The AIDS Assault

And the Band Played On: Politics, People and the AIDS Epidemic, by Randy Shilts, New York: St. Martin's Press, 630 pages, $24.95

Randy Shilts has created a masterful medical mystery story, an extraordinary documentation of the beginnings of our nation's AIDS epidemic. And the Band Played On is a gripping, fact-filled work, packed with accounts of the suffering, struggling, selfishness, and selflessness of real people, that could only have been written by someone with the unique credentials of Shilts, a reporter for the San Francisco Chronicle. Shilts has been covering the AIDS scene as far back as the time when no other newspaper seemed to care a mini-column's worth about it. My only regret is that this book is not a work of fiction.

And the Band Played On is written on a number of interwoven levels. First, it is a mesmerizing documentation of the exponential spread of disease in a community—homosexual men—whose lifestyle provided the ideal medium for the explosive growth in the prevalence of a viral pathogen.

On page after page you meet young and middle-aged gay men, whom you get to know and inevitably like, or at least identify with in some way, only to crash land in grief 100 or so pages later as these men die before your eyes. You will be fascinated, and horrified, by this book. Fascinated, because for nonscientists and scientists alike, a new disease does create an electric, intellectual excitement. There's an instinctual surge of energy to get at the bottom of this new scientific mystery.

But you will be horrified as you learn the grisly medical sequence of AIDS, a disease that might well get the prize for the most gruesome way a human being can die. You meet AIDS victims who are suffering from cryptosporidium, a parasite that normally inhabits the bowels of sheep (one attending physician in desperation called in a veterinarian for assistance. "What do you do with sheep that get this?" he asked eagerly. "We shoot them," said the expert). You shiver in sympathetic suffering when you read of mortally ill young men covered with shingle-like growths, scabs shooting hot, piercing pain at the slightest touch, foam pouring out of their mouths, awaiting the steady march of the AIDS virus toward the human brain.

Second, the book provides a historical and medico-sociological context for today's AIDS epidemic. It offers a compelling description of the first identifiable cases of AIDS in Africa and documents the death of a female Danish physician who suffered from the disease while working at a remote hospital in Zaire in 1976.

We meet physicians who in 1979 and 1980 were puzzled by the previously unknown immune-deficient status of young male patients. And we are reminded of the role that our highly mobile society can play in the rapid spread of a new disease.

The book opens with a description of partying in New York on July 4, 1976, and the chilling realization that on that day alone hundreds of gay men from around the world were in that city to celebrate the bicentennial and, unbeknownst to them, to become infected with the AIDS virus during their short stay. Particularly memorable is Shilts's focus on the so-called Patient Zero, a Canadian air steward who, with his airline pass, was able to criss-cross the nation infecting literally hundreds of men, continuing to do so even after he knew his disease was contagious.

And the Band Played On provides the most complete description yet of the public health climate in which the AIDS virus took hold. As a result of the "liberated homosexual lifestyle" (freely defined as promiscuity, anonymous partners, and specific sexual acts that ensured contamination of the respective partners), there was, in the U.S. gay community starting in the mid-1970s, an unprecedented epidemic of sexually transmitted disease. By Shilts's account, it would be difficult to find a sexually active homosexual male by 1980 that did not suffer from Hepatitis B, some form of "gay bowel syndrome," or other viral, parasitic, or bacterial disease. For those men, disease was an unavoidable cost of their liberation.

In retrospect, of course, the failure of public health professionals to intervene to stem the flow of disease in this community may represent one of the most significant failures of public health in this century, one that apparently left this group spectacularly vulnerable to assault by a new virus. Why didn't the public health community respond in the pre-AIDS epidemic of gay disease? Most of us had absolutely no idea what these men were doing with each other. And gay physicians within the community were unwilling to take action that might be perceived as taking away some newly found freedom, including the right to anal intercourse, "rimming" (politely described as oral-anal intercourse), and other practices that would make a sailor blush.

Third, And the Band Played On is a book of heroes and villains. In the former category reside individuals like Dr. Selma Dritz, an infectious-disease specialist with the San Francisco Department of Health, who was appalled by the spread of disease in the homosexual community and grimly warned of the potential for havoc if a new pathogen ever broke loose. "There is too much transmission going on," she said, but was largely ignored. There was Dr. Don Francis, a prominent government epidemiologist and one of the physicians who helped eradicate smallpox, regularly expressing his fear over the consequences of the failure of blood-bank administrators—and the Centers for Disease Control—to screen blood and exclude homosexual men as donors as soon as the possibility of transmission of AIDS through blood transfusion was evident.

Shilts's villains include Dr. Mervyn Silverman who, as director of San Francisco's Department of Public Health, failed to move in a timely fashion to close the bathhouses, correctly designated by the author as "biological cesspools," for fear of incurring the wrath of gays. And especially pernicious was the role of the blood-bank industry, with its blind insistence that the blood was safe and screening was unnecessary. Blood banks were easily cowed by the homosexual lobby, which resisted discrimination against homosexual donors. The result is that thousands of Americans have died, and many more will in the future.

Finally, this is a book of barely muted outrage derived from the author's belief that this epidemic "was allowed to happen." In fairness, there is substantial emotional venom reserved for the gay community itself, the author making a clear dichotomy between sexually conservative homosexuals and the bathhouse crowd for whom he has understandable disdain.

But ultimately, the author's contempt focuses on "government" for its alleged failure to respond effectively to stem the tide of the AIDS epidemic. Shilts spends a substantial number of pages pointing a finger at the Reagan administration for "not doing enough," with gratuitous references throughout to his belief that if it were Boy Scouts or "straight" businessmen who were affected, the president would have been on first-alert. It is here that I part company with the author's views.

First, it is likely that historians will give "government" pretty good grades for its quick detection of the surge in AIDS-related diseases. The surveillance system in place worked, as alert physicians in 1980 began to report bizarre disease patterns in homosexual men to the Centers for Disease Control in Atlanta.

Second, Shilts largely ignores the other half of the package deal that comes with freedom, in this case sexual freedom: responsibility for the consequences of one's chosen behavior. Where is the introspection here? In noting Shilts's tendency to lay blame for AIDS at the doorstep of government, I am reminded of my feelings when I observe the latest gay-rights parade here in New York. Angry young men, some of them visibly ill, shout their hatred of the Reagan administration. One sign that always shows up in these parades is: "Since Ronald Reagan was elected President, there have been 45,000 cases of AIDS in the United States."

But wait a moment. Can anyone who knows the facts deny that AIDS, as it appears in the homosexual and drug-using population, is a self-inflicted disease? A promiscuous homosexual lifestyle carries inherent health risks, and gays knew this by the mid-1970s when rates of sexually transmitted diseases soared. Just because AIDS or any other fatal disease was not specified on the "morbidity menu" prior to 1982, how can they look to anyone but themselves for an explanation why these infections occurred? This is not to say that gays deserve AIDS, any more than cigarette smokers deserve lung cancer. It comes with the territory.

Was the government blasé about the AIDS epidemic in the years between 1981 and 1984? Yes and no. "Yes" in the sense that 20/20 hindsight now shows AIDS to be a more insidious and formidable opponent than was first thought. But "no" in that federal research dollars were forthcoming, progress was made, and Shilts seems to have forgotten that America had and continues to have other health concerns demanding our attention. While in mid-1983 there were some 1,279 cases of AIDS on record, in that year nearly 450,000 people died from the effects of cigarette-related disease (also the consequence of a chosen behavior).

The reality is that, given the five-year-plus incubation period for AIDS, there was nothing that government or anyone else could do to prevent most of those AIDS deaths among homosexual men occurring prior to 1985. Thus, I reject Shilts's premise that "people died while Reagan administration officials ignored pleas from government scientists and did not allocate adequate funding for AIDS research until the epidemic had already spread throughout the country."

What the Shilts book lacks is the acknowledgement that the homosexual revolution was a health disaster and that there is nothing gay about being a promiscuous homosexual in the age of AIDS. It is not appropriate to continue to promote a political agenda that characterizes promiscuity as normal and acceptable behavior.

During the next decade, all Americans will be called upon to display enormous understanding and support for a dramatically increasing number of AIDS victims. (The Centers for Disease Control estimate that in the year 1991 alone, there will be some 65,000 deaths from AIDS, nearly 70 percent among homosexual men). Instead of blaming government, as Shilts does, we need to work together to get out of this mess, offering every last drop of compassion we can muster to assist the victims of this dreadful disease. But let's not, in the process, spin off on a guilt trip that this epidemic is somehow everyone's fault. We need to get on with the business of caring for the sick, enlightening Americans as to how to prevent further transmission, and accepting the reality—and educating our children to the fact—that some forms of human sexual behavior are simply hazardous to our health.

Elizabeth Whelan is an epidemiologist and the executive director of the New York–based American Council on Science and Health.