Factual · Powerful · Original · Iconoclastic
Hard to believe, isn’t it, that just two years ago AIDS was seen as a threat to the very survival of the human race? Pop scientist Stephen Jay Gould told readers of the New York Times Magazine in 1987: "Yes, AIDS may run through the entire population, and may carry off a quarter or more of us."
And while it’s bad enough being told by nuclear weapons opponents that we have the capability to kill everyone not once but ten times, sex therapist Theresa Crenshaw said we were all slated to die at least twice of AIDS. She told Congress: "If the spread of AIDS continues at the same rate, in 1996 there could be one billion people infected; five years later, hypothetical 10 billion however, the population of the world is only five billion." Don’t snicker. She was then appointed to President Reagan’s AIDS commission.
Even the nation’s former top health official, Dr. Otis R. Bowen, the secretary of Health and Human Services, stated that "if we can’t make progress," we face a pandemic that will make all others, including the Black Death, seem "pale by comparison."
Fortunately, we don’t often hear such alarmism anymore. Yet, if the apocalyptics have at least partly faded, the fear of a vastly expanding epidemic has not. Public opinion polls continue to report that AIDS is considered far and away the nation’s number one health problem. As AIDS takes its toll, what we are seeing is in fact two epidemics: one consisting of actual AIDS cases, the other of fear. The first propels the second. But if our response to the AIDS threat is to be effective, then the scope of that threat must be realistically evaluated. Like the usual fish story, estimates of the size of the AIDS epidemic are proving to be grossly exaggerated. But unlike a fish story, the consequences of this exaggeration will be immense and far-reaching, chief among them a gross misallocation of fear — and of precious public resources. With federal funding for AIDS having passed that for heart disease and matching that for cancer, it’s time to take a close look at this alleged epidemic to end all epidemics.
During the height of the media scare, no AIDS story was complete without reciting the shocking estimates of the number of Americans now infected with Human Immunodeficiency Virus (HIV, the AIDS-causing agent), and still more ominous estimates of the soon to be infected. But it is clear that many estimates of the extent of the AIDS epidemic use statistical formulas or models that, though superficially plausible, may be utterly worthless.
One technique which exaggerates the scope of the epidemic is that used by Crenshaw in concluding that 10 billion persons could eventually die of AIDS. It gains some legitimacy by playing off the "doubling time" figures released by the Centers for Disease Control (CDC). Doubling time is a simple way of referring to the rate of increase in AIDS cases. If, for example, we observe that the number of cases is doubling every year, we say the doubling time is one year. If the doubling time goes from every year to every thirteen months, then the epidemic’s rate of increase is slowing.
Now, the nature of an epidemic such as AIDS — that is, an epidemic based on behavior — is that the virus will pick off the "easy" targets first. (With AIDS, the easiest targets were men who engage in receptive anal intercourse with numerous other men, who also engage in receptive anal intercourse with numerous other men, since this activity has been shown to be by far the most conducive to transmitting the virus.) An epidemic will progress ever more slowly as fewer and fewer easy targets remain. That is, the caseload may increase from month to month, but the rate at which it increases is ever lower. This is a general rule for epidemics.
Obviously, if you freeze the doubling time — rather than allow for its progressive slowing — and then extrapolate over a long period of time, you will produce outrageous results. It would be like observing that flu deaths in the United States one week were twice what they were a week earlier, and on that basis calculating a date at which all Americans would be dead of flu. But some AIDS "experts" have done just that, and the press has happily reported their findings.
For example, Gene Antonio, author of The AIDS Cover-up?, an intentionally terrifying book which he claims has sold over 300,000 copies, used a 2-month doubling time of AIDS cases and predicted that as many as eight million Americans would be infected by the end of 1987 and 64 million by the end of 1990.
A.D.J. Robertson, president of Research, Testing, and Development, Inc., used the same figures in a letter to the Wall Street Journal in 1985. (Notwithstanding his alarmism — or more probably because of it — he went on to serve as an advisor to the White House.)
Another method used by the Hudson Institute yielded the estimate that by 1987 there were up to 2.9 million HIV infections. The problem with these models is that they are no better than the numbers fed into them, many of which will be shaky estimates. Or, to put it another way: garbage in, garbage out. Economists call this "black boxing" — you put figures into a black box and pull out whichever ones you wish. The Hudson Institute report, for example, relies on such discredited authorities as the sex therapists Masters and Johnson.
But what of the "conservative" — and ostensibly more authoritative — figures generated by official government bodies such as the CDC? Even these appear to have been overstated.
In June 1986, in a meeting at the Coolfont resort in West Virginia, officials of the CDC estimated that one million to 1.5 million Americans were infected with HIV. To get the 1.5 million number, CDC first had to estimate the size of the population at risk. That figure was a combination of other figures: an estimate of the prevalence of homosexuals in the population given in the 1948 Kinsey study of male sexual behavior, an estimate of the prevalence of intravenous drug abusers (IVDAs) provided by the National Institute of Drug Abuse, and estimates of the numbers of hemophiliacs, blood recipients, and sexual partners of all of the above. Other than the estimate of number of severe hemophiliacs, whose reliance on blood products made them vulnerable to the AIDS virus but also fairly easy to count, all of the estimates were tenuous "best guesses."
CDC then had to estimate the extent to which each of these groups was infected. To do so, it could rely on little more than spot surveys conducted at such places as sexually transmitted disease (STD) clinics.
CDC was not quick to update its estimate after June 1986 because of a dearth of information about how fast the epidemic was spreading. Some in the media and the self-appointed AIDS experts took it upon themselves to tack on their own estimates of how many new infections had occurred since the CDC arrived at the 1.5 million figure. Masters and Johnson were among these, and used the resulting figure to corroborate their deduction of over three million existing infections.
Finally, in November 1987, CDC admitted — although not explicitly — that the old figure was too high. It did so not by reducing the old figure but by trotting out new data to show that the old figure was still good — a year-and-a-half’s worth of infections later. (Actually, CDC dropped the top end by 100,000 to 1.4 million.) It might be said that CDC waited for infections to catch up to the earlier estimate. Problem is, the entire conception of a growing pool of "seropositivity" (that is, the number of persons infected by HIV) may be a false one.
Current case demographics show that slightly less than three percent of AIDS cases are attributable to native-born heterosexual transmission. But some warn us not to be reassured by this fact, pointing out that the AIDS virus has a long incubation period. They ignore the flip side of this argument — that because of AIDS’s long incubation, cases of actual illness will be diagnosed at increasing rates long after infections may have peaked. And for most of the risk categories, infections clearly have peaked. Studies based on eight cohorts of homosexual and bisexual men indicate that the rate of new infections among homosexuals in major cities — the largest part of the CDC estimate — slowed down to nearly zero (ranging from zero to four percent) between June 1986 and the present. New infections among IVDAs are also slowing dramatically.
On the East Coast, where the "shooting gallery" phenomenon is common, the IVDA population is so saturated with HIV that there’s little room for new growth, except to the extent that there may be new "recruits" to the ranks of IVDAs. On the West Coast, where shooting galleries are much rarer, the overall infection rate is comparatively quite low (meaning there is room for many more infections), but then so is the new infection rate. A study of Los Angeles IVDAs published in the January 1989 American Journal of Public Health found that of 790 tested, only 1.8 percent were seropositive, meaning few old infections and few new ones.
Thus, if the CDC estimate of one million to 1.5 million HIV-infected Americans was "almost certainly too high" in June 1986, as the director of the CDC’s AIDS program, James Curran, puts it, then it’s quite possibly too high now. Writing in last October’s issue of the Journal of Acquired Immune Deficiencies, Joel Hay, a health economist at the Hoover Institution, using what he believes to be the most likely progression rate, estimated that there are only 500,000 to 800,000 Americans infected with AIDS. (More recently Hay told me he believes that this figure is probably too high as well.)
While the number of infections will determine the number of AIDS cases in the long run, in the short run what counts are the cases themselves. Even here, however, the official figures are not as solid as they might seem. At Coolfont, CDC projected that 270,000 cases would be diagnosed through the end of 1991, or 251,000 cases from the beginning of 1986. Unfortunately, a new factor has been added to confuse the situation.
In September 1987, the definition of AIDS was expanded to include several new symptoms of HIV infection, such as dementia and wasting syndrome. The result is that the number of cases considered to be AIDS has increased more than 20 percent above what it would have been under the old definition. If 120 cases are reported during one period now, one should assume that this would have been about 100 under the old definition. So, as Hay has pointed out, the redefinition of AIDS not only inflates the apparent rate of increase, but also masks a previous CDC overestimate. Needless to say, the press ignores the new definition when it cites the rising number of AIDS cases. But much of the increase in cases over the past year-and-a-half is due to the expanded definition.
Last year, the Public Health Service (PHS) and CDC convened their scientists again and announced that they were extending the projected caseload figure to the end of 1993, predicting 450,000 total cases by then. Curran told the media the new projections were unofficial but "pretty well set." The figure of nearly half a million played the media quite well, grabbing its share of headlines. But a week later, at a conference in Stockholm, Curran declined to make a prediction past 1992 and a figure of 365,000. "I’m not comfortable going that far [to 1993]," Curran later told me. "We’re not publishing [the 450,000 figure]." And in fact, it as not officially published.
But as far as most people were concerned, it already had been. CDC has issued no retraction of the figure. It is the 450,000 figure which was used first and it is that figure which will be remembered and used. Indeed, several weeks after the Stockholm conference, the editor of the Washington Post’s Health magazine declared confidently, "No one is questioning the projection that about 450,000 Americans will be diagnosed with AIDS by 1993."
Although it came out of a meeting (closed to the media incidentally) involving some of PHS’s top scientists, the new estimate had nothing to do with epidemiology. In fact, the procedure could have been performed with a pocket calculator. CDC simply extended the rate of increase in cases from 1981-1987 out to 1993. This is a dubious technique, for as Dr. John Pickering of the University of Georgia has pointed out,
If a model is to forecast reliably the incidence of an infectious disease over any extended period of time, then it must be based on the disease’s underlying epidemiology, rather than on the mathematical functions that fit the existing incidence data.
The press treats the CDC projections as sacrosanct; but CDC officials will tell you, as chief epidemiologist Harold Jaffe put it to me, "That’s just stupid." The figures are simply "best guesses" in a range that estimates there will be anywhere from 13,000 to 190,000 new cases during the year 1992. And the breadth of that range itself has only a 68 percent "confidence interval," meaning that there is one chance in three it will be incorrect.
But why is CDC so reticent about relying on its mathematical projections through 1993? Could it be that the epidemic would peak in that year or before? "Yes," Curran told me.
The great unspoken words of the AIDS epidemic are "peak," "plateau," and "crest." While we have become accustomed to hearing ever bleaker news about AIDS, with ever higher caseloads and estimates of caseloads and costs to society ("AIDS Without End" read the title of one recent article in the New York Review of Books), the concept of the epidemic peaking is completely alien to most of the public. But all epidemics do peak, more or less along the lines of a bell curve. For extended epidemics such as AIDS, the entire curve might be so stretched that the peak will actually be something of a plateau for some time, but eventually the cases must fall off.
One of the few epidemiologists venturesome enough not only to talk about such a peak (or a "crest" as he prefers) but to forecast it, is Dr. Alexander Langmuir, the chief epidemiologist at CDC from 1949-1970, where he developed the epidemiological branch as it now exists. Langmuir notes that if one plots reported AIDS cases on a ratio scale similar to that on which the Dow Jones Average or the Standard & Poor’s index is plotted, one sees over a period of years a sharp rise at first but a clear bending as time goes on. Dr. Langmuir says that the point at which the curve goes flat is the crest of the epidemic. After that point, cases will tend to fall off at a rate similar to that at which they had increased earlier on. This principle is called Farr’s Law, after a British doctor who predicted, fairly accurately, the cresting and ending of the Cattle Plague of London a 1865-66 based only on early reports.
Another system Langmuir uses to project the course of the epidemic, a technique which relies on an estimate of the incubation time and on the curve of infections, is based on short studies mentioned for example in the largest San Francisco cohort of homosexuals, which uses blood donated originally to test incidence of hepatitis B, new infections increased from 1.1 percent of the total cohort in 1978 to 11 percent in 1980 to 20.8 percent in 1982, dropping off drastically to 2.1 percent in 1983.
While this cohort doesn’t necessarily reflect the homosexual population of the U.S. a whole, it’s highly possible that it does. None of the other cohorts began as early and hence, when graphed, cannot show an upswing or a peak, but their declines closely match that in the hepatitis B study. This being the case, the peak in frequency of homosexual infections in major U.S. cities was 1982, while 1981 was the point by which one-half of all infections had occurred.
If the exact incubation time of all AIDS cases were, say, five years, then AIDS cases would peak about five years after the peaking of infections. Unfortunately, it’s not that simple. First, AIDS cases can incubate anywhere from seven weeks to an estimated thirty years or more. Second, no one knows for sure how many infections will eventually result in AIDS or how long on average that will take. The bad news here for seropositives is that researchers are moving to a consensus that 99 percent of all persons infected with HIV will eventually get sick, if not succumb to full-blown AIDS.
While predicting average incubation time is still somewhat speculative, several studies, including one based on the San Francisco hepatitis B cohort, show a median incubation time of almost nine years. Langmuir believes that HIV infections among all homosexuals — not just those in major cities peaked no later than 1982. He also believes that homosexual AIDS cases may already have peaked.
Since infections in the other risk groups probably peaked later, this will move the crest for all AIDS cases somewhat later in time. But the modification will probably not be very substantial, says Langmuir, since homosexuals make up more than two-thirds of all present cases.
Langmuir is the first to admit that he is an optimist. He also readily admits to having been wrong twice before in prematurely predicting crests. Yet in neither case was the formula at fault. In one he underestimated the lag time in reporting (cases are often reported months and occasionally years after diagnosis), and in the other he underestimated the incubation period — an almost universal mistake at the time.
Langmuir could be wrong again since no one yet knows for sure how accurate are the estimates of the average time between infection and diagnosis of AIDS, nor exactly when most homosexuals were infected, nor exactly what percentage of all infections are homosexual. Finally, the widespread use of AZT in seropositives who haven’t yet developed symptoms may delay the onset of AIDS, thus significantly extending incubation times.
It’s interesting that the bottom range of the CDC’s 68 percent confidence interval figure shows the epidemic plateauing in 1988 and starting to fall off in 1989, with total new cases for 1992 coming in at 13,000 — almost exactly what Langmuir has predicted. If Langmuir is completely correct, we should expect to see no more than 200,000 AIDS cases among homosexuals — and a corresponding low number among the other risk groups — by the end of the century.
Unfortunately, the lag time in reporting cases to the federal health authorities is so great as to make such a conclusion a difficult thing to grasp until long after it has already occurred. The lag is caused by a delay in reporting from doctors to local public health authorities and then from local authorities to state and federal authorities.
For this reason, the lag-time problem much smaller when one uses figures based on reporting to local health authorities in cities. One way, therefore, to get around the lag-time and check Langmuir’s theory is to investigate the statistics for the three cities with the most homosexual cases (Please see accompanying graphic, "AIDS Diagnoses by Half Years in San Francisco, Los Angeles, and New York City.")
Since at the time these figures were collected even the latest reporting period was thirteen months old, chances are there will be very few new cases added to it, much less to the older periods. As the chart reveals, even if one uses the new case definition, there is a decline in Los Angeles diagnoses and a near-plateau in San Francisco and New York. Subtracting the new-definition cases shows a decline in diagnoses in all three cities.
The good news, then, is that despite all the doomsaying about the inability of our major cities to cope with the problem of more AIDS cases, in some ways the worst is behind them (although for some time the number of living AIDS patients will continue to grow, and this will be a continual burden). The even better news is that as New York, Los Angeles, and San Francisco have gone, so must go the nation. Because of these declines in diagnoses, these three cities no longer provide a majority of the nation’s new cases. Nevertheless, if the AIDS epidemics in those cities peaked some time ago, as the accompanying table and graph indicate, and if, as the cohort studies seem to indicate, the epidemic in the nation as a whole doesn’t lag far behind that in the three cities struck first and hardest, it is entirely possible that the entire epidemic is peaking.
Thus, unless CDC keeps expanding the definition of AIDS to catch earlier and earlier stages of HIV infection (and CDC’s Harold Jaffe says there is sentiment in that direction), it’s going to start talking less and less about its best guess of 365,000 cases by 1993. And fewer people will be betting against Alexander Langmuir’s top-end prediction of 200,000 homosexual cases for the entire epidemic.
But what about non-homosexual cases? Nineteen eighty-seven, as you’ll remember, was the year of the heterosexual AIDS explosion. As U.S. News & World Report put it in January of that year, "the disease of them is suddenly the disease of us." Surgeon General Koop said in 1987, "If the heterosexual explosion follows the homosexual explosion, then we are in for unbelievable trouble." On the same occasion he also asserted his belief that the seropositivity level in the U.S. was "much higher" than the 1.5 million CDC figure.
To the chagrin of many of the experts, no such explosion took place. The good surgeon general now tells interviewers, "From the very beginning, I’ve said there does not appear to be any chance that there will be an explosion in the heterosexual [population]."
Twelve years after the first heterosexual AIDS cases began showing up in New York City (researchers have traced cases back to 1977), AIDS remains confined almost exclusively to homosexuals, IVDAs, recipients of blood products prior to 1986, and the steady sexual partners of the above. As mentioned earlier, slightly less than three percent of all diagnosed AIDS cases in this country have been attributed to heterosexual transmission in native-born Americans. In New York City, the heterosexual AIDS capital of the United States, out of more than 18,000 total cases, only seven males have been identified as having contracted AIDS through heterosexual intercourse.
If other health departments interviewed patients as carefully as New York does, efficiently screening out those IVDAs and active homosexuals who don’t admit to homosexual intercourse or shared needles, we might find but a score of such men in the entire country.
Blood tests also indicate that AIDS remains tightly confined to a few high-risk groups. The prevalence of HIV infection in military recruits not belonging to the aforementioned high-risk groups has been estimated at 0.02 percent or less, or one in 5,000. In first-time blood donors this figure drops to 0.006 percent, or six per 100,000. While it’s true that these groups are not fully representative of the general population, the self-selection factors that make them different can be assumed to be constant.
Therefore, there’s no reason to think that a significant overall increase in seropositivity would not also show up in their ranks. If it were true that, as Masters and Johnson boldly asserted, there were 200,000 non-drug using heterosexuals infected in the nation, or that, as Kevin Hopkins and William Johnston of the Hudson Institute more boldly assert, there are 200,000 to 500,000 such heterosexuals in the country, they wouldn’t consider themselves high-risk and wouldn’t know to opt out of blood donations or military applications. In other words, if they were out there, we’d know it.
Thus, a team of CDC scientists writing in the February 5, 1988, issue of Science, noting the above donor and military figures, concluded, "These preliminary data suggest that the proportion of ’unexplained’ heterosexual HIV transmission is not much higher than predicted from analysis of reported cases of AIDS."
In an editorial in the October 7, 1988, Journal of the American Medical Association, Dr. H. Hunter Handsfield, director of the Seattle-King County Department of Health, wrote: "Even when the prolonged interval from HIV infection to overt AIDS is taken into account, it is likely that the classification of reported cases accurately reflects the actual patterns of transmission."
More recent figures from blood testing of all women giving birth in California during last October showed that out of 43,301 tested, only thirty-six proved positive. Considering that this is the land of East Los Angeles, Watts, and Oakland, and that these women are by definition heterosexual, sexually active, and of the ages during which IV drug use is most common, a rate of 8.3 per 10,000 is wonderful news. The media greeted it with silence.
Just as CDC has been forced to reduce its estimate of the number of seropositives, so too has the City of New York. Originally, in 1987, its Department of Health estimated 500,000 infections in the city. Later, this figure was dropped to 400,000 when better information on infection prevalence and the size of at-risk groups had been collected. This past July the New York Times ran an article quoting community leaders responding to the news that AIDS researchers were coming to a consensus that almost all seropositives would eventually fall ill. As usual, the line was that of maximum hype.
Said the chairman of New York State’s AIDS Advisory Council: "I shudder to think what happens if we try to put 400,000 people into the system without better preparation than we have shown to date." A spokesman for the Gay Men’s Health Crisis, a major private agency, said the projection was "numbing, absolutely numbing." Mathilde Krim, the well-known AIDS fundraiser, rounded the Department of Health figure up to half a million and accelerated the incubation rate by assuming they would all die within a decade, saying, "Half a million people are going to die here in the next ten years . . ."
No one quoted by the article noted that the 400,000 figure was completely at odds with the CDC estimate of one million to 1.4 million infections in combination with the New York City Department of Health’s estimate that 15 percent of those cases would be New Yorkers. (The resulting figure would be 142,000 to 210,000 infections.) Nor did anyone quoted by the Times note that the 400,000 figure was incompatible with the extreme slowing of reported AIDS cases.
Thus, it came as a shock when the following week the Department of Health released new numbers that sliced the old figures in half, estimating that there were in fact 20,000 total infections in the city. With the 400,000 figure generating such dread, one might think that this revised, lower estimate would cause an outpouring of relief.
Not a chance. Members of an activist group called the AIDS Coalition to Unleash Power (ACT-UP), which promotes whatever will advance the curing and patient-care of those now suffering from HIV, besieged the director of the Department of Health, Stephen Joseph. They heckled him at public appearances, disrupted his private meetings, and demanded his resignation. Joseph says he has also received hostile phone calls at home and at the office. Eleven ACT-UP members were arrested at a sit-in outside his office.
The New York Native, the city’s leading homosexual newspaper, later depicted Joseph on its cover with a Cheshire Cat grin, spouting mumbo-jumbo about the number of seropositives in the city.
"It’s the statistical cure of AIDS," said Dr. Barry Leibowitz, president of the Doctors Council, a union representing physicians on the Health Department staff and at several hospitals. He said he feared that the new estimate would be "used to give us less when we desperately need more" funds and services to treat current as well as future patients. Writer Kristin Loomis, in the March 6, 1989, New York magazine, strongly implied that the reduction was a conspiracy on the part of the Health Department to make up for the lack of hospital beds. As part of her evidence, she stated that "last fall the CDC proposed a range of 150,000 to 380,000 infections in New York City." In fact, officials with both the New York Department of Health and CDC confirmed to me that CDC never proposed a range for New York nor any other city.
In any event, the lowered estimate wasn’t a cure for anything except an earlier faulty estimate, and Joseph and his staff were quick to point out that the estimates upon which the city planned its medical services weren’t based on the estimate of seropositivity. Instead, they were calculated from the projected caseload for the next three years, a mathematical extrapolation from the present caseload trend.
The adjustment also reflected a reduction in the estimate of infected New York homosexuals in the city from 250,000 to 50,000. According to Joseph, "Our previous estimates were based in part upon extrapolation from data published by Kinsey several decades ago, estimating that one out of ten men engaged in homosexual behavior..." The new estimate, he explained, was based in part on more refined estimates of the number of homosexuals in San Francisco, which a telephone poll in 1984 indicated to be about 56,000, including bisexuals.
For some time ... Health Department researchers have noted a disparity between the ratio of AIDS cases to the estimated number of gay men in New York City versus San Francisco: New York City, with a total population ten times that of San Francisco, has been estimated to have a population of gay men several times larger than San Francisco’s, yet its AIDS caseload of homosexual men is less than twice that [of San Francisco] ...
Assuming that the ratio of seropositive homosexual men with AIDS is about the same in the two cities, "that would produce," said Joseph, "an estimate of 50,000 HIV-infected gay men in New York City, rather than the previously estimated 200,000 to 250,000."
Kinsey’s data: Conveniently misinterpreted.
Thus the bitter reaction of the New York homosexual population to the new figure was a natural response to a double whammy. First, homosexuals worried that reducing the estimate might reduce impetus to find a cure. But second, the new figures implied that New York’s homosexual population might not be as large as previously assumed, and any dramatic reduction of the estimated size of the homosexual population seriously threatens their own power base. Could the long-assumed Kinsey "ten percent" be just a myth?
According to lore, Alfred Kinsey, in his landmark 1948 study, found that ten percent of all Americans are homosexual. The importance of this 40-year-old statistical assumption to the cause of the acceptance of homosexuality in our society cannot be overstated. "We are everywhere!" was one of the rallying cries of the Gay Liberation Movement. The 10-percent figure is also regularly employed as a lobbying tool by such groups as the National Gay and Lesbian Task Force (NGLTF), which claims to represent "23 million Gay and lesbian persons."
But the fact is, Kinsey never gave any such ten percent figure. What he said was that 10 percent of males are "more or less exclusively homosexual for at least three years between the ages of sixteen and fifty-five." Dropping the "more or less" and the "three years" reduces to four percent the figure that Kinsey says applies to men who are exclusively homosexual throughout their lives. A new Kinsey report, conducted in 1970 but fast released in the January 20 issue of Science, tends to confirm this four percent figure. Further, the first Kinsey report indicated that there are far fewer lesbians than male homosexuals.
Gay activist groups wanted more bodies — at least on paper.
Whether for purposes of deciding who is represented by the NGLTF or who has HIV, the ten percent figure hardly seems a good indicator. Nevertheless, it is the ten percent figure that New York had used earlier to arrive at its estimate that there were 400,000 homosexuals in the city. (CDC, incidentally, uses the four percent figure in its calculations.)
Already buffeted by AIDS, by the public scrutiny the epidemic has brought to the homosexual population and its sexual practices, and by the inherent stigma in being identified with a particularly hideous disease, homosexual activists were naturally disinclined to hear that the population they allegedly represent is much smaller than had been widely believed. Indeed, the columnist Patrick Buchanan picked up on the New York figures and made just that point in a column last September.
Such was the outcry at the new figures that New York City quickly came up with yet another estimate. This time it covered itself in two ways. First, it took a hint from CDC and set a range of seropositivity — from 149,000 to 229,000 — effectively allowing its estimate to go even lower. Next, it denied that its lower estimate necessarily meant that there were fewer homosexuals in the city than previously believed. "A number of commentators have inferred that our new estimate of infection strongly implies that the male gay/bisexual population ... is much smaller than the 250,000-500,000 commonly asserted," said the new report. Instead, it stated that the lowered number of infected homosexuals could simply mean that the percentage of homosexuals infected was much smaller than previously believed.
And it indeed is possible that seropositivity levels are much lower than previously believed. Estimates of seropositivity in New York are based on sampling at STD clinics which might well be unrepresentative of homosexuals. But the report’s statement clearly contradicts Joseph’s earlier statements. By rejecting the Kinsey figure (the mythical ten percent, that is) and accepting the San Francisco figures, there can be no other conclusion but that Joseph was saying New York had little more than twice as many homosexuals as San Francisco’s 56,000, and that therefore New York’s homosexual population is far below the alleged Kinsey ten percent.
Further, the new explanation — that it might not be that there are fewer homosexuals, just fewer infected homosexuals — is an implicit rejection of the validity of San Francisco’s seropositivity studies. In order to keep the homosexual level in New York at 250,000, the seropositivity level among New York homosexuals would have to be reduced from 50 percent to about 20 percent. San Francisco’s seropositivity studies all indicate that about 50 percent of that city’s homosexuals are infected.
Nevertheless, as convoluted and inconsistent as this new explanation was, it helped get the city off the hook with angry homosexuals. Joseph also used the new explanation to blast Buchanan, accusing him of advancing "an agenda of bigotry and divisiveness," notwithstanding that the New York Times had come to the same obvious conclusion that Buchanan had.
Pat Buchanan was vilified, but he was right.
As to the true level of seropositivity among homosexuals, the explanation for the lack of infected homosexuals is probably a combination of both fewer homosexuals and lowered levels of seropositivity. Kinsey properly rated homosexuals on a continuum instead of making a flat calculation. Similar caution should prevent us from offering a flat figure for the number of homosexuals who are seropositive.
If one regards any man who has ever engaged in a sex act with another man as a homosexual, then the degree of seropositivity among homosexuals is probably quite low. If one regards this category as comprising only those who engage in a fairly active homosexual life (what most of us regard as being homosexual), then the seropositive rate is probably quite high. In any case, the myth of the Kinsey ten percent could prove to be yet another casualty of the AIDS epidemic.
Having viewed the political pitfalls New York City encountered with its estimates, the New York State Department of Health stuck its finger into the political winds and was much more circumspect. It announced that it would not rely upon the new New York seropositivity estimate, and, completely ignoring the plateauing of actual cases in the city, in December New York State health officials extended their projections to show an unabated increase in cases for the next five years. New York’s Loomis, of course, also ignored the plateau, as indeed she would have to in order to write her terrifying article about how the city was grossly unprepared for the tidal wave to come.
But is there really anything wrong with exaggerating the epidemic? Is there any harm done by "erring on the side of caution" by pumping funds, and attention in general, toward AIDS?
Yes. We live in a world of finite resources. Money and attention devoted to one cause means resources pulled off another. There is a connection between the perception of AIDS as a national catastrophe and the willingness to fund the campaign against it. It isn’t the present caseload; there are still fourteen causes of death in America that are ahead of AIDS. It’s the predictions of millions or tens of millions or hundreds of millions of future cases that has so many Americans rating AIDS as the number one health priority. As ACT-UP is well aware, to challenge those predictions is to challenge the idea of pouring massive resources into the fight.
Indeed, rumblings of discontent with our AIDS preoccupation are already being heard. Just before stepping down recently as director of the National Cancer Institute (NCI), Dr. Vincent DeVita bemoaned the loss of resources to the AIDS industry. AIDS "has been an extraordinary drain on the energy of the scientific establishment," he said. "It’s taken a lot of intellectual energy away from the cancer program." The American Heart Association, for its part, has begun running television ads showing the risk of getting AIDS versus that of getting heart disease in order to prompt more donations for heart research.
Despite the far greater health threat posed by cancer, federal AIDS funding, allocated to PHS at $1.3 billion (of which about $400 million goes to education, not research), now nearly matches cancer funding. (Cancer funding, with the AIDS portion pulled out, comes to about $1.45 billion for next year.) Even if AIDS kept up with the CDC projection and didn’t peak until 1993, AIDS cases diagnosed that year will be but one-fourth of all 1993 cancer deaths. Each year a million cases of cancer are diagnosed, almost half of which end in death. This will be true next year and the year after that, with no peaking or decline until scientists bring one about. Heart disease kills even more people than cancer, over 750,000 Americans a year, yet its funding this fiscal year is only slightly more than $1 billion. In the Bush Administration’s proposed budget for 1990, AIDS will surpass cancer at $1.6 billion.
As the Washington Post recently reported, AIDS research has drained cancer research to a point where NCI’s ability to fund promising new proposals is more restricted than at any time in the past two decades. During fiscal year 1989, only 25 percent of cancer grant applications approved by review committees will receive funding.
During the 1970s, between 43 and 60 percent of such approved grants were funded. Two top NCI doctors have recently left the agency, partly in frustration over this. "They bled cancer to feed AIDS in terms of people’s time," one of the doctors told the Post.
Perhaps, as some have suggested, we could just trade funds earmarked for F-16s or MX missiles for AIDS research. But even this wouldn’t solve one major part of the problem, which is a drain on the number of researchers. This is pretty much a zero-sum game. It takes up to a decade to put a high school graduate through medical school. Thus in the short run, AIDS researchers must come from — and indeed have come from — other research areas, primarily but not exclusively cancer.
Last year, in a medical newspaper called the Scientist, two young psychiatric researchers spoke of having to resist the "seduction" of AIDS research money. "Unfortunately," they wrote, "many other young scientists may have no choice but to go into the field that offers the most easily obtained funding. If this happens, other areas of research important to the welfare of the US. public will be neglected for years to come."
One of the two retiring top NCI officials told the Post that NCI "is withering away." Further, in last year’s appropriations bill, Congress specifically called for hiring an additional 780 AIDS researchers. Where will they come from? They’ll come from the same place they’ve been coming from. For non-AIDS work, the National Institutes of Health has lost almost 1,100 employees since 1984. During the same period, according to Science magazine, the number of employees engaged in AIDS work has increased by more than 400, to 580 workers or their full-time equivalents.
AIDS is a disease, not the Andromeda Strain from outer space.
A slogan making the rounds on signs and bumper stickers reads, "The government has blood on its hands: One AIDS death every half hour. " Assuming the premise that government has a duty to fund the curing of disease, why doesn’t it have blood on its hands for the twenty-seven cancer deaths every half hour? Or forty-four heart disease deaths? Of course, a comparison of death counts is not the only appropriate factor in allocating funding and researchers.
Another argument used to support massive AIDS spending refers to federal spending for patient care: we should fund AIDS research now so we won’t have to spend so much on AIDS patient care in the future. In other words, "Pay me now or pay me later." But when the psychiatric researchers mentioned above made a comparison, they found that in terms of persons affected and patient costs, direct and indirect, the toll caused by psychiatric disorders swamps that of AIDS. And the ratio of AIDS research and development spending to federal patient costs is vastly out of proportion to other deadly diseases.
For example, cancer research expenditures will equal about 4.5 percent of cancer patient costs. For heart disease it is about 2.9 percent. And for Alzheimer’s disease a cruel malady that, because people are living longer, will take an ever-higher yearly toll unless medical intervention becomes possible-federal research expenditures will equal less than one percent of federal patient costs. But with AIDS, using a conservative estimate for federal patient costs, federal research expenditures will be an almost incredible 230 percent greater than federal patient costs for AIDS patients this year.
AIDS is a terrible disease. Its newness makes it seem all the more so. But it is just a disease and not an Andromeda Strain as the novelist Michael Crichton has taken pains to point out. And while its awesome fatality rate is a curse, its extremely inefficient transmission is a blessing. It’s time to take AIDS out of the realm of science fiction and put it within the wide spectrum of diseases and other problems which continue to plague mankind and which, we may hope, will eventually themselves fall victim to man’s increasing collective knowledge. It’s time for the AIDS hysteria to end and for some rational thinking to begin.