HEADLINE: AIDS Dissidents' War on Drugs; ACT-UP; San Francisco and public-health groups continue to clash over the question of what causes AIDS. Is it HIV or a combination of social and environmental factors? The solution won't be found by silencing either camp, but by doing just the opposite -- taking up their concerns.
BYLINE: Tim Vollmer
What causes AIDS? Far from being resolved 20 years after the syndrome became a household word, the question has flared in recent months, escalating what appears to be a war between official public-health groups and self-proclaimed "dissident" groups.
The public-health and science establishments contend that, by claiming HIV isn't the cause of AIDS, groups like ACT-UP/San Francisco are encouraging gay men and others to be sexually irresponsible and thus, further spread the virus. They are calling for community condemnation and, in some cases, for criminal prosecution to stop these groups' disinformation campaigns.
The dissidents counter that an aggressive "AIDS Inc." is promoting a crisis mentality that insures governmental funding and pharmaceutical profits but obscures more fundamental health threats like poverty, the social oppression of women and a pervasive drug culture that they believe lead to AIDS. Their sensationalistic protests, they insist, are the only way for small groups to draw attention to the corrupting effects of consolidation by governmental, academic and commercial interests in health care.
Though usually more subdued, this type of debate is nothing new in America's public-health arena. In fields such as drug abuse, for instance, officialdom has tended -- counterproductively, in the view of many -- to place both responsibility and "blame" for solving the problem on the individual, thereby ignoring the role of economics, culture and society.
To avoid the fate of drug policy in America -- with its "just say no" prevention philosophy as well as its increasingly incarcerated target population -- the AIDS field needs to find a new way for mainstream public-health groups and AIDS dissidents to converse.
A renewed debate would absorb and moderate radical protests by groups such as ACT-UP/SF. At the same time, it would encourage the discussion to include environmental and social sources of ill health in a society disproportionately prone to concentrate on the behavior of certain types of individuals and groups....
While ACT-UP/SF disruptions are somewhat similar to the original ACT-UP's actions, which included closing down bridges and disrupting conferences, the message of the currently active group (the San Francisco chapter split off the original in 1990 and regrouped in 1994) is diametrically opposed to its predecessor.
While the original ACT-UP pushed for easier and speedier access to anti-HIV medication, the current ACT-UP claims that the anti-viral drugs are more toxic than HIV. ACT-UP/SF and similar groups have aggressively courted allies to fight the dispensing of these drugs. Though unsuccessful, they joined conservative politicians in calling for decreases in funding for HIV prevention and treatment to slim down the industry they say has grown around the virus.
Dissident groups have had recent success abroad with groups who have been traditionally suspicious of Western commercial interests. In particular, South Africa President Thabo Mbeki has expressed concern that attention given to the HIV epidemic is due to corporate desire to sell products rather than the virus' relative threat to public health. The emphasis on HIV, according to Mbeki distracts from the poverty left from apartheid and past Western colonialization.
Anger at ACT-UP/SF's and similar groups' tactics and success has been raging at full boil in public health for several months. Officials are concerned that the most radical claim of the "dissidents" -- that HIV is harmless -- discourages condom use, thus further spreading the disease, and delays treatment with increasingly promising drugs. The view also gives politicians here and abroad, public health officials warn, an excuse to deny funding and support for those afflicted by a still growing epidemic.
Public health officials have fiercely derided the view that HIV is harmless, commonly referring to the dissidents as "flat-earthers" and comparing their view to denying the Holocaust. The Canadian head of the International AIDS Society has even called for "jailing" dissidents as threats to the public.
In San Francisco, the feud has become exceptionally heated, personal and riled over the summer by clumsily presented HIV/STD statistics by public health officials and the "outing" of local prevention workers as "barebackers," i.e., people who don't use condoms. There were even physical altercations between the groups at meetings.
Just a few weeks ago, more than 200 people from public health and community groups signed a declaration condemning ACT-UP/SF and announcing the formation of an alliance to stop ACT-UP/SF's message. This follows calls for charging "dissidents" with assault and for investigating their medical marijuana distribution operations.
Although the frustrations of mainstream authorities are understandable, and criminal behavior must be prosecuted, an aggressive campaign against "dissident" groups is very unlikely to silence them, and is more likely to give them further exposure and anti-authoritarian appeal. Mbeki has already compared the dissidents' struggle to the long battle against apartheid in his country.
At present, ACT-UP/SF and similar groups benefit enormously from being the most prominent, if not the only, proponents of looking at potential social aspects of AIDS. Although the claim that HIV is harmless gets all the attention, the bulk of "dissident" thinking can be boiled down to looking at social conditions and drug safety -- concerns that are not being championed aggressively by AIDS officialdom.
A more effective, but admittedly more difficult, strategy would be to beat ACT-UP/SF at its own game and start giving social aspects of HIV transmission as much attention as individual behavior. Just as the original ACT-UP was absorbed when authorities began to channel resources toward developing AIDS drugs, these newer groups would lose the irrelevance if their issues were dealt with elsewhere. This, however, is not the American way.
Except for initiatives like the "New Deal" in the 1930s and the "Great Society" in the 1960s, public consideration of social conditions has not been broadly popular in American society. During periods like the "Red Scare" of 1919, McCarthyism in the 1950s and Reagan-era attitude that turned liberalism into a dirty word, such consideration has even been politically vilified as undermining standards of individual responsibility.
Since political biases affect government funding policies, American public-health researchers have traditionally left serious social analysis to the smaller pools of researchers in Europe and elsewhere, and excelled instead in investigating individual aspects of disease transmission and risky behaviors.
This approach has primarily focused on changing individuals' behavior-- usually getting them to abstain from risky behaviors -- by means of education, of treating mental illnesses like depression and addiction, and, if nothing else works, of punishment and incarceration. Americans have also been the leaders in pursuing high-tech (and usually politically neutral) solutions to medical problems, an approach that has even been intensified by the deregulation of the health industry during the last decade. Loosened FDA rules, pressure by AIDS and cancer activists, and an explosion in biotechnology have produced a rapidly growing number of new medical drugs.
A further proclivity to narrow AIDS prevention and treatment to these two options dates back to the Reagan-era. Even back then, observers warned that, due to concerns of politicians of appearing pro-gay and of gay activists avoiding negative publicity, the government was funding only two narrow prevention and treatment avenues: "Just say no" to unsafe sex prevention programs and drug research. Confronting anti-gay prejudice and improving over-all gay social conditions have never been well-funded parts of official policies.
Beyond giving groups like ACT-UP/SF an excellent opportunity to exploit, focusing exclusively on the individual has left social sources of problems unarticulated and ill addressed.
For example, beyond using condoms when having sex with an HIV-positive person, HIV prevention has not really taken into account modern sexuality. Sexuality is becoming the basis of an individual's sense of "identity," of relationships, and even of community. Though the trend is perhaps most progressed among gays, sex increasingly determines the value and meaning of life among heterosexuals, too, theorists contend. Thus, to "just say no," may deny an individual an identity, a meaning and a place in the community.
In similar fashion, some argue that traditional sexual patterns, which give men far more control of sex than women, have been neglected in attempts to prevent the heterosexual spread of HIV in both America and Africa. Calling for more condom use is the easy way out, these critics contend, when the real issue is the far more difficult problem of changing gender roles to sexually empower women.
If society's influences on behavior are ignored, however, individuals who continue to engage in prohibited activities are either irresponsible or criminals. Authorities have no other explanation for why some keep saying yes when told to say no.
This is the same train of logic followed in the drug abuse field, where zero tolerance and harsh punishments have overshadowed a more sympathetic view that poverty and social dislocation have led to entrenched drug cultures, especially among African Americans and other stigmatized groups. The bias applies to how Americans view the problem of teen pregnancy.
This bias toward holding the individual accountable for social conditions may explain why, at a time when AIDS is growing faster in black and Latino communities than in white, there is renewed interest in criminal laws against unsafe sex, forced HIV testing of accused criminals, and court-mandated treatment of minors who test positive. It could be a crime to have AIDS.
Another reading of enduring high rates of unsafe sex and HIV transmission, however, is that the current "just say no" approach to unsafe sex can only be partially successful in a society in which people are judged by their sexual appeal and activities.
Individuals may find themselves under conflicting pressures in a situation that may not be resolvable. Moreover, these demands are being placed upon gays and nonwhites in communities already weakened by historical stigma and related health problems. Right now, the only really sympathetic ear to their complaints are groups like ACT-UP/SF, which, like radical animal rights, anti-genetic engineering, environmentalist and "anti-globalization" groups -- the "dissidents" in their fields, -- already have a strong anti-corporate bias. It has been an easy expansion of their views to argue that the HIV epidemic is a corporate conspiracy to deny responsibility for the unhealthy effects of capitalism and instead to develop ill health as a new market.
Attempts to silence ACT-UP/SF, by deriding its views and vilifying its members, discourages open discussion of other aspects of AIDS prevention and treatment. Adopting the opposite tack -- taking up "dissident" and other disciplines' concerns about social and non-viral aspects of AIDS, including possible over-zealous medicating -- would quickly make ACT-UP/SF irrelevant, as well as broaden the scope of prevention and maintain long-term trust in treatment.
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AIDS CONTROVERSIES
Heated controversies are not new to AIDS, a syndrome that has generated stormy rhetoric and confrontations from the very beginning. The following is an overview of some of the major controversies:
-- 1982-1983: AIDS epidemic rages furiously; community groups like newly formed Sisters of Perpetual Indulgence begin distributing "safe sex" pamphlets and conducting bathhouse demonstrations of condom use in the absence of any official reaction to the disease. Public officials react to this by saying they're publishing pornography.
-- Mid-1980s: Bathhouses are closed in San Francisco and New York City as criticism of gay "fast-lane" lifestyle mounts; groups form to protect sexual freedom and sex clubs go underground; official prevention begins focus on promoting condom use in high-risk groups as the main way to curb transmission.
-- 1985: Discovery of the Human Immuno-deficiency Virus is announced; French researchers sue American researchers over stolen glory and viral particles; columnist William F. Buckley calls for infected people to be tattooed and quarantined; gay activists call the test a CIA plot to identify gays. "Anonymous" testing sites set up across the country, defying critics of AIDS "exceptionalism" who call for names reporting and partner tracing.
-- 1987: "Patient zero," a promiscuous gay flight attendant described by author Randy Shilts, is credited with bringing the virus to the United States (African origins scrutinized, but African epidemic ignored); gay author Larry Kramer co-founds AIDS Coalition to Unleash Power, and ACT-UP groups; Nobel-winning virologist Peter Duisberg says over-medication and recreational drug use is the real cause of AIDS after a previous cancer drug, AZT, is prescribed in high doses to AIDS patients.
-- 1988: Prevention Point activists independently start "clean needles" exchanges nationwide; many get arrested until cities declare "state of emergency" and look the other way.
-- 1989: ACT-UP closes Golden Gate Bridge.
-- 1991: ACT-UP splits into two groups over social issues, one side supporting anti-viral drugs and the other, by 1994, supporting Duisberg.
-- 1992: "Concorde" study from Europe shows disappointing results for AZT ushers in gloomy period in treatment; alternative remedies such as acupuncture and Chinese herbs are increasingly explored by patient population; laws changed to allow quicker approval of experimental drugs.
-- 1996: Virologist David Ho declared Time's Man of the Year, and his work leads to the quick approval of protease inhibitors; debate emerges over the efficacy and safety of the difficult-to-take "cocktails."
-- 1999: "AIDS Inc." critique of a self-proclaimed and Internet-wired "AIDS dissident" movement garners attention of South African President Thabo Mbeki, who then questions the need for expensive anti-viral drugs.
-- 2000: Five thousand researchers from around the globe sign a letter affirming HIV as the cause of AIDS and protesting inaction by the South African government during the Durban AIDS Conference; criminal charges filed against ACT-UP/SF after scuffles ensue at public meetings and city hearings; public health and community leaders announce the "AIDS Activists Against Violence and Lies" to protest ACT-UP/SF's message.
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Yoshie