The War This Time: Lessons for Today’s Epidemic from the Battle Against AIDS
Sometimes, the new looks a lot like the familiar. For those over 40, the sight of a septuagenarian Republican president shrugging off a rising health threat which contradicts his ideological predispositions is déjà vu all over again. Today, it’s Donald Trump and his brazen, almost impressive attempts to walk the tightrope of downplaying the threat of the virus while simultaneously taking credit for aggressive steps to stop it, all while locking reality within the prison of his pre-existing worldview: that whatever the circumstance, the Democrats and the media collectively are endeavoring to undermine him. Then, of course, it was Ronald Reagan, and his more genteel elective avoidance of gazing too seriously at the earliest rise of the AIDS epidemic. While the times are different, as is the bug, some of the lessons learned from the past are timeless. As the most recent health crisis America has faced prior to the current looming fight, the battle against AIDS holds lessons in the political sphere that might be of assistance in reacting to COVID-19’s spread.
The first is that science does not give a damn about ideological predispositions, but predispositions appear to care an awful lot about science. Trump’s defining statement about COVID-19 will likely be remembered as his offhand taunt that the malady is a “foreign virus.” Trump has tweeted, in reference to coronavirus, that “we need the wall more than ever,” and has blamed China for the “China Virus”. His House consigliere, Kevin McCarthy, has followed suit and deliberately referred to the disease as “Chinese Coronavirus”. Not to be outdone, Senator Tom Cotton has used the term “Wuhan virus” and declared that “China will pay for this.” Trump, meanwhile, spent most of February downplaying the effect of the virus, and repeatedly expressed far more concern that the CDC’s warnings were spooking the stock market. In each case, by forcing biological imperative into the box of ideological human frailty, the Administration and its fellow travelers fought the wrong enemy as a threat metastasized and in doing so, helped advance the very thing they feared.
The Reagan Administration would understand. Reagan’s presidency was the first in which evangelical Christians played a key role in electoral politics, and their views on gay men and women were unequivocal. Speaking in 1980, Bob Jones III predicted “God’s judgment is going to fall on America as on other societies that allowed homosexuality to become a protected way of life.” Just as central to the new administration was a rock ribbed belief in cutting government spending. So when doctors began to note a strange new disease primarily striking the gay community in 1981, they faced an Administration predisposed to downplay the onrushing demon. The frontline responders, however, played it straight. Once doctors in the CDC realized they were up against a pathogen of unusual and deadly malevolence, they formulated a plan to federalize the threat to public health. Dr. Don Francis, an epidemiologist at the CDC, remembered that in 1982:
Then I shifted at the direction of the higher levels of CDC to make a plan of prevention. I think we called it Operation AIDS Control, and that plan was terribly expensive — it was $30 [million], $40 million per year at the federal level and more at local levels, state and local. We would launch programs for testing and counseling and education for HIV/AIDS. That program was outlined in several pages by me, and several pages [of the] document went to the director of CDC. … It went to Washington, and the word that we got back from Washington, as best as I can recall, was something like, “No, we’re not going to fund it, and we want you to look pretty and do as little as you can.”
Fighting the disease cost money, and worse, it was money spent on the very people the Reagan coalition was elected to ignore and disdain: sexually active gay men and intravenous drug users. As late as 1986, the Reagan Administration actively sought to cut funding for AIDS by 11%; astoundingly, during the height of the crisis, Dianne Feinstein’s budget for fighting AIDS as the then-mayor of San Francisco was higher than that of the entire federal government. Reagan did not so much as mention the word “AIDS” until 1985, and did not speak in depth about the disease until 1987, when 21,000 Americans had already died. He did, however, find time to laugh at a joke told by Bob Hope in 1986 referencing Reagan’s recently deceased friend Rock Hudson, at the rededication of the Statute of Liberty: “I just heard Lady Liberty has AIDS. Nobody knows if she got it from the mouth of the Hudson or the Staten Island Ferry.” By being slow to recognize the emergent threat and largely indifferent when it did, the Administration closed the coffins on millions. Viruses don’t recognize ideology, and they don’t care about the political beliefs of their hosts. Every second spent in hatred of the perceived political enemy, be they gay men or Chinese nationals, is a second not spent on meeting the threat at hand. The need for politicians to disenthrall themselves from chosen beliefs and act with alacrity, as early as possible, is the lesson of the AIDS crisis, and it’s one that the Trump Administration has, in its nationalistic response, forgotten to date.
Not all politicians acted with indifference, and that brings us to the second lesson worth remembering. Congress, vilified and impotent as it is today, played a key role in responding to the insurgent threat AIDS posed to public health. Mostly forgotten today is the role of Representative Henry Waxman (D-CA), who stumbled upon AIDS when he, as a freshman member of the Subcommittee on Health and the Environment concerned about the Reagan Administration’s deep cuts to federal spending on public health, sent an aid to the CDC to determine whether any public health issues were being unaddressed by lack of funding. What he found, almost accidentally, was the earliest examination of AIDS. Waxman called the first hearing on AIDS in April, 1982, when just 300 reported cases existed. Waxman was no doctor, but he set a tone that members of Congress need to remember and follow today: in the face of testimony and actions laced with political overtones- testimony on anal sex and drug abuse, testimony about despised and forgotten Americans suffering from a disease that Americans feared for a time was airborne- Waxman continuously asked simply what the public health servants believed needed to be done, and then set about drafting the legislation and finding the funding to do it.
He had plenty of opposition, most notoriously from Republican Rep. Bill Dannemeyer, whose reaction to AIDS crisis included reading a speech into the Congressional record titled “What Homosexuals Do” and proposing rounding up gay men and quarantining them on an island in the South Pacific. The Administration certainly did him no favors, either: Waxman had to threaten to subpoena documents withheld by Reagan’s secretary of health and human services, which showed scientists pleading for far more money than publicly admitted. Yet by listening to dedicated Congressmen like Waxman, and by burying AIDS research in bills funding less politically divisive medical research, Congress managed to first allocate funds for AIDS research in May, 1983. That funding eventually helped cover the cost of AZT, the first drug which slowed the disease’s progression. Congress finally began earmarking funds for AIDS directly in 1986, but only after a steady progression of Congressional testimony prompted by and fueled by Waxman. In other words, Congress can make a difference, but more importantly, in facing a global pandemic, it must make a difference. No other entity controls the purse strings necessary to allocate funding for research, testing, and eventually, hopefully, vaccination. Individual Congresspeople in the AIDS crisis refused to simply follow the Administration’s lead; they took it upon themselves to dare to know for themselves, and to eventually follow the scientists urging a far more expansive fight against a growing plague. Today, Congress is a shell of its former self, but if there is ever a time to reclaim any portion of its former prominence, now certainly is it. Follow the example of Waxman: figure out what the nonpartisan public servants need, and twist the arms needed to get it to them, consequences be damned. With an expansive bill passed by the House on Friday to address many of the issues created by COVID-19, and even Mitch McConnell now pledging to pass it, just perhaps the bar of low expectations may yet be exceeded. Yet far, far more remains to be done.
A third lesson: get help into the hands of people who need it, early and often. We failed to do this in the AIDS crisis, leaving the fight to those in no condition to battle on their own behalf. A 1988 Congressional study found that 86% of health insurers screened applicants for signs of HIV, and many used sexual orientation in denying coverage. Lacking health insurance, most AIDS sufferers delayed seeking early intervention and treatment, potentially increasing the spread of the disease dramatically. Sick gay people were already undesirable, but sick, gay, and poor were even worse.
What became the Ryan White Comprehensive AIDS Resource Emergency (CARE) Act helped turn the tide. Waxman’s bill, and the companion bill authored by Sen. Ted Kennedy, languished in the Senate, where noted homophobes like Jesse Helms held it up as promoting special “gay rights”. (In 1991, Helms received an unusual comeuppance, when activist Peter Staley draped a giant condom over his house). When it finally passed in 1990, the Act provided a payor of last resort for a host of anti-HIV services for the poor and uninsured suffering from the disease. It was, and is, one of the only disease-specific acts passed by Congress, and has been extremely effective in providing funding for states, municipalities, clinics and other health care providers with the capacity to reach underserved populations. It took years for the CARE Act to pass, but once it did, it played a critical role in ameliorating the suffering of victims existing in the twilight of fear and societal rejection. The Act wasn’t simply charitable: it also represented a dawning recognition among low-risk Americans that what affects the poor affects us all, and therefore that addressing those who suffer from a disease, no matter who they are and what resources they have, is a blessing for the entire concept of public health itself. Today, still, over 500,000 Americans receive care on an annual basis from CARE affiliated programs. Of all of the programs ever passed by Congress, the unsung CARE Act may well have saved the most lives.
The lesson should be clear. Coronavirus doesn’t discriminate, but its effects may well vary based on the resources provided to fight it. While HIV and COVID-19 are very different viruses, what they share in common is that poorer members of our society, burned by the impossibly high cost of health care, often choose to ignore illness rather than fight it. The hourly worker hiding a cough today is no different than the gay man terrified of exposure thirty years ago; each is undermining public health because the society in which they live makes concealment a rational, if selfish choice. Getting resources into local hands, quickly and in sufficient amounts to serve underserved areas may well be the key to long-term prevention and fight against the virus. HIV and COVID-19 both require early detection and aggressive action which, if ignored, threatens the rest of the population exponentially. Thirty years ago, the American public establishment finally learned that brutal lesson, but it took 9 years and 100,000 dead to get there. We must move far quicker now, and if we’re smart about it, we will.
Finally, we need dignified public servants, inoculated not only against the diseases they fight but the politics that hamstring urgent response. Reagan’s Surgeon General, C. Everett Koop, risked conservative disapproval by demanding early sex education and the use of condoms. White House aides tried to get him to delete the reference to condoms in a 1986 report on AIDS, but he refused to alter the report or make it more morally judgmental: uncontroversial today, heroic in 1986. Whether today’s Surgeon General Jerome Adams shows a similar courage of convictions is yet to be determined. Speaking on CNN, Adams said that he’d seen no indication that people who want to be tested for the virus cannot be, and that speaking of Trump (thirty years his senior), the President “sleeps less than I do and he’s healthier than what I am.” If we are lucky in any respect, it is the presence of Dr. Anthony Fauci, the current head of the NIH. Foregoing the pathetic self-abnegation of other members of the Trump orbit, Fauci directly contradicted the President in public statements about coronavirus. Testifying in Congress on March 11, Fauci stated bluntly that “Bottom line: things will get worse.” Of testing, which the Administration claims is widely available, “That is a failing, let’s admit it.” Fauci is the rare Trump-era official who actually is the right man at the right time, and if his name sounds familiar, it’s because he represents a direct link to the earlier era. Since his appointment to the NIH in 1984, Fauci essentially operated as the government’s AIDS czar, tackling the research into the disease and helping to speed through research that eventually broke the back of its devastating mortality. With more public servants like Dr. Fauci, we will hopefully once again reap the benefit of knowledge, experience, and judgment.
We are in the early stages of the COVID-19 fight, and it will require a higher level of social cohesion than Americans have displayed in generations to win this war. And war it is, for in wartime, Americans have needed to band together in a cause greater than any of them in order to preserve the guts of a society worth saving. That is precisely what is needed, here and now: for the first time in generations, sacrifice will be demanded of each and every American. Perhaps we will learn from our recent past and apply the lessons of victory, if belated and tragic, in the HIV saga to better position ourselves in the battle yet to come.