care, or New York’s, where the epidemic rages out of control among IV drug abusers.
Though the new cooperative spirit provides reason for optimism, there is a major caveat: Key elements of the plan are dependent upon the approval of the county Board of Supervisors, whose conservative majority has blocked previous AIDS initiatives proposed by county health officials.
“We have an outstanding work plan,” said city of Los Angeles AIDS Coordinator Dave Johnson. “The key issues, come this spring, will be getting it funded and getting it through the Board of Supervisors without impediment.”
At a time when state and federal officials are reining in AIDS spending, the estimated public and private cost of early medical intervention alone for the 112,000 county residents believed to be infected totals $500 million a year.
Whatever the supervisors decide, the board’s response will be critical in determining the course of the epidemic: not only how many will get sick and how many will die, but also whether the crisis-plagued public health system can continue to deliver even minimal levels of care to huge segments of the population.
Despite earlier hopes, the AIDS epidemic has not leveled off or peaked. Between January and November, 1989, the latest period for which figures are available, new cases of full-blown AIDS in the county totaled 2,274, up 28% from the comparable period a year earlier.
Even if the spread of HIV were halted tomorrow, cases of full-blown AIDS would continue as people infected years ago became sick. County planning documents estimate that, within two years, the cumulative total number of cases will more than double, to at least 19,000. The total could rise to as high as 44,000, based on infections in past years.
Despite the grim projections, Los Angeles has a choice. Will it go the way of San Francisco, widely praised as a model of compassionate and cost-effective AIDS care? Or will Los Angeles resemble New York City, the third major center of the epidemic, where people are dying in the streets as the unchecked spread of the virus among drug addicts fills public and private hospitals beyond capacity?
While some credible voices suggest that the same forces that unleashed disaster on New York--poverty, drug addiction, racism, denial and homophobia--are poised to strike here, others believe that AIDS in Los Angeles will follow its own course somewhere between the New York and San Francisco experiences.
“Comparisons among cities are fraught with variables that can confound analysis,” said George Ersek, who oversees AIDS programs for the Health Resources and Services Administration in Rockville, Md.
The geographic, political and ethnic contours of Los Angeles County present opportunities for containing the epidemic--as well as obstacles. The county’s vast sprawl and poor public transit system, for example, are believed to have slowed the spread of the virus among needle-using drug addicts.
On the other hand, that same sprawl has made AIDS invisible to large segments of the county’s diffuse population. That, critics charge, has led to complacency in the overall community’s response.
“There is a continuing sense in Los Angeles that AIDS is somebody else’s problem,” said David E. Gooding, executive vice president of Transamerica Life Insurance. Gooding, one of the few ranking downtown officials to take a high-profile role in the AIDS struggle, is a board member of AIDS Project Los Angeles.
The contrast with other big cities is stark. Despite New York’s problems containing the disease, top corporate executives there staff AIDS task forces and open their coffers to local AIDS charities. In contrast, business leaders in Los Angeles--with the primary exception of those in the entertainment industry--have remained comparatively aloof.
To cite just one comparison, Chevron, based in San Francisco, donated $125,000 for Project Open Hand to buy a new kitchen for its meals-on-wheels program for AIDS patients. Arco, based in Los Angeles, has given from $3,000 to $4,000 to AIDS causes since the epidemic began--an average of $500 a year.
Other unique aspects of Los Angeles are its rich ethnic mix and a population that includes more than 1 million undocumented immigrants--many of them poor, uneducated and hard to reach with AIDS-prevention messages.
AIDS educators fear that their task has been complicated by the Roman Catholic Church’s unyielding stand against the use of condoms, and that Latinos are suffering disproportionately as a result.
“In the past two months, our clinic has found 45% (infection rates) among gay and bisexual Latinos,” said Osborn, compared to 17% among Anglo gays. “The figure just leaps out at you. . . . It is really alarming.”
“The gay white male experience, horrible as it has been, will look like a walk in the sun compared to what is coming in the ghettos and barrios of Los Angeles,” added Dr. German Maisonet, a private physician who treats AIDS-infected intravenous drug abusers.
Despite efforts to educate the black community by such groups as the Minority AIDS Project, denial remains a powerful force. Dr. Wilbert Jordan, a black physician who directs the AIDS clinic at Martin Luther King Jr./Drew Medical Center, said that fewer than 10% of black ministers responded to his letter inviting their congregations to “adopt” an AIDS patient to raise awareness about the disease.
And when county health officers sponsored a forum for Latino doctors on treating AIDS and HIV infection, only three showed up. “We invited over 1,000, and 75 to 150 would have been a good showing,” said Dr. Martin Finn, the county’s top AIDS health officer.
Finally, the political contours of Los Angeles County may hamper the response to the epidemic. Supervisors, for example, have twice spurned recommendations to fund programs that would distribute bleach to IV drug users--steps New York and San Francisco instituted years ago.
“Under the present political philosophy of the board, we will never have an effective battle against AIDS in Los Angeles,” said Michael Weinstein, president of the AIDS Hospice Foundation and a frequent critic of the county’s response to the epidemic.
“There’s a definite lack of leadership--and, I would add, a lack of will,” said Mary Nalick, director of the City of Angels Hospice in Hollywood. Although the facility is widely admired for providing excellent care to end-stage patients, to date it has received no government funding because of one bureaucratic obstacle after another.
“We’ve managed to exist with no public money and no client money for a year,” said Nalick, who has been forced to rely on an unsteady stream of foundation grants and private donations. “Basically, I beg.”
Dr. Neil Schram, former head of the City-County Task Force on AIDS, still seethes when he thinks back to his first visit to the Los Angeles Board of Supervisors in 1985 to warn of a killer that would wipe out tens of thousands of county residents.
Schram had waited four years since AIDS first appeared to sound the alarm. Here at last was his chance to urge leaders to mount aggressive educational efforts to stem the spread of the fatal disease, to avert panic and to shore up a sagging health-care system to cope with the tidal wave of patients to come.
“As I delivered my testimony, Pete Schabarum stood in a corner and talked to a friend,” Schram recalled. “Ken Hahn and Deane Dana were absent. Ed Edelman listened. And Mike Antonovich sat there and watched me, watching him, while he made calls on his portable telephone.”
Schram, a South Bay physician, was not mollified when people more familiar with the ways of local government assured him that such inattention from supervisors was typical for hearings. To Schram, the episode drove home “the egregious and shameful leadership vacuum” that has characterized the county’s response to AIDS.
County supervisors insist that they have taken the epidemic seriously all along. But Edelman, the only supervisor who consented to an interview, said he feels “lonely and frustrated” when supporting AIDS issues on the board.
Despite years of urging from public health officials, for example, Los Angeles County did not adopt legislation barring discrimination against people with AIDS until February, 1989--after the cities of Los Angeles, Santa Monica, Berkeley, Riverside and Pasadena and various California counties enacted similar measures.
The civil rights legislation was hotly contested and was approved by the Los Angeles County Board of Supervisors by a 3-2 vote.
Many people within county government believe that Schabarum was betraying his own feelings when he said at a board meeting earlier this year that “the man on the street . . . could care less about funding” AIDS care. Last year, alone among supervisors, Schabarum refused a special briefing on AIDS by county health officers.
Judy Hammond, an aide to Schabarum, said the supervisor reflects his “conservative, working-class district,” which includes such cities as Pomona, Arcadia and Whittier.
“We get all the extremes, including mail that says, ‘Let them die, they brought it on themselves,’ ” she said.
Antonovich aide Dawson Oppenheimer said the board’s conservative majority has refused to approve bleach distribution to needle-using addicts because it is “very concerned about sending out the wrong message to young people.”
“AIDS kills, but drugs kill too,” he added. “There is no safe way to take drugs.”
Many county health officials, especially in the AIDS office, say they are demoralized, caught between the increasingly noisy demands of AIDS activists and the truculence of top officials and supervisors.
Finn, formerly the county’s top medical officer and now medical director of the AIDS Program Office, recalls testifying at a 1984 state legislative hearing that Los Angeles needed a three-fold increase in AIDS prevention education funds. “I was called on the carpet by (County Health Department Director Robert C.) Gates,” he said, and admonished for speaking out.
Gates, in an interview, said he does not recall the incident.
The health chief defends the department’s response to AIDS, given the political and economic realities in the county. This year’s county AIDS budget, including state and federal funds, will climb to $60.4 million from $51 million a year ago and $30 million a year before.
“I work for the board,” Gates said. “The fact that I am not visibly and vocally standing up to the Board of Supervisors does not mean that I am not expressing to the board what needs to be done to deal with AIDS. . . . My style is to convince people privately, rather than to engage in public confrontations.”
Gates takes pride in the new 20-bed inpatient AIDS ward at County-USC Medical Center. The facility, opened in September and long a priority of AIDS activists, is modeled on one opened at San Francisco General Hospital six years earlier.
But outpatient care at County-USC remains “a scandal,” said Mark Kostopoulos of ACT UP, the AIDS Coalition to Unleash Power, and some county health officials privately agree.
Consider 40-year-old Ernesto Oliva, who had to wait six weeks to get an appointment after he tested positive for HIV. When he was finally seen, doctors found that his immune system had deteriorated so badly that he might have been struck by deadly pneumonia while he waited; doctors immediately instituted preventive treatments.
The outpatient facility at County-USC, known as ward 5P21, is so crowded that patients like Bill Oxendine must take intravenous chemotherapy treatments on a bench in a public hallway due to the shortage of infusion rooms.
“You get the drugs, but in a way that robs you of your human dignity,” said Oxendine, 44, who was diagnosed as having Kaposi’s sarcoma six months ago.
County officials originally intended to open a new outpatient clinic at the hospital this year, but funding delays and red tape have delayed that until next September, at the earliest.
County health department’s response to the epidemic is its establishment of an HIV clinic in West Hollywood. The facility formerly housed a clinic that catered mostly to gay men with sexually transmitted diseases.
“Somewhere in 1984, the numbers of clients began to drop as gays adopted safe-sex practices,” said Dr. David Dassey, the clinic’s director. “By 1986 and 1987, they were off precipitously.”
So, in conjunction with the city of West Hollywood, county officials converted the under utilized clinic into what they hope will be a model for providing outpatient care for patients infected with the virus.
Since March, the clinic has been monitoring HIV-positive patients. Within a few months, it will open a treatment room in an effort to forestall the development of full-blown AIDS.
“My crude guess is that we’ll be able to enroll 750 patients and take some of the burden off of County-USC,” Dassey said. But he fears that the clinic, which has already evaluated 550 patients, will itself be overwhelmed when it begins offering treatment. And, already, the facility is suffering from staffing problems and a high turnover rate.
“If we are going to advise people to get tested for HIV, we need to have services ready for them if they test positive,” he said.
Although there are common elements in the responses of the gay communities of the three cities hardest hit by AIDS, there are also important distinctions.
New York, for example, was the birthplace of ACT UP.
San Francisco is the home of Project Inform, a clearinghouse for information on experimental medical treatments. Although ACT UP and Project Inform have taken root in Los Angeles, the primary route to “self-empowerment” here has been markedly different.
It can be seen every Wednesday evening at West Hollywood Park, in an auditorium a few hundred feet away from the HIV clinic, where about 500 people touched by the AIDS epidemic gather in a spiritual response to the disease personified by the self-proclaimed metaphysical counselor Louise L. Hay.
Every week, the sick, the dying and the worried-but-well gather to hear the blond and personable Hay dispense her New Age bromides.
Hay’s basic message can be summarized in two words: “Love yourself.” She peddles variations on the theme in books, meditation tapes, videos and personal appearances throughout the country. “Go up to a mirror, look into your eyes, and say, ‘I love you, I love you, I love you,” Hay told her rapt audience at one of her “Hay Rides” (suggested donation: $10) one recent evening.
The meeting concluded with a group meditation and the singing of her trademark song: “I Love Myself the Way I Am.”
“Southern California is the seed bed where all sorts of new religious expressions take root and bloom,” said the Rt. Rev. Oliver Garver, Episcopal bishop of Los Angeles. “It doesn’t surprise me at all that new organizations would grow up seeking to address, in spiritual ways, this painful and personal tragedy.”
Garver, a board member of AIDS Project Los Angeles, suspects that more people with AIDS in Los Angeles resort to such groups than in New York or San Francisco because they feel politically disenfranchised. “Even in 1989, we are still knocking on doors and confronting deaf ears,” he said.
Some gay leaders were slow to mobilize against AIDS in Los Angeles. When Sheldon Andelson died of AIDS in December, 1987, obituaries noted his distinguished career as a gay leader, lawyer, banker and member of UC Board of Regents. Most obituaries did not mention, or glossed over, Andelson’s part-ownership of Los Angeles County’s biggest gay bathhouse during the 1970s and early 1980s, the 8709 on West Third Street.
Some people charge that the influential gay leader’s involvement in the commercial-sex industry seriously hampered the battle against AIDS here. When AIDS first burst onto the scene in 1981, gay doctors like Neil Schram repeatedly beseeched Andelson to take a leadership role in combatting the epidemic. His requests, Schram said, were ignored.
“He wasn’t the only one,” Schram recalls. “During the early years, gay newspapers wanted nothing to do with AIDS.” One newspaper that featured AIDS on its cover was banished from several gay bars.
Municipal Judge Rand Schrader, head of the County AIDS Commission and an old friend of Andelson, said that for Andelson, the bathhouse was more than a money-making business.
“To him, it represented our hard-won sexual freedom,” said Schrader, noting that Andelson began his legal career defending consenting adults against charges of sodomy before the act was decriminalized in California.
Andelson finally shut down the bathhouse in 1984.
But although gay leaders may have been slow to act, many gay men and lesbians at the grass-roots level reacted heroically during the early years of the epidemic. Gays, for example, largely founded and staffed AIDS Project Los Angeles, which provides food, shelter, case management, dental services and transportation to people with symptomatic HIV disease.
After several rocky years when it was threatened with insolvency, APLA is returning to financial and operational health under Stephen Bennett, its new chief executive.
There are other success stories, powered largely by an extraordinary volunteer effort. Gay men and women continue to pour hours into volunteer work at AIDS Project Los Angeles, the Shanti Project, the Gay and Lesbian Community Services Center, the AIDS Hospice Foundation, Minority AIDS Project and dozens of other community-based organizations that battle the epidemic.
Take Phill Wilson, whose lover died of AIDS last month. Working with a group called Black and White Men Together, Wilson--who is infected with HIV--runs workshops designed to reinforce safe-sex practices among blacks.
Certainly, gays have been generous financially. With Hollywood donating the talent, gays in Los Angeles have opened their coffers to support star-studded benefits for a host of AIDS-related causes. They have also organized politically, though not nearly as effectively as in San Francisco, where gays have much more political clout.
Some people believe the reason has to do with the socioeconomic structure of Los Angeles’s gay community.
Indeed, there appear to be two AIDS epidemics among gays: one for those who can afford private medical care, and a second for those who must rely on county health facilities. While those with insurance are able to fight for access to experimental drugs, the poor must struggle for basic medical services.
Torie Osborn of the Gay and Lesbian Community Services Center believes that gay clout in Los Angeles also is weakened because so many more gay people remain closeted here compared to San Francisco.
“There are a lot of powerful gay people--in corporations, in government, in the professions--who could have made a difference but didn’t dare to because they were in the closet,” she said.
Even though gays account for 89% of the AIDS cases in Los Angeles, nine years into the epidemic they are finding it difficult to maintain a wartime footing.
“You can walk down (the gay strip on) Santa Monica Avenue in West Hollywood and not even realize there’s an epidemic going on,” said Paul Monette, author of “Borrowed Time: An AIDS Memoir,” a searing account of his lover’s struggle with AIDS.
Partly, this reflects what psychologists call “healthy denial” as the epidemic’s dreary role call of death drones on. But Monette believes the reasons go deeper. “Los Angeles is fantasyland,” he said. “Maybe our capacity for denial is greater.”
Now that the epidemic has lost its novelty, “there’s a sense out there that AIDS is all over now,” he said. And, with current and expected treatment advances, “it seems like the light at the end of the tunnel is no longer an onrushing freight train.”
But AIDS is far from over. “I recently came back from Europe and found out that four friends had died,” Monette said. “Whatever the perceptions, the death and the suffering are not stopping.”
AIDS in Three Major Cities
The following are selected AIDS statistics through Sept. 30, 1989, for New York, Los Angeles and San Francisco, the three major centers of the epidemic which together accounted for 34.5% of the nation’s AIDS cases. The data shows that Los Angeles has more than twice as many female cases and three times as many pediatric cases as San Francisco, even though its total caseload is only 11% higher.
New York Los Angeles San Francisco Total cases 22,571 8,063 7,277 Total deaths 12,246 5,306 4,706 Children under 13 536 70 22 Adult women 2,934 244 91 Gay/bisexual contact 10,916 6,474 6,164 Heterosexual IV drug use 6,166 325 159 Reported new cases, 4,081 1,928 1,458 year to date Total cases White 39% 65% 82% Black 33% 16% 7% Latino 27% 18% 8% Projected net municipal outlay $229.6 $20.5 $19.9 (millions) for AIDS prevention and care, current fiscal year*
* Does not include private contributions, state and federal expenditures or payments from private insurers. Aids Cases Per Census Tract in Los Angeles Metro Area Census tracts are based on population and range in size in the Los Angeles Basin from very largest-about 72 square miles-to the smallest-less than a mile square.)
No. of cases Map area No. of tracts per tract White 1,312 0 to4 Gray 159 5 to 9 Dark gray 78 10 to 24 Striped 11 25 to 49 Black 14 50 to 124
Map shows reported AIDS cases between January, 1983, and December, 1988 Source: Department of Geography, California State University, Northridge and Los Angeles County Department of Health Services