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Harden: So you would say that the reason the Public Health Service did not move as rapidly as it might have in education of the public was due to political policy pressures.
Krause: I do not think it is just political. I think political policy represents the public's social outlook. I think that the public, on the one hand, behaves one way, but on the other hand, its nature is conservative. It still values behavior from a stricter past. It behaves one way sexually, but its social outlook is different. I am not really blaming the [Ronald] Reagan administration. I think that Reagan and the people have what they want. They want it both ways. They want to be sexually free and at the same time they want to give the appearance of faith, God, family, and so forth.
In an Anglo-American conference Whitescarver and I organized a year ago in September (1988), the purpose was to identify similarities and differences between the American strategy to combat the AIDS epidemic and that of Britain.
In 1983 or thereabouts, Sir James Gowan, the head of the Medical Research Council (MRC) visited us and by then I was convinced that they (England) had to do something to get ready. I had known Gowan for years; we are the same age, and we both went into government at the same time. I left Rockefeller, a very pristine place, and came to NIAID. He left Oxford, also a pretty pristine place, and went to London as the head of the MRC in 1975. So, in 1982, he said, “What should we do?” and I said “Get ready.” He said they did not have any cases there, did I think AIDS would come? I told Jim that it certainly would since it is a sexually transmitted disease and there was no way to keep it out of England. People travel worldwide. In 1983, I said the same thing to Sir Gustav Nossal, Director of the Eliza and Walter Hall Institute [of Medical Research] in Australia. As a result, they did things differently. Many feel that they did not do enough, but they certainly did prepare for the epidemic.
It is impressive what the British have done in the public information arena, under the direction of Dr. Spencer Haggart, chief executive, Health Education Authority for England. He talked about the four objectives of their campaign. First, to educate with the facts, second, to dispel myths, third, to give advice on prevention, and fourth, to provide information on behavior modification. They have had two campaigns to inform the public, one was two years ago and the other was more recently. These were covered by newspapers, television spots, the whole bit, and they had letters from [Prime Minister] Maggie [Margaret] Thatcher. They also put in a program to evaluate their campaign. Their information, as we saw on their television clips, was very explicit, they were not little pansy things. As far as I know, we have not even got our television clips out yet. It is not the CDC's fault, it is just that the CDC has not been able to come up with something that would not be offensive to the television audience in this country. It is beyond me, what with Dallas and the soaps on television. The British used very explicit material.
Their first questionnaire was designed to see what the general British population felt. Did the people believe that explicit information was offensive? Only five percent thought so. Ninety-five percent thought it was appropriate. Seventy-five percent of the adults had read or at least looked at the information leaflet. After the information program, a survey indicated that among the general population, casual and anal sex was reduced by fifty percent. Among homosexuals, the number of partners per year fell from more than ten to four.
It was clear from the survey that there was a negative attitude toward the use of the condoms, and advertising was needed to constantly reinforce a positive view. The British evaluated again with a second survey, and the phone calls to a hot line doubled. The calls from women went from thirty-three to fifty-four percent, which is interesting from the angle of safe sex, since it means you were doing something. The demand for HIV [human immunodeficiency virus] blood testing rose by 300 percent. Serious press such as the Times of London felt the information campaigns were acceptable, but the tabloids, as one might expect, were hostile.
The Dutch and others have gotten themselves much better organized. Several years ago, the Minister of Health, a woman, when on television, had a dildo, a dummy penis, on which she put a condom to show people how to use it. I can not imagine Mrs. [Margaret] Heckler having done that. We have fallen behind here, but I think the Public Health Service, in general, should be in the lead position. In this instance we may not have provided as much leadership as we should have, but I also think that when it comes to matters of sexuality, the government can not go too far beyond what the people themselves are prepared to accept.
Harden: When you left NIAID in the summer of 1984, the AIDS virus had been identified. You moved from a government position into an academic position at Emory University School of Medicine. What can you report about investigation into AIDS and the reaction to it from outside the government?
Krause: There are various aspects to that. It certainly is true that there was concern in the medical community, particularly among those who were involved with taking care of these patients. They were overwhelmed. They were working very hard in infectious diseases, but internal medicine people were and are the lowest paid of the specialties along with pediatricians. A single AIDS patient on a given day may take as much of an internist's time as the time a surgeon takes to do open-heart surgery.
I do not mean to say that internists were not taking care of the AIDS patients because of this. They were taking care of the AIDS patients. I do not mean to say that they were grumbling, but they were overworked, and they were among the underpaid of the health profession. How do we get more physicians to take care of people in the sub-specialty of infectious diseases? I do not know.
Another area that is a matter of concern relates to the health care workers in intensive care units, during surgery, and so forth, who feel that they should have the right to know if a patient has AIDS, because then they will take different precautions. I can see both sides of this issue. In the days of the tuberculin test, if you knew a patient had tuberculosis, the precautions you took in chest surgery were entirely different than for the non-infected patient. The medical professional was at great risk from tuberculosis. Now people are at risk in taking care of people with AIDS. That does not mean they are not going to do it, but they are at risk. If they have to treat every patient as if he or she is a potential AIDS patient, procedures become difficult to manage. I think this is an ethical issue, and on this I come down on the side of [Dr.] LeRoy Walters, an ethicist. There are those who favor and those who do not favor selective screening. It is Walters's belief that testing is morally justifiable, if it is accompanied by counseling, by protection of confidentiality, and if there are built-in safeguards of non-discrimination for those who are AIDS-antibody positive.
In regard to the subject of health care and the duty of health care workers to give care to everyone, it is Walters's view that if the general measures for infectious disease control in the hospital do not work to prevent the spread of the disease to health care workers, then it would be appropriate to freeze blood for surgery patients and other patients who might be at high risk to personnel. I think sooner or later we are going to have to come to this, but as he said, the safeguards have to be built in.
From several points of view, I developed an appreciation of the frustration and even anger of the gay community concerning their perceptions about the medical response to the AIDS epidemic as a consequence of my experience at Emory University School of Medicine from August 1984 until January 1989. When I went to Emory in 1984, I assumed we would become a major center for AIDS basic and clinical research, patient care, and a center for clinical trials. We had the CDC next door. We supervised Grady Hospital, a large public county facility. Atlanta was known to be a city with a large gay population. But to this day, Emory has no comprehensive AIDS program. So what went wrong? The fact is all of my efforts to develop such a comprehensive program were stonewalled by the Southern establishment of Atlanta that decides such matters. I do not even know who they are. You do not hear from them directly. You do not get told directly do not do this or do not do that. You get word secondhand.
Was it homophobia? I do not know. The Atlanta Constitution wrote an extensive article on the “do nothing“ response of Emory. It is a very good article and should be referenced to this interview. Atlanta should have had the most comprehensive AIDS center in the South. Because of our inaction, the University of Alabama, Birmingham, and Duke University have taken the lead. So I now understand the frustration of the gay community concerning their perceptions of a slow response to the challenge of AIDS. I was not prepared for the social attitudes of the deep South. I had lived in New York City for twenty years and in Washington, D.C., for ten years. Issues of life style were not so controversial as in the South. Indeed, in the South, as near as I can tell, controversial issues are better left unsaid. So as I say, I now know full well the frustration of the gay community.
Harden: Do you recall when you first realized that AIDS was occurring internationally–in Africa and other countries, Third World countries and Europe? Could you give me some perspective on this?
Krause: NIAID had a good deal to do with that, and I think the institute has not been given the credit that it deserves. That is behind me now, of course. I have had enough honors and glory, and I do not need to worry about that too much. But it does put the story in perspective. We knew there was a “Haitian connection.” Early on we had the four H's: hemophiliacs, homosexuals, Haitians, and heroin addicts. We could not get into Haiti because they were so damned mad that we called AIDS the Haitian disease. It was not a disease of Haitians. It was true that there was an unusual percentage of people of Haitian origin with AIDS living in the United States. That is why we came to use that phrase to identify them. By Haitians we did not mean the people of Haiti.
The Public Health Service could not get into Haiti in 1983, because the Haitians were so angry, but on the other hand, Haitian tourism was falling off. Haiti needed help. [Dr.] Karl Western was a big help here. He is somebody you should talk to. He had worked with PAHO [Pan American Health Organization] before he became my special assistant for international health. He organized a meeting between the assistant minister of health for Haiti and PAHO. PAHO was neutral ground. The Haitians were incredibly angry with us, but we had a good discussion, and they extended an invitation for us to go to Haiti. It was in the spring of 1983. I took Dr. Tom [Thomas] Quinn, an epidemiologist, and Dr. Clifford Lane, a clinical investigator, with me. Also somebody from the CDC [Dr. Harry Haverkos]. I have forgotten his name now, I apologize for that. We got there and were met by the assistant health minister. He took us to the hospital, where we were going to talk with Haitian doctors, but the doctors were so angry with the Americans that they would not talk. The assistant minister said that the Americans were going to see AIDS patients, even if he had to take them on rounds himself. So we did go on rounds, and the first three patients we saw were women, and three or four of the first ten patients had tuberculosis. This was new for us. A large percentage of women, and tuberculosis as an opportunistic infection.
Once we finally got over the first rough hurdles, we reviewed their data with Dr. [Jean] Pape, a Haitian doctor who had trained at Cornell [University] and who was already working with our STD unit or our tropical medicine unit or both at Cornell.
You know that people think the scientific community did not do anything, but, my God, it is like the free marketplace, all kinds of things go on all the time that go unnoticed. I did not even know this doctor until I met him. He was very well trained, a very good clinician, who had been interested in diarrheal diseases.
We won the local doctors over. Pretty soon they came around to our hotel and talked. We spent ten days there, and at the end it was quite clear that there was a community in which AIDS was being spread. Homosexuality in Haiti was probably a livelihood, not just a way of life. AIDS was going from male prostitutes to females. Now it is history. But we helped out and the young doctors came to the NIAID clinical services to learn more about AIDS from Dr. Fauci.
Haitians are wonderful people. I brought home art, and I enjoyed the people tremendously. They are French-speaking, extremely artistic, and talented people. They have a tragic history, and because of this, large numbers of them in the 1960s had gone to Zaire as engineers, accountants, etc. When they were kicked out, some of them came back to Haiti, some of them came here and to Canada, and a few went to Europe. AIDS traveled with them from Africa.
My own view is that AIDS started in Africa, because of societal changes and urbanization. It had probably been confined and transmitted very sporadically in the rural communities, not spreading very far because people did not travel very far. Since they have a lot of STDs, something must have happened to the social barriers, and the diseases broke out. Certainly in recent times prostitution has flourished in the large urbanized cities of central Africa. That is a change.
Since the introduction of Western medicine and the needle, many medicines are given by needle injections. Patients demand needle injections, and as a result needles are used over and over again. Undoubtedly this fostered the spread of AIDS.
Whatever the reasons, all sorts of social changes resulted in an epidemic. Infectious diseases take advantage of what I call undercurrent opportunity. Malaria is a good example. In World War II, malaria was reported in Archangel, north of the Arctic Circle, for the first time in history, but now it has retreated all the way back to the tropics. The mosquito is still there in Archangel, but malaria is not. There is an old saying in the Mediterranean, that “malaria flees before the plow”; but, as I have noted “it returns on the wings of war.” Undercurrents of opportunities–it is true for every infectious disease.
In the summer of 1983 in Vienna at the international conference of infectious diseases, I gave a talk on “Koch's Postulates and the Search for the AIDS Agent.” It was published in 1984. Many people have quoted that paper because that is where I suggested that AIDS might have always have been there in Africa, and that epidemiologic changes had brought it out. The paper set forth useful ideas in the epidemiology of AIDS in a historical context.
In Vienna I met Dr. Luc Eyckmans, the head of the Institute for Tropical Medicine in Antwerp. Quinn, Whitescarver, Western, and Peter Piot (Belgium) were there as well. We planned the strategy for getting into Zaire. We set up a program in which the Belgians would be involved. Later Quinn and I went to Antwerp for future planning. We got together a team and about that time we bumped into the CDC doing the same thing. [Dr. Joseph] McCormick and [Dr.] Jonathan Mann, from the CDC, wanted to do their own thing and did not see why NIAID had to get involved. As far as I was concerned, we had to be involved because, by congressional mandate, the CDC can only take research a certain distance. So we ended up with a compromise. Ken Sell can tell you more about that. The compromise was that the CDC representative was the director of the project and the NIH person was the director of the laboratory. Since then, Projet SIDA has been a very productive and important laboratory. But get the full story from Quinn, Sell, and Dr. Henry L. Francis. Francis was NIAID's person in Zaire. That is the story of my international connection.
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