A Calm Look at AIDS

Fear is the main source of superstition, and one of the main sources of cruelty. To conquer fear is the beginning of wisdom.

--Bertrand Russell, "An Outline of Intellectual Rubbish"

"AIDS will never become an overwhelming danger to the general public," Dr. Robert C. Gallo said to me in February 1987. Dr. Gallo is the codiscoverer of the AIDS virus and the chief of the National Cancer Institute's Laboratory of Tumor Cell Biology at the National Institutes of Health. He has the first patent to produce the virus for laboratory study and is acknowledged as a leading AIDS researcher.

Gallo said this during an unprecedented wave of media hysteria and confusion about AIDS. Public-health officials appeared to be outdoing one another in predicting widespread catastrophe. Magazine-cover stories and broadcasts warned about the danger of AIDS to all sexually active people, heterosexual as well as homosexual. And although everyone agrees that for those in high-risk groups, the disease has reached epidemic proportions, there is growing controversy among researchers about the gravity of the crisis threatening the heterosexual public.

"It is not a plague," Gallo said firmly. "To start saying that this is going to overwhelm people--that's not true."

Gallo's view is unorthodox, but a few years ago, when heterosexuals were ignoring AIDS, he recognized the danger of the illness. Fearful that straights would dismiss it as a gay disease, resist funding research and abandon those who were infected, he worked to alert the public.

Now Gallo is afraid that people--particularly heterosexuals not in a high-risk category--are succumbing to an unnecessary panic that could have political and sociological repercussions for everyone: gays, straights, men and women.

"We're in a difficult position," Gallo said. "If you underestimate the danger, you can cause trouble." He believes that people should not be lulled into a false security--and advocates the use of condoms and safe sex. "But if you overestimate the danger, you can also cause trouble," he said. "You can even drive people to suicide. I wouldn't promote any panic. The worst thing we can do is overdo it, exaggerate the danger."

Gallo pointed out that he is not an epidemiologist and does not work on a day-to-day basis with patients, though he is a physician. He said that it has been "established" that an infected man can pass the AIDS virus to a woman through heterosexual intercourse. The AIDS virus, carried in semen, can enter a woman's system through ruptures in the vagina, the mouth or the anus. It can even be transmitted from a man to a woman through artificial insemination, a procedure that is unlikely to cause trauma or rupture. But the virus is not easily transmitted. "You don't get infected in small doses; you need a big dose," Gallo said.

Although the virus may be transmitted from women to men, Gallo and others who agree with him say that unless it moves easily from females to males, the risk of large-scale infection of the heterosexual population is slight. And since he believes there is little evidence that women can transmit the virus to men "efficiently enough," the danger of AIDS to the heterosexual community is being overstated.

"Woman-to-man transmission," Gallo said. "It's more difficult to get hard data on that. I personally don't know of a single case [in America] of a man getting the virus from a woman [through heterosexual intercourse]. In Africa [where AIDS seems to affect men and women in equal numbers], it happens; but that may be due to differences in sexual practices, more promiscuity or a greater incidence of venereal disease."

Or it may be due, as some researchers suggest, to the use of insufficiently sterilized needles in clinics; to the use of dirty needles in tattooing; to ritual clitoridectomy (removal of part of the female genitalia), which can lead to pain and bleeding during vaginal intercourse and a corresponding increase in anal sex.

"In America," Gallo said, "it's very difficult to find the virus in vaginal fluid. We've never found it." (Researchers at the University of California at San Francisco have found the virus in vaginal secretions, but in amounts so small that, according to Dr. Jay A. Levy, "the disease cannot easily be passed from women to men through vaginal intercourse.")

Gallo is not alone in calling for a calmer look at the facts. Dr. Joseph Sonnabend, who helped discover interferon in the blood of AIDS patients and is a founder of the AIDS Medical Foundation, has been one of Gallo's most prominent critics. From the very beginning of the AIDS crisis, they have disagreed on almost every aspect of AIDS theory. Gallo suggested the single-virus, single-disease model. Dr. Sonnabend suggested the multifactorial (many causes) model. One of the few points on which they agree is that there is little evidence that the disease can be readily transmitted from women to men and that, as a result, there is little reason to believe that AIDS will spread among the heterosexual, non-needle-abusing population as it has among homosexuals.

"I've never seen a case of female-to-male transmission," said Sonnabend, who, as a New York City physician, has treated hundreds of AIDS and AIDS Related Complex cases. "I don't believe they exist.

"Women are at risk," he added, "but I see no evidence that women can transmit AIDS to men. In fact, I see a lot of evidence that they cannot. AIDS is caused by exposure to infected semen and blood that's introduced into the body; since women don't make semen and don't usually introduce blood into the male during sex, it is unlikely that they can transmit the disease to their male partners.

"The scenario they [many Government researchers and much of the media] are promoting is that the disease will spread among heterosexuals through sexual contact the same way it spread among homosexuals," Sonnabend said. "But if women do not give it to men, the only way you can get the disease is if you have sex with a homosexual or bisexual man or an I.V.-drug abuser. If you don't, you won't get it. You won't get it even if you have sex with a woman who has had sex with someone in a high-risk group."

Like Gallo, Sonnabend dismisses the relevance of AIDS in Africa to Americans: "In Africa, you have to look at conditions that are peculiar to those cultures."

Gallo called for caution, saying that unless scientists find a vaccine for AIDS, the disease "will be with us forever; and if you get infected, you're infected for life. Every group [both gay and straight] coming into its sexually active period will face some danger."

But he said the risk of infection may resemble the epidemiological danger people face from syphilis and gonorrhea, which today appear in persistent but sporadic clusters of cases.

"For the general public, the magnitude of risk of getting AIDS is not great," said Gallo. "AIDS will never spread in the heterosexual community the way it did in the homosexual community."

Both researchers emphasize that they are in no way downgrading the severity of the crisis for homosexuals and other high-risk groups, among whom the disease has, indeed, reached epidemic proportions. But even in the beleaguered homosexual community, safe sex and other changes in sexual behavior seem to be slowing the rate of increase of the disease.

In America in 1982, the number of cases doubled every six months; by the fall of 1986, it took ten months to a year for the number of cases to double; and if the Centers for Disease Control's prediction of a tenfold increase of cases by 1991 comes true, it will take a year and a half to two years for the number of cases to double. Which means the rate of increase of cases is decreasing.

There are some AIDS researchers and analysts who forecast a much bleaker picture than do Gallo and Sonnabend. Drs. Margaret Fischl and Gordon Dickinson of the University of Miami School of Medicine, among others, believe that there is evidence that heterosexuals--both men and women--are, indeed, at risk. "AIDS travels in both directions," Dr. Dickinson said. "There is no scientific reason to suppose it doesn't."

Dickinson acknowledged that they were dealing with extremely small numbers. In the Fischl-Dickinson study, three of eight men with female sexual partners with AIDS tested positive for the virus during the period they were being monitored, and those men were thought to be monogamous, heterosexual and non--drug users, "though you can never be absolutely certain," Dickinson said. He believes that it is possible for the virus to be transmitted from women to men during vaginal sex through tiny breaks in the skin on the penis. He feels that AIDS will have a major impact among heterosexuals, "but not the degree of spread it had in the homosexual community."

Dr. Mathilde Krim, the founding co-chair of the American Foundation for AIDS Research, one of the most visible advocates for AIDS research, also believes that it poses a danger for all sexually active people. She, like others who share her view, speaks of a future in which the disease could sweep through society with the severity of a plague or the world-wide influenza epidemic of 1918.

"AIDS has the potential for becoming a true pandemic," said Dr. Krim. She rejected Gallo's conclusions on heterosexual transmission, saying she believes that AIDS can be spread with equal ease between men and women. "In ten years, it could affect even 1,000,000 people. Worldwide, it could be 10,000,000, 100,000,000. God knows."

Krim cites three sources in support of her opinion: the Fischl-Dickinson study discussed above, a researcher at Montefiore Hospital in New York City and calculations on heterosexual transmission by Dr. Timothy Dondero of the CDC.

The Fischl-Dickinson study involves small numbers of men. The researcher at Montefiore declined to have his name used or to confirm any statement about his work. And Dr. Dondero confirmed that his statistics showed a rise in heterosexual transmission but said that the data on male-to-female and female-to-male transmission were unclear. "People who say the virus spreads with equal efficiency are speculating," Dondero said. He added that the spread of AIDS into the heterosexual community is "difficult to project."

Among people who are at high risk for the disease, AIDS is a terrifying threat to life. Any analysis of the situation must confront the possibility that Krim and those who believe as she does are correct. Those who believe the grimmer scenarios also fear--justifiably--that to downplay AIDS's threat to heterosexuals is to undercut efforts to cure, or to control, the disease. They are right. Any error should be on the side of caution.

Yet, as an editorial in The New York Times said of AIDS earlier this year, "dramatic alarms are well meant. They may one day be genuinely alarming.... But in the meantime, fears that it is spreading into the heterosexual population are just that, fears.... AIDS is grim enough without exaggeration."

In an examination of AIDS and heterosexuals published in the Times in October 1986, reporter Erik Eckholm concluded, "For now ... most of the country's heterosexuals apparently face only a slight risk of exposure to AIDS."

And in a Times article in March 1987, Philip M. Boffey wrote: "Although most people ... visualize the disease sweeping through singles bars, swingers clubs and colleges or high schools, that sort of transmission has thus far been minor. The overwhelming majority of the AIDS cases attributed to heterosexual transmission so far have been caused by intravenous drug users, especially in the Northeast."

Some recently published research also supports the contention that AIDS is not spreading among heterosexuals as it has among homosexuals. New York City's Department of Health published a report in its City Health bulletin late in 1986 stating that "over seven years, this route of [female-to-male] transmission should be measurable."

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But the measurements have been statistically insignificant, according to the report. Although infected women have been able to provide much substantiation about the men "at risk for AIDS" with whom they had sex, only two infected men--out of all those studied--claimed to be able to identify the women who had infected them.

That suggests that a considerable number of men with AIDS--many of whom may be closet gays or secret drug addicts--are lying about how they contracted the disease. The report cited 102 men with AIDS who in previous interviews had claimed that they had contracted it through sexual encounters with prostitutes. Twenty-four who were located and were willing to talk later admitted that they had really gotten infected through gay sex or by sharing needles. Three men who had originally claimed that they had gotten AIDS from sleeping with Haitian women later admitted that they were homosexual.

"The fact that the New York City Department of Health reclassifies 39 percent of these cases," the report said, "strengthens the belief among clinicians and investigators that most, if not all, N.I.R. [no identified risk] patients probably have engaged in high-risk behavior." That is, drug use or homosexual acts.

The conclusions of the New York City Department of Health report may well reflect the situation in other cities (particularly those in which homosexuality is less acceptable and in which men are more likely to hide homosexual encounters). Nationwide, there has been no meaningful increase in AIDS cases among the no-identified-risk category, which, according to the CDC, comprised three percent of all cases five years ago and still accounts for only three percent.

Some researchers tend to view skeptically other national statistics on AIDS, such as those being released by the Armed Forces. When men test positive and are asked about their behavior, the fact that they may face disciplinary action or discharge for admitting to drug use or homosexual acts taints the statistics. Men may claim only to have had contact with prostitutes, which tends to inflate the figures surrounding prostitution and AIDS.

A recent study done at the El Paso County Health Department in Colorado Springs, Colorado, and published in the April third Journal of the American Medical Association indicated that, in fact, the controversial Army study of 1985, which has been used to prove heterosexual AIDS transmission, was seriously flawed. The Los Angeles Times of April seventh quoted Dr. John Muth, director of the health department, as saying that the military statistics "are almost certainly wrong."

John Potterat, director of the sexually transmitted disease-control program for Colorado Springs, told U.P.I., "There's this idea that there's going to be this real flood of heterosexual cases and I don't think we're going to see that. Why panic the entire population when, in point of fact, the risk is very, very small?"

Dr. Joyce I. Wallace of the Foundation for Research on Sexually Transmitted Diseases has conducted studies on 175 heterosexual men who frequent prostitutes and believes that "all sexually transmitted diseases are bidirectional." She said, "Please don't give your male readers a false sense of security," adding, "not that AIDS is caught easily; it isn't." Her studies found that five of 175 men who claimed no other risk factors than their many visits to prostitutes (two percent) contracted AIDS; but of the five, three were later reinterviewed and found to have engaged in high-risk activity. That left only two men (one percent) who were presumed by Dr. Wallace to have been infected by the prostitutes.

Dr. George Rutherford, medical director of the AIDS office at the San Francisco Health Department, believes that female-to-male transmission is probably significantly less efficient and that, therefore, the dangers of prostitutes' spreading the virus have been overstated. He told the Chicago Tribune that heterosexual AIDS would remain a disease of inner-city narcotics addicts. "There's not going to be widespread transmission in the middle class," Dr. Rutherford said.

In any case, those skewed statistics make it seem as if there were a greater risk of getting AIDS through straight sex than there may really be. As the New York City Department of Health bulletin said in its special AIDS issue, number five, "Despite the increasing magnitude of the AIDS epidemic since 1981, there has been no data to support new modes of transmission of human immunodeficiency virus since 1982."

"New modes" means heterosexual transmission.

"The proportion of cases not explained by blood transfusion, needle sharing or sexual exposure to semen"--cases of possible heterosexual transmission--"has decreased over the period 1981 -- 1986."

The Department of Health concluded that it was "unable to prove female-to-male transmission."

Other studies bear that conclusion out.

Dr. Frank Polk of Johns Hopkins University said in the December 13, 1985, issue of The Journal of the American Medical Association that there was virtually no evidence of significant female-to-male transmission of the AIDS virus.

The evidence of heterosexual, female-to-male spread of AIDS so far has primarily rested on the stories of men--many of whom, like those cited in the New York City Department of Health report, may have something to hide. And anecdotal evidence is a poor basis for public policy.

(As we went to press, JAMA published the newest report from the CDC on heterosexual transmission. "In the United States at the present time, a heterosexual woman is at greater risk for acquiring AIDS through sexual intercourse than is a heterosexual man," the study concluded. The percentage of women who were infected through heterosexual contact rose from 12 to 26, the report said, but women still made up 6.7 percent of all AIDS cases--the same as five years earlier--and most of those were infected through intercourse with drug users and bisexual men. The report tends to confirm earlier opinion that the virus moves with greater efficiency from men to women than from women to men.)

None of this is meant to suggest that AIDS is not a serious threat to public health. Or that since the disease may not spread among straights as it has among gays, straights should not be concerned about it. Or that heterosexual men should be less concerned than heterosexual women. The problem is real and tragic.

But when the nature of the problem is exaggerated or misstated, other serious problems result. Even among researchers who do not share Gallo's and Sonnabend's conclusions, there is a growing awareness that all the talk about epidemic has produced its own backlash.

Dr. Tom Peterman, a medical epidemiologist in the AIDS program at CDC and director of the centers' heterosexual-contact study, is among those who believe that AIDS can be spread through all sexual acts, including fellatio, and that as a result, heterosexuals--especially those with a large number of partners--"need to take precautions." Even so, he said, "if you want to ask, Do I think there are going to be millions of heterosexuals infected? the answer is no."

To accept the idea that the general heterosexual population is not at great risk, say some who fought hardest to arouse public concern, is to chance the renewed neglect of the homosexual community. But to deny it is to chance a backlash of violence against homosexuals.

Indeed, in Seattle, even before the current wave of AIDS hysteria, a gang armed with baseball bats roamed the streets attacking anyone they suspected of having AIDS with a ferocity that a local newspaper compared to that of a Ku Klux Klan lynching. National statistics show that reported attacks against gays have increased by 100 percent. As USA Today reported in March 1987, "Every month, more and more cases of gays' being attacked are reported. . . . Many are attributed to 'AIDS backlash."' Thus, the civil rights of high-risk groups, which include those who have most recently become politically empowered, become more vulnerable to attack.

As to other long-term effects of AIDS hysteria, researchers are concerned about the psychological implications of a constant drumbeat of AIDS fear. "If you unnecessarily create panic," said Sonnabend, "it brutalizes people emotionally as badly as beating them physically." Some also question the effects on children who are learning about sex in the context of disease and death. Are the risks to all heterosexuals convincing enough to justify the dread that may be engendered in an entire generation? How will that generation view its own sexuality? What idea of human sexuality will, it pass along to the next generation?

Looking calmly at the research gives us a chance to catch our breath and to take an alternative view: As terrible as it is, AIDS may affect a relatively small portion of the population. Fear of AIDS, on the other hand, affects everyone.

The real AIDS crisis is as much psychological as medical. The plague is one of fear and ignorance that has the potential to wreak as much havoc as any disease. Exaggerating the risks of AIDS for whatever reasons, even humane reasons--promoting funding for research, avoiding stigmatizing gays--benefits no one.

' "People visualize AIDS sweeping through singles bars ... that sort of transmission has been minor.' "